Abstract
Background
In the United Kingdom, over 1 million elective surgeries were cancelled due to COVID-19, resulting in over 1.9 million people now waiting more than 4 months for their procedure – 3x the number last year. To address this backlog, the healthcare service has been asked to develop locally-designed ‘COVID-light’ facilities. In our local system, 822 patients awaited orthopaedic surgery when elective surgery was permitted to resume. The phased return of service required a careful and pragmatic prioritisation of patients, to protect resources, patients, and healthcare workers.
Aims
We aim to describe how the COVID-19 Algorithm for Resuming Elective Surgery (CARES) was used to consider 1) Which type of operation and patient should be prioritised? and 2) Which patients are safe to undergo surgery? The central tenets to this were patient safety, predicted efficacy of the surgery, and delivering compassionate care by considering biopsychosocial factors.
Methods
Orthopaedic surgeons were provided with details of patients on their waiting list. They prioritised patients into those for surgery within 1 month (Urgent: e.g. arthroplasty for rapid deterioration from avascular necrosis or infection, or in the lowest quartile of Oxford Hip/Knee/Shoulder scores), < 3 months (Soon: e.g. revision or second-stage arthroplasty), and > 3 months (arthroplasty for end-stage arthrosis). The surgeon-led stratification was then reviewed by a multidisciplinary surgical prioritisation team, including anaesthetists and operating theatre managers, to consider medical history, the need for additional intraoperative services (such as cardiac physiologists, or specialist equipment requiring industry ‘reps’), and the risk of postoperative deterioration requiring HDU/ICU. The MDT also reviewed what the impact of disease and further delay may have on a patient's mental health, ability to work, or ability to care for dependents. The CARES protocol created an aggregate score for efficacy, compassion, safety and surgical risk to equitably rank patients.
Results
The implementation of CARES stratified the waiting list into 122 (14.8%) patients requiring urgent surgery, with high likely health-gain or biopsychosocial gain, of whom 76 were low-risk and 46 were high-risk – medically moribund or complex. There were 232 (28.2%) patients required surgery within 3 months, and 468 (57.1%) patients were deemed safe to delay for > 3months.
Alongside i) staff- and patient-screening, ii) adequate personal protective equipment, and iii) increased used of regional anaesthesia, the healthcare system was reconfigured, to create two surgical pathways. ‘Green Well’ patients were scheduled for surgery at a clean site – an elective surgical centre with no on-site HDU/ICU. ‘Green High-Risk’ patients underwent surgery at the general hospital (with on-site HDU/ICU) in operating rooms (ORs) which were physically segregated from ‘Red’ ORs reserved for COVID-19+ or trauma patients. In 6 weeks, 164 patients underwent surgery with no transmission of COVID-19 between patients or staff.
Conclusion
Our healthcare system safely resumed elective surgery as early as the top 2% of hospitals nationally. This was facilitated by CARES stratification (which factors safety, efficacy, and compassion), MDT-led decisions, and surgical pathway reconfiguration. This generalisable, validated approach could be widely applied to facilitate restarts globally.
