As the second winter of COVID-19 looms, with the highly contagious Omicron variant spreading quickly, it’s important to integrate lessons on surgical case prioritization learned from previous surges. If the winter of 2020-2021 is any indication, spikes will continue to occur as Americans gather together indoors more frequently and return from holiday travel. A few states have already placed restrictions on scheduling elective procedures and more are likely to follow suit.
By combining shared experiences of health systems around the world with cutting edge technologies, it is possible to make this crisis manageable for perioperative leadership and potentially, improve upon the pre-existing models for managing OR time.
This two-part blog series will examine the steps that are most integral in preparing for potential restrictions. The first step is to have a case prioritization process in place. Choosing a system with strong academic support will help to reduce the influence of intra-hospital politics from derailing the process before it begins. This post explores best practices for surgical case prioritization and provides an analysis of available models from around the globe. Part 2 of this series will examine the second step, incorporating a case prioritization process into surgical scheduling, while considering wait times and backlog volumes.
Why you should prioritize surgical cases
If your hospital’s mix of surgeons perform time-sensitive procedures and patient quality of life outcomes are substantially impacted, it is important to ensure there is adequate capacity to address higher urgency cases within a reasonable timeframe. This allows cases in the backlog to be balanced against future cases yet to be scheduled, and will help to optimize the flow of patients through the OR.
Surgical case prioritization best practices
A prioritization model must be a tool hospital staff, surgeons, and schedulers are able to understand and willing to use. Models included below have demonstrated histories of success and are approachable for any hospital or health system of various sizes.
Another important consideration is balancing clinical urgency with inpatient capacity. Many of the most urgent cases will require inpatient recovery stay time, thus reducing bed availability for COVID-related admissions. Models factoring in wait time can support the balance between high and lower acuity cases.
Prominent surgical case prioritization models
Descriptive: SWALIS is a system based on the Italian Government’s case prioritization guidelines that solely take into account clinical urgency to assign a case one of five levels. Each priority level is associated with a maximum time before treatment (MTBT). This model is easy to understand and requires minimal administrative oversight, but it does not take into account other factors such as equipment needs and risk to the patient and hospital. This model is favored due to ease of implementation and clarity of the segmentation.
- “A model to prioritize access to elective surgery on the basis of clinical urgency and waiting time,” National Institutes of Health and Springer Link
Prescriptive: British Columbia Ministry of Health SPR, the model used in British Columbia, Canada, is similar to the Italian model in that it breaks cases into groups by clinical urgency. However, instead of the surgeon subjectively determining the priority level, this model prescribes a level based on the procedure. This system is especially effective if instructing prioritization methodology to clinic staff proves challenging, yet requires considerable time with decision-making and prioritizing each procedure, along with modifier considerations at the organization level.
- Patient Prioritization Codes (Interior Health, Canada)
- Surgery Wait Times (British Columbia)
- BC Patient Condition and Diagnosis Descriptions
Qualitative Patient Need: GSPT. New Zealand is one of the first countries to implement clinical priority assessment criteria (CPAC) nationwide. One CPAC tool being used is the General Surgery Prioritization Tool (GSPT). It uses a 0 – 100 scale for each case based on aspects of the impact on the patient’s quality of life and health to determine a relative priority.
- General Surgery Prioritization Tool: A pilot study (see appendix a.) Hunter, R.J., Buckley, N., Fitzgerald, E.L., MacCormick, A.D. and Eglinton, T.W. (2018), General Surgery Prioritization Tool: a pilot study. ANZ Journal of Surgery, 88: 1279-1283.
Qualitative Multi-Factor: MeNTS, published in the Journal of the American College of Surgeons, uses a mix of subjective and objective scores in different categories to create a cumulative score between 21 and 105. Higher scores equate to a greater risk to reward for the procedure. The process of scoring each case requires 21 factors to be rated on a scale of 1 to 5, making this best-suited to systems with strong administrative staff capable of evaluating each case.
- Medically-Necessary, Time-Sensitive Procedures: A Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic, Journal of the American College of Surgeons (2020). Prachand VN, Milner R, Angelos P, Posner MC, Fung JJ, Agrawal N, Jeevanandam V, Matthews JB.
Choosing the right surgical case prioritization model
The two most important factors to consider when adopting a prioritization model for your hospital or health system are consistency and compliance. Collaborating with physicians and service lines to establish appropriate priority levels creates understanding and alignment with hospital leadership and fosters consistency. It is also important to consider the model’s ease of use and amount of work required per individual case. New scheduling processes that increase staff workload may be half-heartedly complied with or ignored altogether. The SWALIS model addresses both factors, making it the favored model.
With little national or state-level guidance on this subject, each hospital organization has a great deal of leeway to choose a method that fits their unique needs. If you are having difficulty in choosing a path forward, LeanTaaS can help. Contact us at email@example.com to continue the conversation.
The next step: translating priority scores into surgical scheduling
Once case prioritization is established, perioperative leaders must balance it with considerations of patient wait time and overall backlog volume. Look out for a further post, “Managing surgical wait times in the intra-COVID world: part 2”, to discuss this problem, and its solutions, in more detail.
Below are useful academic resources discussing the importance and process of surgical case prioritization.
- COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures (American College of Surgeons)
- Curtis, A.J., Russell, C.O.H., Stoelwinder, J.U. and McNeil, J.J. (2010), Waiting lists and elective surgery: ordering the queue. Medical Journal of Australia, 192: 217-220. doi:10.5694/j.1326-5377.2010.tb03482.x
- Davis B, Johnson SR. Real-time priority scoring system must be used for prioritisation on waiting lists. BMJ. 1999;318(7199):1699. doi:10.1136/bmj.318.7199.1699
- Edwards RT. Points for pain: waiting list priority scoring systems. BMJ. 1999;318(7181):412–414.
- Mullen, P. M. (2003). Prioritising waiting lists: how and why? European Journal of Operational Research, 150(1), 32–45. doi:10.1016/s0377-2217(02)00779-8
- Testi BEc, E. Tanfani BEc, R. Valente MBBS, PhD, G. L. Ansaldo MBBS and G. C. Torre MBBS. Prioritizing surgical waiting lists. Journal of Evaluation in Clinical Practice. 2006; ISSN 1356-1294.
- Scoring system for NZ, GSPT