Issued: 4/29/2020
Traditionally, surgical procedure prioritization depends on illness acuity and resource
availability after shared decision making with patients. During an emergency such
as the COVID-19 pandemic, decisions must take into consideration new influences on
the safety of benign gynecologic procedures. Prioritization of patients must be fluid
as the pandemic waxes and wanes and is likely different in the peaks than the troughs
of infection incidence. At the peak of the infectious curve, all surgeries except
those that are a threat to life or limb are cancelled, as the risk to individuals
coming out of self-isolation is high and could overwhelm already taxed health care
resources. The trough represents a new normal, where the risk of COVID-19 infection
still remains, but at a diminished rate. In the trough, the risk of infection to
individuals scheduled for surgery must be weighed against the morbidity of their benign
condition. In this scenario, patients with severe comorbidities, or those who would
require rehabilitation or a skilled nursing facility after surgery should likely be
delayed until a vaccine or effective therapy is available. [If surgery cannot be
realistically postponed until a vaccine or effective therapy is available, when patients
are anticipated to need rehabilitation or a skilled nursing facility, counseling about
potential associated COVID infection with accompanying morbidity and mortality should
be a component of informed consent.] Between peak and trough, the decision to proceed
with surgery lies in between the two extremes. In the deceleration phase, liberalizing
restrictions should start with individuals with urgent conditions who are severely
affected by their gynecologic condition, weighed against their underlying health condition.
How to prioritize surgeries, weighed against the risk to patients of undergoing surgery
during a pandemic, has necessitated the development of tiered systems that can adapt
to quickly changing environments.
The American College of Surgeons (ACS) developed several tiered ranking systems for
prioritization of surgeries. (1,2) The first scale outlines how an institution should
prioritize staffing and utilization of resources and ranges from “Alert” to “Condition
Zero” based on the number of patients with COVID-19 who are admitted to the hospital.
The second scale is the “Elective Surgery Acuity Scale”. This is a tiered scale ranging
from 1-3; the first tier are elective surgeries, the middle tier are urgent surgeries,
and the third tier are emergency surgeries. Each tier is further dichotomized into
patients with and without significant comorbidities. Similar to the ACS tiered response,
Goldman et al, described a tiered system ranging from “0”, emergency surgeries and
outpatient procedures that should be performed at the peak of the curve to “4”, non-essential
surgeries that can be delayed until the threat of infection has subsided for urologic
procedures.(3) In addition, there has been a publication by Weber LeBrun et al. that
outlines the initial response to the COVID pandemic, but does not follow the ACS tier
system.(4)
We have adapted the ACS tiered ranking list to develop guidance for urogynecologic
and benign gynecologic surgeons. (Figure 1
) The system is meant to help surgeons and their health care systems decide who should
go to the operating room as the pandemic unfolds and does not list all elective surgeries
in each tier. This guidance is not meant as a substitute for clinical judgement of
an individual surgeon and the process of shared decision making with patients. This
is particularly important for women with medical comorbidities in whom increased exposure
to infected individuals outside the home outweighs the urgency of their gynecologic
condition. Continued use of telemedicine to address symptom management while surgery
is delayed may be helpful.
Figure 1
Modified Elective Surgery Acuity Scale (mESAS) for Benign Gynecologic Indications
and Surgeries
*Tier “b” indicates patients with complicated medical conditions that, in the environment
of COVID-19, may place them at high risk for ICU admission and increased perioperative
morbidity and mortality. This will likely affect the order of prioritization of individuals
for surgery. For example, in an environment where we are just opening surgical suites,
we may determine that even though the acuity of the surgical problem is high, that
the tier 3b women would not go to surgery prior to the tier 2a women. On the other
hand, when the risk of COVID morbidity and mortality is lower, a tier 3b woman might
go ahead of tier 2a woman who is healthy. Ranking of the tiers is dependent on the
COVID environment.
AMH: anti-mullerian hormone; ASC: ambulatory surgery center; AUB: abnormal uterine
bleeding; CPP Chronic pelvic pain; EIN: endometrial intra-epithelial neoplasm; LARC:
long-acting reversible contraception; MUS: midurethral sling; SIS: saline infusion
sonography; SAB: spontaneous abortion; TOA: tubo-ovarian abscess; TVUS: transvaginal
ultrasonography; PMB: postmenopausal bleeding; UDS: urodynamics; EMB: Endometrial
biopsy; UTI: urinary tract infection.
Figure 1:
In addition, we have applied the tiered system to outpatient procedures. (Figure 2
) All decisions should be made in the context of local and state directives. Many
places across the globe have been in the “Condition Zero” level of planning where
all but emergency surgeries are cancelled, regardless of the prevalence of COVID-19
cases in a specific area. As we approach reopening surgical services to women with
non-emergent surgical problems, a new calculus is needed. The tiered system must
take into account the patient's gynecologic condition, as well as their medical comorbidities,
and be able to adapt to changing conditions, as we re-open, and re-close, gynecologic
surgery services for women through the pandemic. Surgical technique and personal
protective equipment availability must also be considered.(5) Local disease prevalence
and reopening strategies may supersede this document and we defer to clinical decision
making in coordination with other local resource considerations.
Figure 2
Acuity Scale for Office-based Gynecologic Procedures
Figure 2:
CPP: Chronic pelvic pain; ISC: intermittent self-catheterization; IUD: intra-uterine
device; LARC: Long-acting, reversible contraception; LEEP: Loop electrosurgery excision
procedure; PTNS: percutaneous tibial nerve stimulation; SIS: saline infusion sonography;
TVUS: transvaginal ultrasonography; UDS: urodynamics
References
1
American College of Surgeons. COVID-19: Guidance for Triage of Non-Emergent Surgical
Procedures. https://www.facs.org/covid-19/clinical-guidance/triage. Accessed 21 April
2020.
2
Ross SW, Lauer CW, Miles WS, Green JM, Christmas AB, May AK, Matthews BD. Maximizing
the calm before the storm: a tiered surgical response plan for COVID-19. Am J Coll
Surg. 2020. Epud ahead of print.
3
Goldman HB, Haber, GP. Recommendations for Tiered Stratification of Urologic Surgery
Urgency in the COVID-19 Era. J Urol. 2020. Epub ahead of print.
4
Weber LeBrun EE, Moawad NS, Rosenberg EI, Morey TE, Collins WO, Smulian JC. COVID-19
Pandemic: stage management of surgical services for gynecology and obstetrics. AJOG.
2020. Epub ahead of print.
5
A Message from the SRS and ASRM Regarding Surgery During the COVID-19 Pandemic.https://www.asrm.org/news-and-publications/news-and-research/announcements/a-messagefrom-the-srs-and-asrm-regarding-surgery-during-the-covid-19-pandemic/
6
Joint Statement on Abortion access during the COVID-19 Outbreak. ACOG, ABOG, AAGL,
AGOS, ASRM, SASGOG, SFP, and SMFM. 18 March 2020. https://www.acog.org/news/news-releases/2020/03/joint-statement-on-abortion-access-during-the-covid-19-outbreak.
Accessed 22 April 2020.
Filed under "COVID-19, News, Press Releases/Statements".