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This document is for perioperative staff and contains guidelines for assessing all non-leveled surgical cases at Duke Health hospitals and surgery centers. Uploaded 03.21.20

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Dear Perioperative Colleagues,

PLEASE READ THIS CAREFULLY AND IN ITS ENTIRETY.

After extensive discussion with many surgical leaders around the country, in various viral status areas, thorough review of the American College of Surgeons COVID guidelines, consultation with DUHS executive leadership, and direct discussions with our surgical department chairs and site-specific Periop Executive Committee chairs, we are establishing the following guidelines for assessing operative case conduct.

For all non-leveled cases we will institute:

  • 48-hour Advance Elective Surgery Evaluation
    • All elective cases will be reviewed by the Department Chair or Chair designee(s) regarding patient-specific needs and case urgency, and reported to the Surgeon-in-Chief. Classification of cases as:
      • Canceled (cases are canceled without plans for rescheduling)
      • Indefinite postponement (cases canceled, but to be put in place for eventual rescheduling, without a medically necessary timeline)
      • Postpone, with priority for rescheduling within 30 days postponement (cases canceled, but to be put in place for rescheduling ASAP, with priority to be done within 30 days)
      • Proceed pending day of surgery capacity assessment (Cases that will NOT be canceled, but could be canceled if the situation changes rapidly; i.e. subject to same day assessment)
      • Priority proceed (Cases will NOT be canceled, and will have priority to be conducted with levels cases)
  • The ICU, inpatient ward, PACU and ambulatory capacity, faculty, APP and house staff availability, and supply chain capacity, will be assessed by the site-specific Periop Exec triad leaders and anesthesia leads in collaboration with the site-specific COOs, and reported to the AVP perioperative services. Classification of services will be:
    • Capacity available (available capacity to augment the schedule and pull previously canceled cases forward)
    • Capacity constrained (capacity sufficient to deal with anticipated volume, but no excess capacity)
    • No capacity (cases will need to be canceled to satisfy capacity constraints)
  • Nursing and ancillary staff will be assessed by the site-specific AVP for nursing and reported to the System AVP for nursing. Classification of services will be:
    • Capacity available (available capacity to augment the schedule and pull previously canceled cases forward)
    • Capacity constrained (capacity sufficient to deal with anticipated volume, but no excess capacity)
    • No capacity (cases will need to be canceled to satisfy capacity constraints)
  • The system triad (Surgeon-in-Chief, System Periop AVP and System AVP for Nursing) will proceed with finalizing schedules based on the 48-hour advanced assessments. During this time, system assessments can be made to shift volume or adapt to system needs.
  • Day of Surgery
    • Sites should proceed with the schedule as posted unless otherwise notified.
    • A “go/no-go” call will be held each morning to evaluate the final schedule at 6AM. This will involve the Periop System Triad, the site-specific Periop Exec Triad leaders and anesthesia leads, and the site-specific COOs. Any adjustments to the schedule based on changing logistical or medical concerns will be made at this time, and results of that call will be implemented by site-specific Periop Exec Triad leaders and anesthesia leads.
    • Add-ons will be made during the day based on the current leveling system.

This approach will allow day-by-day, data-driven assessment of the changing risk-benefit analysis that will influence our clinical care delivery for the foreseeable future. It will allow an ability to take into consideration the expert opinion from our front-line faculty and staff, as well as our site-specific leaders, and facilitate granular understanding of the medical and logistical issues that will alter our ability to deliver the best care possible.

Of note, we will not be classifying cases with a blanket term “elective,” as this does not recognize the broad spectrum of risk associated with cases that fall outside our leveling system. Also, we anticipate, based on current CDC and NIH projections, that COVID will be a factor in our area for at least 3 months. As such, simply canceling a case for people with progressive medical conditions will not make the cases go away, but rather increase the morbidity and mortality of the conditions when they represent. Finally, although COVID is a clear risk to all, it is but one of many competing risks. Thus, we do not think it appropriate to assign cases solely based on COVID-associated risks, but rather to assimilate the entire picture for each case on each given day.

With this approach, prioritization based on medical necessity will be determined by physicians with sufficient subject matter expertise, and implementation based on the changing logistical and system- wide landscape will be conducted in a coordinated fashion with our Health System.

Thank you for your professionalism.

Allan

Allan D. Kirk, MD, PhD, FACS

Surgeon-in-Chief

Duke University Health System