key: cord-310288-onr700ue
authors: Sciubba, Daniel M.; Ehresman, Jeff; Pennington, Zach; Lubelski, Daniel; Feghali, James; Bydon, Ali; Chou, Dean; Elder, Benjamin D.; Elsamadicy, Aladine A.; Goodwin, C. Rory; Goodwin, Matthew L.; Harrop, James; Klineberg, Eric O.; Laufer, Ilya; Lo, Sheng-Fu L.; Neuman, Brian J.; Passias, Peter G.; Protopsaltis, Themistocles; Shin, John H.; Theodore, Nicholas; Witham, Timothy F.; Benzel, Edward C.
title: Scoring system to triage patients for spine surgery in the setting of limited resources: Application to the COVID-19 pandemic and beyond
date: 2020-05-29
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.05.233
sha: 
doc_id: 310288
cord_uid: onr700ue

Abstract Background As of May 04, 2020, the COVID-19 pandemic has affected over 3.5 million people and touched every inhabited continent. Accordingly, it has stressed health systems the world over leading to the cancellation of elective surgical cases and discussions regarding healthcare resource rationing. It is expected that rationing of surgical resources will continue even after the pandemic peak, and may recur with future pandemics, creating a need for a means of triaging emergent and elective spine surgery patients. Methods Using a modified Delphi technique, a cohort of 16 fellowship-trained spine surgeons from 10 academic medical centers constructed a scoring system for the triage and prioritization of emergent and elective spine surgeries. Three separate rounds of videoconferencing and written correspondence were used to reach a final scoring system. Sixteen test cases were used to optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high-priority elective, or low-priority elective scheduling. Results The devised scoring system included 8 independent components: neurological status, underlying spine stability, presentation of a high-risk post-operative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations, and local disease burden. The resultant calculator was deployed as a freely-available web-based calculator (https://jhuspine3.shinyapps.io/SpineUrgencyCalculator/). Conclusion Here we present the first quantitative urgency scoring system for the triage and prioritizing of spine surgery cases in resource-limited settings. We believe that our scoring system, while not all-encompassing, has potential value as a guide for triaging spine surgical cases during the COVID pandemic and post-COVID period.

every inhabited continent. Accordingly, it has stressed health systems the world over leading to 4 the cancellation of elective surgical cases and discussions regarding healthcare resource 5 rationing. It is expected that rationing of surgical resources will continue even after the pandemic 6 peak, and may recur with future pandemics, creating a need for a means of triaging emergent and 7 elective spine surgery patients. 8 9

Methods 10

Using a modified Delphi technique, a cohort of 16 fellowship-trained spine surgeons from 10 11 academic medical centers constructed a scoring system for the triage and prioritization of 12 emergent and elective spine surgeries. Three separate rounds of videoconferencing and written 13 correspondence were used to reach a final scoring system. Sixteen test cases were used to 14 optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high-15 priority elective, or low-priority elective scheduling. 16 17

Results

The devised scoring system included 8 independent components: neurological status, underlying 19 spine stability, presentation of a high-risk post-operative complication, patient medical 20 comorbidities, expected hospital course, expected discharge disposition, facility resource 21 limitations, and local disease burden. The resultant calculator was deployed as a freely-available 22

web-based calculator (https://jhuspine3.shinyapps.io/SpineUrgencyCalculator/). 23 24

Conclusion 25

Here we present the first quantitative urgency scoring system for the triage and prioritizing of 26 spine surgery cases in resource-limited settings. We believe that our scoring system, while not 27 all-encompassing, has potential value as a guide for triaging spine surgical cases during the 28 COVID pandemic and post-COVID period. 29 in acute respiratory distress syndrome (ARDS) and/or death. 1, 2 Since that time it has spread 4 rapidly to affect nearly every country, placing significant stresses on the global healthcare 5 system. 3 In order to mobilize resources to combat this pandemic, the Centers for Medicare and 6

Medicaid Services (CMS), 4 the Centers for Disease Control and Prevention (CDC), 5 and multiple 7 professional organizations 6,7 recommended the cancellation of elective surgical procedures. In 8 spite of this, it was recognized that there were cases, many of them neurosurgical, which required 9 urgent or emergent intervention to minimize patient morbidity and maximize the chances of an 10 optimal outcome. 8 In response, several centers have presented frameworks for the management 11

of neurosurgical patients presenting during the COVID-19 pandemic. [8] [9] [10] [11] Additionally, a triage 12 scoring system has been previously developed in an attempt to guide spine surgery consults. 12,13 13 However, to date, there has not been a systematic, multi-institutional scoring system that 14

includes resource availability and disease burden to aid in triaging spine surgery patients during 15 this crisis. Though certain symptoms referable to chronic spinal conditions may not necessarily 16 be life threatening, these can cause significant pain and disability prompting the challenge of 17 determining who and when to operate in times of crises. 18 19 It is recognized that effective triaging of these cases in the post-COVID era will be essential to 20 prevent the healthcare system from being overwhelmed by the backlog of elective spinal cases 21 that have been deferred because of the COVID-19 pandemic. [14] [15] [16] Recently, a scoring system 22

aimed at triaging such cases has been published in the general surgery literature, 17 however no 23 comparable system has been described for spine patients. Here we present an applicable example 24 of such a system assembled based upon input by a multi-institutional collaboration. This scoring 25 system is designed to assist in two ways. First, it may assist spine surgeons and administrators 26 with triaging surgical patients during the COVID-19 pandemic. Second, the scoring system may 27

help health systems triage elective cases in the post-COVID crisis, which is likely to also see a 28

relative shortage of surgical resources and has been described by some as a potential collateral 29 pandemic. 15 30 31 Methods 32

Scoring System Development 33

To generate this scoring system, the first author proposed an a priori scale highlighting those 34 elements thought to be pertinent to the triaging of an operative spine patient in the setting of 35 limited resources. The elements applicable to the spine patient included the patient's current 36 neurological status (rapidity of progressive, severity), the presence of underlying spinal 37 instability, and radiographic evidence of neural element compression. Several general elements 38

were added that could be used to triage any surgical patient, including general patient 39 health/comorbidities, expected resource utilization, current resource availability, and local 40 disease burden. Medical comorbidities were pulled from the Charlson Comorbidity Index 18 and 41 from previously published series describing comorbidities associated with increased symptom 42 severity in patients infected with the SARS-CoV-2 virus. 2, [19] [20] [21] [22] [23] After identifying these elements, 43

weights were initially assigned based on input from surgeons at the lead institution using a 44 modified Delphi approach that included both neurosurgical and orthopaedic spine surgeons. 45

Component weighting of the preliminary scale was tested using ten example spine patients, 46 3 testing the assessed urgency of the patient as determined by the scoring system against the 47 consensus opinion of the group of surgeons. 48 49

After identifying a preliminary scoring system, a multi-institutional group was convened, 50

including neurosurgical and orthopaedic spine surgeons from multiple institutions with varying 51 levels of experience. A modified Delphi approach was again used to alter the weights assigned to 52 the categories to refine the preliminary score. Three rounds of written communication, polling, 53

and electronic teleconferencing sessions were used to solicit input. Example cases were again 54 devised to test the degree of agreement between the scoring system and the consensus opinions 55

regarding the urgency of the hypothetical patient's issue (Supplemental Data). The final scoring 56 system was then deployed as a freely available, web-based calculator (Figure 1 ; 57 https://jhuspine3.shinyapps.io/SpineUrgencyCalculator/). 58 59

Details of the multi-institutional panel 60

The study group was comprised of 16 spine surgeons representing 12 the degree of impairment that their deficit causes in ambulation or the ability to perform 75 activities of daily living (ADL). 76 77

The scoring system runs from -19 (lowest priority elective case) to 91 (highest priority emergent 78 case) and classifies cases as "emergent," "urgent," "high-priority elective," or "low-priority 79 elective" as identified in Table 2 . Additionally, in they have not provided an algorithm for the prioritization of such cases in the setting of potential 106 resource shortages. Here we present a scoring system devised by a multi-institutional 107 collaboration that aims to assist with these triage issues. The ability to assist with both 108

populations is a strength of this scoring system, which we feel may be a useful tool for health 109 systems both during the COVID pandemic and in the post-crisis period, as they struggle to 110

accommodate the large volume of non-emergent surgical cases. Additionally, though we hope 111 such a need does not arise, the present scoring system could also have value in the triaging of 112 patients if a "second wave" of the coronavirus pandemic occurs, which may lead to further 113 resource limitations. 26 Such a wave occurred during the 1918 Spanish influenza pandemic 27 and 114 many experts have speculated that a similar phenomenon could occur during the present 115 pandemic. 26, 28 Furthermore, the framework of the proposed scoring system could apply to future 116 pandemics where healthcare resources are similarly stretched as the current COVID-19 117

pandemic. 118 119

Prior examinations of triaging in neurosurgery 120

There have been several broad descriptions of triage strategies presented in the neurosurgical 121 literature, 29, 30 and guidelines from the American College of Surgeons (ACS) currently divide 122 surgeries into five levels based upon apparent acuity. 11 However a large proportion of spinal 123 cases require emergent or urgent addressal 29 In addition to a perceived lack of granularity, neurosurgical triage systems published in the pre-130 COVID era have predominately focused on emergent surgical issues. Triage amongst non-131 emergent cases has been largely overlooked. One exception to this is the "Accountability for 132

Reasonableness (A4R)" framework described by Ibrahim and colleagues 32 to emphasize 133 scheduling fairness and minimize operating room downtime at an academic center seeing a 134 mixture of emergent and elective cases. Unlike the present scoring system however, their 135 framework was purely qualitative -triaging was performed by a single stakeholder without an 136 obvious means by which surgical cases were ranked. Another exception is the Calgary Spine 137 Severity Score proposed by Lwu et al. 12 that assessed spine referrals based on the clinical, 138 pathological, and radiological aspects. Similar to the A4R framework, however, this score was 139 not intended for implementation in the setting of a crisis or the acute resource shortages that are 140 expected in the post-COVID era. 15 constituted an urgent case, namely a surgical issue requiring treatment within 2 weeks that was 155 not identified in the emergency list. Elective cases were similarly identified as all cases that did 156 not fall into the above two categories. Unlike the system presented here, however, no formalized 157 system was identified for the prioritization of cases within the urgent or elective categories. Neuro-Oncology (SNO) made recommendations to prioritize adjuvant therapies (e.g. 167 chemotherapy and radiotherapy) over earlier surgical intervention for spinal and intracranial 168 malignancies, as this will decrease the risks posed by hospitalizing oncologic patients in the 169 same facility as COVID-19-positive patients. 33 However, the groups acknowledge that this is not 170 always possible, and that care deferral may cause some elective cases to progress to the point of 171

requiring urgent operative management. The European Association for Neurosurgical Societies 172 has attempted to address the question of how to prioritize elective neurosurgical cases through an 173 "Adapted Elective Surgery Acuity Scale." Unfortunately, while this scale provides some 174 guidance, the three tiers it employs are quite broad and there are no guidelines for prioritizing 175 cases within a category or a given diagnosis (e.g. "degenerative spinal pathology"). 34 176

Consequently, we feel the need for a means of triaging both emergent and elective spine cases 177 remains unmet. 178 179

While there have been several general frameworks highlighting those cranial pathologies 180 requiring emergent management, 8, 10, 11 there has only been one description of a framework for 181 triaging emergent spine surgeries. 25 Derived from the experiences at a single Italian center tasked 182

with treating cord compression and spinal instability, the framework of Giorgi and colleagues is 183 a care pathway intended to expedite the identification, treatment, and safe discharge of patients 184 with spine emergencies. Priority within the system was based upon American Spinal Injury 185

Association (ASIA) grade and radiographic evidence of instability. Though good results were 186 described for the 19 patients treated under the framework, the pathway is non-quantitative and 187 seemingly lacks the granularity to prioritize between two or more emergent patients. Similarly, it 188

is not equipped to triage non-emergent cases. 189 190

A more quantitative approach was described by Jean and colleagues 35 based upon nearly 500 191 respondents to an internet survey, asking respondents to assign an urgency score to each of nine 192 hypothetical cases. The authors found mild-to-moderate agreement regarding the extent of 193

surgical urgency for each case (range 22.8-37.0%), however, their "acuity index" was simplistic 194

in that it was based solely upon the perceived case risk and case urgency assigned to it by 195 respondents. Case risk was graded on a 1 to 4 scale ("no risk" and "cannot postpone") and case 196 urgency on a 1 to 5 scale ("leave until after the end of the pandemic" and "case already done"). 197

The scale itself did not incorporate neurological status, patient comorbidities, or local resource 198 limitations, all of which are likely to influence the timing of operative management. Because of 199 this lack of granularity, it is unclear that this "acuity index" can be generalized to other case 200 scenarios, thus limiting its potential utility relative to the multidimensional scoring system 201 described here. 202 203 204

Limitations 205

As with scoring systems published in other domains of neurosurgery, the present scoring system 206

is not intended to be prescriptive in its guidance. Rather, we present it as a potential tool to aid 207 surgeons and healthcare systems when triaging patients in times of national crisis or global 208 resource shortages. As with the triage frameworks presented to date, the present scoring system 209 is derived from expert opinions. Consequently, the scoring system is limited by the biases of the 210 surgeons recruited and their respective institutions. We attempted to address this by recruiting 211

surgeons at multiple levels of training, at academic centers spread across a large geographic 212 region subjected to varying COVID-19 burdens. Furthermore, by only including surgeons into 213 the decision-making process of the urgency of spine patients, there is potential that additional 214 points from the non-surgical and administrative personnel could have altered the final scoring 215 system. Additionally, in an effort to maximize the usability of the scoring system, it was 216 necessarily simplified and is consequently not all encompassing. For example, the broad term of 217 "new neurologic deficit" was included under the "High-Risk Postoperative Complication" 218 category, however, this leaves it up to the treating surgeon whether this new deficit is "high-219 risk". Therefore, while it can assist in determining surgical priority, final disposition should be 220 based upon the clinical judgment of the treating surgeon and institution. Nevertheless, we believe 221 that it can be an effective tool for informing clinical stakeholders as to how each patient's case 222 may be triaged at peer institutions. Our scoring system is also limited by the fact that it operates 223 on the assumption that the patient desires surgery at the same time recommended by the treating 224

surgeon. This is not always the case and the ultimate timing of surgery must therefore rely on an 225

in-depth discussion between provider and patient. Finally, the present scoring system was 226 devised with the COVID-19 pandemic in mind. Consequently, it could be argued that it may not 227 be applicable to other resource challenging situations, and future pandemics may limit resources 228

in a manner not assessed in the current work. However, we feel that the modular structure 229 employed could easily be adapted to other crises that cause a shortage of medical resources. 230 Therefore, the present system may have utility beyond the present crisis and any "second wave" 231 that may arise. 232 233

Conclusion 234

Here we present a scoring system for the triaging of spine surgery patients during times of crisis 235 and severe resource scarcity. Our system was developed by a multi-institutional panel using a 236

modified Delphi technique and has the potential to assist surgeons, hospital administrators, and 237

other clinical stakeholders in assigning priority to both emergent and non-emergent spine surgery 238

patients. While not intended to be prescriptive, this scoring system may prove useful as a guide 239 during both the COVID crisis and the post-COVID period to help prioritize patients with the 240 greatest surgical needs, though determining the urgency of an individual procedure should be left 241

to the operating surgeon. Additionally, we believe the modular structure of the scoring system 242 implies that it may potentially be adapted to other crises resulting in an acute shortage of medical 243 resources. 244 245 Tables  Table 1: Spine surgery urgency scoring system  Table 2 : Proposed timeframes for surgical treatment based upon urgency score Figure 1 . Screenshot of web-based calculator deployed based upon scoring system identified (https://jhuspine3.shinyapps.io/SpineUrgencyCalculator/) 0 Key: ADL -activity of daily living; ASC -ambulatory surgery center; d -day; hrhour; mo -month; SNF -skilled nursing facility; wk -week †Whether the complication requires surgical intervention or can be treated with nonoperative management is made at the discretion of the attending surgeon ‡Vital structures include spinal cord, esophagus, trachea, aorta, lung, §Medical comorbidities included: active malignancy, age >65, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, current cigarette or vape use, diabetes mellitus, history of myocardial infarction, interstitial lung disease, moderate-to-severe liver disease. Urgent (e.g. within 2 weeks) 10-14

High-priority elective (e.g. within 6 weeks) <10

Low-priority elective (e.g. delay until after COVID-19 crisis) Key: COVID-19 -Coronavirus disease 2019

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