key: cord-252833-0lb60y12
authors: Rusch, Valerie W.; Wexner, Steven D.
title: The American College of Surgeons Responds to COVID-19
date: 2020-07-14
journal: J Am Coll Surg
DOI: 10.1016/j.jamcollsurg.2020.06.020
sha: 
doc_id: 252833
cord_uid: 0lb60y12

nan

The COVID-19 pandemic abruptly and perhaps irrevocably changed the way we live, conduct our business affairs, and practice medicine and surgery. In mid-March 2020, as COVID-19

infections escalated exponentially across many areas of the US, the Centers for Disease Control (CDC), the Surgeon General and the American College of Surgeons (ACS) recommended that hospitals and surgeons postpone non-urgent operations in order to provide care to COVID-19 patients. [1] [2] [3] It quickly became obvious that the COVID-19 pandemic presented unprecedented medical challenges. ACS leadership including the Board of Regents and Officers (Appendix) worked with the ACS Executive Director (Dr David Hoyt) and staff to rapidly organize a response to the COVID-19 crisis. The aim of this effort was to support ACS members and Fellows, as well as the broader medical community, in continuing to provide optimal patient care. Because other similar public health crises could arise in the future, we report the measures taken by the ACS to respond to the COVID-19 pandemic.

As the COVID-19 pandemic spread rapidly from Asia to Europe and on to North America, a lack of national preparedness became obvious in many countries, including the US. One of the most urgent needs was the rapid dissemination of accurate information regarding the care of COVID-19 patients. Physicians and surgeons were initially forced to confront an overwhelming medical crisis via informal electronic exchange of anecdotal experience. Therefore, the ACS leadership convened a COVID-19 Communications Committee (CCC) to provide timely, relevant and comprehensive information through an ACS COVID- 19 

One of the first and most important ACS initiatives was the creation of guidelines for the selection of patients needing urgent operations (including some cancer procedures) during the immediate, temporary suspension of non-urgent surgery. The ACS worked with surgical leaders across disciplines and throughout the country to create appropriate guidelines that were quickly referenced by the Centers for Medicare and Medicaid Services (CMS), and many surgical societies and health care systems. [1] [2] [3] [4] As the COVID-19 pandemic started to wane in May 2020, a similar process was undertaken to create guidelines for the safe resumption of elective surgery, again accompanied by close communication with CMS. [5] [6] [7] [8] In addition to inclusion in the Bulletin and posting on the ACS website, dissemination of these guidelines was amplified through webinars, and press releases and interviews.

Starting in mid-March 2020, each Division of the ACS rapidly undertook specific measures to respond to the COVID-19 pandemic. Although space precludes discussion of all of these activities, we highlight some of them here.

The indefinite and immediate national curtailment of non-urgent surgery had a dramatic financial impact on many practices which was most acutely felt by surgeons in private practice. At the suggestion of one of the Regents (Dr James Elsey), a Practice Protection Committee (PPC, Appendix) was established to collaborate closely with the staff of the ACS Washington DC office, to advocate for support of surgical practices and provide fellows with accurate and up-todate information. The PPC meet weekly by video conference to identify critical advocacy issues and information that needed to be disseminated to ACS Fellows, including insurance coverage for telehealth services, financial assistance programs for surgical practices, questions to consider in consulting tax advisors, and accommodations for student loan forgiveness. The PPC was instrumental in selecting topics to be included in the Bulletin and also led a webinar (attended by 250 surgeons) in mid-April to provide education to surgeons on financial issues.

As they do every day, staff from the ACS Washington DC office played an essential role in advocating for the support of surgical patients and practices through regular communication with CMS and nearly daily communication with the White House COVID-19 Task Force. With the approval of ACS leadership, they submitted on behalf of the Surgical Coalition (a large group of surgical societies) several letters to Congress regarding federal financial assistance programs and legislative initiatives that were key during the COVID-19 crisis. 

Cancer Programs The ACS Cancer Programs including the Commission on Cancer (CoC) played a pivotal role in responding to the COVID-19 pandemic. Cancer patients faced the dual risk of having their cancer diagnosis and treatment delayed and, as a highly vulnerable population, of contracting COVID-19. Through its multidisciplinary membership, the CoC was able to rapidly develop disease-specific guidelines for triaging cancer patients for treatment and to define what elements in cancer staging and care could be modified to reduce the risks of COVID-19 infection. 18 As noted above, these guidelines were posted on the ACS website and immediately disseminated through multiple media channels and webinars, each of which were attended by 250 to 1,000 interactive participants. The CoC emphasized that the immediate needs of cancer patients during the pandemic should take top priority and that most cancer operations could not be considered "elective" or non-urgent. The CoC, which is responsible for accrediting approximately 1500 cancer centers across the US, specified that centers should not be held accountable for practice deviations implemented to protect patients from COVID-19. Similarly, as the incidence of COVID-19 started to wane in late April 2020, the CoC drafted guidelines for the progressive resumption of more elective cancer care. 19 

As the COVID-19 pandemic developed across the US and most health care institutions banned professional travel, the COT made the difficult decision to convert the annual spring COT meeting and the ATLS (Advanced Trauma Life Support) Global Symposium to virtual meetings.

The COT made special accommodations to support trauma centers including a one-year extension of all trauma center verifications and a delay in the deadlines for data submission to the Trauma Quality Improvement Program (TQIP). The COT also provided access to the ATLS and ASSET (Advanced Surgical Skills for Exposure in Trauma) videos and educational materials for just-in-time trauma training for surgeons who were deployed to cover trauma calls. The second focus of COT was to provide resources to support trauma systems. With help from members of the COT Disaster Committee and Trauma Systems Committee, a guidance document was published to support trauma medical directors in maintaining trauma center access and care during the pandemic. 20 To ensure that governmental and healthcare system leaders understood the importance of preserving the trauma system and the need for regional coordination to support the distribution of patients and resources among hospitals, the COT published a statement on the importance of these issues 20 which was then widely distributed through state and federal advocacy teams.

Modeled on experience in South Texas and Washington state, the COT developed a guidance document for setting up a regional medical operations center and worked closely with the FEMA (Federal Emergency Management Agency) Healthcare Resilience Task Force to promote this approach and identify potential sources for funding. The infrastructure described in this document 21, 22 not only supported the ability to manage the surge of COVID-19 pandemic patients but also the healthcare system's response to future outbreaks and mass casualty events.

In addition, the COT worked with trauma registry vendors and TQIP participants to collect confirmed and suspected COVID-19 cases via ICD-10 diagnosis codes in order to understand the impact of pandemic on trauma care and account for those challenges when conducting riskadjusted benchmarking.

The regional structure of the COT in every US state and Canadian province and many countries worldwide, provides an opportunity for lessons learned to be shared around the globe.

For example, a webinar for the trauma health system in Saudi Arabia presented by Dr Eileen Bulger, Chair of the COT, on the ACS guidelines garnered 3,900 attendees and the New York City COT shared a summary of their lessons learned through the ACS website.

The ACS Division of Research and Optimal Patient Care houses all the Quality Improvement programs in the ACS, which include all the verification/accreditation programs as well as all the clinical data registries (eg NSQIP and TQIP). Given the several decades of experience in creating and maintaining clinical data registries, the ACS leaders decided to address the paucity of COVID-related data by collecting data, with the overarching goal to support a better understanding of COVID-19.

Several clinical data developments at the ACS during the pandemic were achieved -both in the current ACS registries, and also the development of a new registry, aptly named the ACS COVID-19 Registry. The following is a brief description of the achievements, which were described and messaged through the ACS Newsletter. Importantly, there was a substantial response by hospitals who subsequently registered to participate in the registries.

The purpose of this newly developed registry was to collect key data on all COVID-19 patientsboth non-operative and operative patients. It was developed with the input of several expert clinicians at several sites in different "hotspots" who were in the midst of treating COVID-19

patients. In addition to patient demographics, variables were designed to allow ease of data collection and based on relevant severity predictors, admission information, hospitalization information, therapies used, discharge information, as well as other factors. All patients ages 18 and older were eligible. Data were collected from hospital admission through discharge.

Participation in the registry is free of charge. All hospitals worldwide were invited to participate. At the time of this writing, the registry was released and hospitals have joined and are collecting data. We continue to communicate with health care providers and facilities through the Newsletter to provide registry updates and to invite more to join in this important initiative.

The ACS houses several registries (NSQIP, TQIP, MBSAQIP, Peds NSQIP, NCDB). By way of an example, the National Surgical Quality Improvement Program (NSQIP) is a risk adjusted outcomes clinical data registry. It provides amongst the most accurate risk-adjusted surgical outcomes. The inpatient and post discharge surgical outcomes of COVID patients across settings remains largely unknown. Hence it was decided to add a COVID variable into the programthus a risk adjusted (including COVID) outcome may be evaluated and benchmarked. This will be important given the single institution publications that have reported high mortality and complication rates. In addition to NSQIP, other ACS registries are also adding COVID related variables. Given the rigor and high-level accuracy of data collection in the ACS registries, we hope important data will be collected that will help in our diagnoses, treatments, and decisionmaking for these patients. As with the COVID-19 Registry, communicating the COVID relevance of the current ACS registries through the Newsletter was important for the readership to know and understand -both in terms of participation, but also in terms of understanding some of the important things the ACS and its membership are performing to combat this pandemic.

The ACS has a long history of partnering with the US military. In 2014, the ACS and US Department of Defense (DOD) created a formal relationship designed to bring lessons learned from military conflicts to the civilian sector and to assist military personnel in maintaining surgical readiness between times of conflict. An excellent example of this collaboration was the DOD's response in deploying 1,000-bed hospital ships to New York City and Los Angeles and in building mobile field hospitals in multiple cities including New York, Chicago, New Orleans and Hartford. In addition, military medical teams provided care in civilian hospitals. 23 Conclusions Through an intensive and cohesive group effort by ACS staff, leadership and Fellows, the College has successfully managed the unprecedented challenges of the COVID-19 pandemic and supported its members in continuing to provide high quality patient care. The response by the ACS was multifaceted but was based first and foremost on providing surgeons around the world a single source of easily accessible and highly reliable information. In the US, the ACS also served as a steadfast advocate for surgeons' practice needs at the state and federal level and for measures aimed at supporting optimal patient care. This approach provides a template for managing future such crises should they arise.

All crises of this scope offer opportunities for learning and behavioral change. In the remarkably short span of 6 months, the world changed radically. The COVID-19 pandemic has irrevocably opened opportunities for working remotely via electronic platforms including, telemedicine, a greater ability to work from home, to hold even large meetings electronically, the expansion of virtual methods for training surgeons, and virtual site visits for programs needing ACS accreditation / verification. In the midst of stress, loss and grief, there are also many future opportunities which the ACS is now striving to bring to fruition.

Appendix.

Factsheet: State action related to delay and resumption of "elective" procedures during COVID-19 pandemic

COVID-19: Recommendations for management of elective surgical procedures

COVID-19: Guidance for triage of non-emergent surgical procedures

Coronavirus updated: New information on elective surgery, PPE conservation and additional COVID-19 issues

CMS releases recommendations on adult elective surgeries, non-essential medical, surgical, and dental procedures during COVID-19 response

Healthcare Facility Guidance: Summary of recent changes

Joint statement: Roadmap for resuming elective surgery after COVID-19 pandemic

Association of American Medical Colleges. Important guidance for medical students on clinical rotations during the coronavirus (COVID-19) outbreak

Accreditation Council for Graduate Medical Education

Additional education: Cross-specialty summit on the impact of COVID-19 pandemic on surgical training

Emergency restructuring of a general surgery residency durng the coronavirus disease 2019 pandemic: The University of Washington experience

Orthopaedic education during the COVID-19 pandemic

Pracitcal implications of novel coronavirus COVID-19 on hospital operations, board certification, and medical education in surgery in the USA

Doctors and nurses are already feeling the psychic shock of treating the coronavirus

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

The mental health consequences of COVID-19 and physical distancing. The need for prevention and early intervention

The American College of Surgeons. COVID-19 guidelines for triage of cancer surgery patients

ACS guidelines for triage and management of elective cancer surgery cases during the acute and recovery phases of coronavirus disease 2019 (COVID-19) pandemic

American College of surgeons Committee on Trauma. Maintaining trauma center access and care during the COVID-19 pandemic: Guidance document for trauma medical directors

Assistant Secretary for Preparedness and Response. Establishing medical operations coordination cells (MOCCs) for COVID-19

Federal Emergency Management Agency (FEMA)

letter to emergency managers requesting action on critical steps

How to partner with the military in responding to pandemics -a blueprint for success