key: cord-0845887-9kpapoie
authors: Waxman, Sergio; Garg, Aakash; Torre, Sabino; Wasty, Najam; Roelke, Marc; Cohen, Marc; Salemi, Arash
title: Prioritizing elective cardiovascular procedures during the COVID‐19 pandemic: The cardiovascular medically necessary, time‐sensitive procedure scorecard
date: 2020-06-26
journal: Catheter Cardiovasc Interv
DOI: 10.1002/ccd.29093
sha: 939791f20e366f54ac38ae33a2978a1047c27016
doc_id: 845887
cord_uid: 9kpapoie

BACKGROUND: Following the surge of the coronavirus disease 2019 (COVID‐19) pandemic, government regulations, and recommendations from professional societies have conditioned the resumption of elective surgical and cardiovascular (CV) procedures on having strategies to prioritize cases because of concerns regarding the availability of sufficient resources and the risk of COVID‐19 transmission. OBJECTIVES: We evaluated the use of a scoring system for standardized triage of elective CV procedures. METHODS: We retrospectively reviewed records of patients scheduled for elective CV procedures that were prioritized ad hoc to be either performed or deferred when New Jersey state orders limited the performance of elective procedures due to the COVID‐19 pandemic. Patients in both groups were scored using our proposed CV medically necessary, time‐sensitive (MeNTS) procedure scorecard, designed to stratify procedures based on a composite measure of hospital resource utilization, risk of COVID‐19 exposure, and time sensitivity. RESULTS: A total of 109 scheduled elective procedures were either deferred (n = 58) or performed (n = 51). The median and mean cumulative CV MeNTS scores for the group of performed cases were significantly lower than for the deferred group (26 (interquartile range (IQR) 22–31) vs. 33 (IQR 28–39), p < .001, and 26.4 (SE 0.34) vs. 32.9 (SE 0.35), p < .001, respectively). CONCLUSIONS: The CV MeNTS procedure score was able to stratify elective cases that were either performed or deferred using an ad hoc strategy. Our findings suggest that the CV MeNTS procedure scorecard may be useful for the fair triage of elective CV cases during the time when available capacity may be limited due to the COVID‐19 pandemic.

The coronavirus disease 2019 (COVID-19) global pandemic has created the need to put forth strategies to rationalize healthcare resources that extend to the catheterization laboratory setting. 1, 2 This is due to concerns regarding the availability of hospital beds and personal protective equipment (PPE), skilled personnel, the risk of COVID-19 transmission to patients and providers, and the need for hospitals to provide safe care for patients with and without COVID-19 infection concomitantly, which may further strain healthcare systems.

At the peak of the pandemic, federal and state orders limited the performance of elective procedures to conserve human and material resources. 3 Prachand et al. 4 used the term of medically necessary, time-sensitive (MeNTS) procedures to stress the fact that most outpatient surgeries and procedures are in fact, clinically necessary, and that the term "elective" usually refers to the timing of such procedures that can be "elected" without having a negative impact on the outcome of the procedure or the disease process, as opposed to urgent or emergent cases. They designed a scoring system to prioritize and triage surgical cases that are medically necessary but still elective, incorporating elements that reflect on the use of limited resources and risk of COVID-19 transmission. Although such a prioritization system would also be helpful in the Catheterization Laboratory setting, some of the variables used were not applicable to cardiovascular (CV) procedures, where other patient and procedural factors may be more relevant.

Having a triaging tool that can be applied specifically to CV procedures remains timely as government regulations and recommendations from professional societies have conditioned the resumption of elective procedures on the availability of strategies to prioritize cases. [5] [6] [7] We proposed and evaluated the use of a CV MeNTS procedure scoring system for standardized triage of procedures performed in the Catheterization Laboratory.

The study was approved by our Institutional Review Board. We retrospectively reviewed records of patients that were scheduled to have a CV procedure performed in the catheterization laboratory at two hospitals, Newark Beth Israel Medical Center (Newark, NJ) and Saint Barnabas Medical Center (Livingston, NJ) between April 15, 2020 and May 10, 2020. During this period, Executive Order 109 was in place in the state of New Jersey, 8 which directed the suspension of all adult elective surgeries and invasive procedures and applied to all medical and dental operations that could be delayed without undue risk to the current or future health of the patient, as determined by the patient's physician. Some of these patients underwent their procedures at the discretion of their physician after discussion with and approval by the respective directors of the catheterization laboratories and prioritized ad hoc to be performed during this period. Thus, we had two groups of elective patients: (a) those who had been scheduled but deferred (deferred group), and (b) those who had been scheduled and still allowed to proceed during this period based on perceived medical need and tolerable impact on resource utilization and risk of COVID-19 transmission.

We scored patients in both groups utilizing our proposed CV MeNTS procedure scorecard, which is designed to stratify procedures based on a composite measure of hospital resource utilization, risk of procedural complications and COVID-19 exposure and transmission to patients and staff, and time sensitivity and medical need. For purposes of our study, a comparison between deferred and performed groups would serve as proof of concept of the score's ability to stratify patients based on the composite measure above, and thus to be utilized as an objective prioritization tool if the demand for procedural services exceeds capacity due to the pandemic. 

The cumulative score for individual patients was reported as a continuous variable between 15 and 64 points as described above. Mean (SE) and median (interquartile range (IQR)) score values were calculated categorically (procedure, patient and disease factors) and cumulatively for both performed and deferred groups. Data were also stratified by type of procedure (i.e., cardiac catheterization, heart 

A total of 109 scheduled outpatient procedures were either deferred (n = 58) or performed (n = 51) during the study period. The types of procedures included electrophysiology (n = 23), cardiac catheterization (n = 39), endovascular (n = 18), heart failure (n = 17), and structural heart disease (n = 12). Table 1 

We report a CV MeNTS procedure scoring system that can be used to prioritize elective CV procedures during the COVID-19 pandemic based on a composite measure of resource utilization, risk of procedural complications and transmission of COVID-19 infection, and time sensitivity and clinical need. In our study population, the cumulative CV MeNTS procedure score was significantly lower in the group of elective cases that were performed compared with those that were deferred during a period of time when New Jersey's Executive Order 109 was in effect. 8 Our findings suggest that the CV MeNTS procedure scorecard may be a useful tool for the triage of elective cases during the time that many states in the country relax restrictions on the performance F I G U R E 3 Distribution of cumulative cardiovascular (CV) medically necessary, time-sensitive (MeNTS) procedure scores for deferred and performed cases. Cumulative CV MeNTS procedure scores were calculated for elective procedures that were either deferred (n = 58) or performed (n = 51) based on ad hoc prioritization. Median and mean cumulative scores were significantly lower in the performed group compared with the deferred group, demonstrating the utility of the CV MeNTS procedure score to stratify procedures according to the composite measure of resource utilization, risk of exposure to coronavirus disease 2019 (COVID-19), and time sensitivity based on medical indication

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Medically necessary, timesensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic

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Safe reintroduction of cardiovascular services during the COVID-19 pandemic: guidance from North American Society Leadership

Prioritizing elective cardiovascular procedures during the COVID-19 pandemic: The cardiovascular medically necessary, time-sensitive procedure scorecard

The authors declare no conflicts of interest.

https://orcid.org/0000-0001-6896-9211