key: cord-0855319-2koq6tyx
authors: Ramey, Wyatt L.; Hurlbert, R. John
title: COVID Contingencies: Resource Rationing on a Global Scale
date: 2020-09-28
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.08.108
sha: ab8348dcc367fb453f5ed08ef5d3c4041b4d6fcf
doc_id: 855319
cord_uid: 2koq6tyx

nan

Since the beginning of 2020 and its rapid spread across the globe, the COVID-19 pandemic has presented unique challenges to healthcare providers of all specialties (1) .

Hospitals, particularly in "hot zones," have been forced to reallocate both personnel and equipment to effectively combat the massive surge in cases that have overwhelmed many healthcare systems internationally. Spine surgeons have not been immune to the necessary procedures and policies put in place in order to limit patient risk and ration resources such as personal protective equipment (PPE) and ventilators. Algorithms have begun to emerge proposing to guide surgical urgency, weighing the presence-of or potential-for neurological compromise against system capacity in order to limit treatment in the face of a global pandemic (2, 3).

As capacity has become threatened at our institution, proposed surgeries are reviewed on a case-by-case basis by an oversight committee that designates level of acuity across surgical specialties. Relative to spine surgery and even under "Pre-COVID" circumstances, our urgent cases have been normally defined by the presence of an acute neurologic deficit or the risk of one if surgery is not provided in a timely fashion. This includes any combination of:

• progressive cervical or thoracic myelopathy It is well known that Italy was one of the hardest hit countries in the early stages of the international spread of COVID-19. The disease was more densely focused in the northern regions of Italy where the majority of confirmed cases affected individuals greater than 70 years of age, more often men than women, and was "severe" in a quarter of those affected (4).

Italy during the height of the disease and its inevitable effect on spine surgery and their healthcare system. Their strategy for quantifying available healthcare resources factors in doubling-time of the disease obtained from government data, and ICU capacity -which together determine an alert status of red, yellow, or green (high, medium, or low system stress). Similarly, they organize spinal conditions J o u r n a l P r e -p r o o f into categories of red, yellow, or green: Red = acute spinal cord and/or root compression; Yellow = chronic but progressive cord and/or root compression, intractable pain, impending deformity; and Green = absent or stable neurologic deficit, minimal or absent pain (3) . In this approach only surgical cases with the same or worse color-code as the healthcare alert status can be performed. For example, during "Green" system stress all types of spine surgeries are performed but during "Red" system stress only "Red" designated spine cases can be considered for surgery. This framework for enabling spine care is particularly clever in that it intuitively quantifies both system stress and the severity of spinal disease in an easy to use context, thereby providing objective decision criteria for surgeons and hospital administrators alike.

At the University of Arizona we developed a similar approach for spine surgeries, designating two levels of importance consisting of emergent/urgent (Tier II = acute or progressive neurologic deficit or impending deformity +/-intractable pain), and elective (Tier I = chronic or non threatening disease with normal or stable neurologic function). While our surgical oversight committee has a less quantifiable method for determining system stress, it more broadly looks at trends of cases seen in the region, positivity rates, number of beds and ventilators unoccupied, and the amount of PPE available to providers for the coming weeks.

These resources are re-evaluated weekly guiding whether or not surgical cases will be restricted to Tier II only, or if Tier I cases will be allowed to go forward. At the peak of oue COVID hospitalizations (June -July) surgical capacity was limited to 50% of normal; Tier I (elective) cases were put on hold for 6 consecutive weeks. course was relatively uncomplicated and he was discharged home. In both cases, consultation with infectious disease and internal medicine were critical in achieving a collaborative, multidisciplinary approach to treat the novel coronavirus acquired in spine surgery patients.

The novel coronavirus has fundamentally changed healthcare systems around the world and how all specialties practice medicine for now and the foreseeable future. Given the wide variability of spine pathologies ranging from emergent to elective and acute to chronic, spine surgeons in particular have had to adapt to the challenges presented by COVID-19. There is a great necessity to minimize stress on the healthcare system while keeping up with the number of our patients who need surgery, even if only elective. We commend Rispoli et al. for their exceptional dedication and commitment to both their own spine patients and those who benefitted from their strategic approach to prioritizing surgical treatment of spine pathologies in a time of regional crisis. Since Italy was one of the first epicenters outside of China, their work serves as a compelling example for how to treat spine patients in the midst of a pandemic.

Without a guarantee of an effective vaccine in the near future and a rising number of COVID-19 cases still in many areas around the world, developing a balanced, methodical strategy for the treatment of spinal disease patients during this pandemic is imperative. Close communication using a multidisciplinary, collaborative approach will maximize the ability of healthcare systems to simultaneously manage both the COVID-19 pandemic as a whole and the many patients who continue to need our care.

A pneumonia outbreak associated with a new coronavirus of probable bat origin

COVID-19 and Spinal Surgery J Neurosurg Spine

Spine surgery in Italy in the COVID-19 era: Proposal for assessing and responding to the regional state of emergency

Coronavirus disease 2019 (COVID-19) in Italy