Adult Cardiac Surgery During the COVID-19 Pandemic: A Tiered Patient Triage Guidance Statement



## Abbreviations and acronyms
Timely reprioritization can be considered given the dynamic nature of some patients with cardiovascular disease. Each individual patient should be given careful consideration, weighing risks and potential therapeutic alternatives, including medical treatment, catheter-based therapy, or even a recommendation to transfer to a center with lower COVID-19 penetrance and more available resources. Under these circumstances, it is important to recognize that regional competitors must now become collaborators.
Programs are encouraged to limit in-person clinic evaluations and testing for appropriately selected patients who can be safely deferred, understanding the uncertainty of the pandemic duration. Telephone and video visits should be incorporated for both new patient evaluations and postoperative assessments. As the morphology of the typical cardiac surgery practice evolves, program leaders must determine how to effective and safely "skeletonize" hospital and office staffing, including surgeons, advance practice providers, and administrative and clerical personnel, and in some cases, creating opportunities for team members to work from home. There should also be specific consideration to accommodate individuals at higher risk of COVID-19 because of advanced age or the presence of underlying health conditions.
As our surgical volume declines over the next several months, it is essential that the cardiothoracic surgical community maintains its commitment to the health and safety of its patients. While hospitals shift their focus to medical management of this outbreak, cardiac surgeons may feel uncertainty about their role. In addition to our expertise in the care of advanced cardiac disease, there will also likely be an expanded need for the use of extracorporeal membrane oxygenation, requiring cardiac surgical direction and partnership with the Extracorporeal Life Support Organization.We must continue to serve as leaders, experts, and members of our medical community, willing to play any role necessary in this time of need.

## Essential services deferred
All inpatients who cannot be discharged safely without surgical intervention/correction, including emergency services All patients who are outpatients Patients deteriorating while waiting would need to meet criteria for admission before consideration for surgery < Programs are encouraged to adopt a mechanism by which patients can be screened regularly to identify those having increased symptoms or progression of disease < Transcatheter interventions will follow the same recommendations < Alternative percutaneous therapies with rapid discharge from the hospital should be considered < Thoracic organ transplant guidance is provided by the United Network for Organ Sharing Asymptomatic outpatients and patients with anatomy and physiology suggesting delay can be provided with reasonable safety < Programs are encouraged to adopt a mechanism by which patients can be screened regularly to identify those having increased symptoms or progression of disease < Transcatheter interventions will follow the same recommendations < Alternative percutaneous therapies with rapid discharge from the hospital should be considered < Thoracic organ transplant guidance is provided by the United Network for Organ Sharing CAD, coronary artery disease. Only emergency services based on resource availability All inpatients judged to be stable and capable of waiting All outpatients < With extreme reductions in operative capacity, ability (or inability) to perform surgery should be evaluated in the case of emergent cases, and alternate arrangements at peer institutions with potential capacity should be sought < Thoracic organ transplant guidance is provided by the United Network for Organ Sharing
[table] Table 1: Guiding Statement for Patient Triage During Tier 1 (0%-30% Inpatient COVID-19 Load, Mild Reduction in Operative Capacity) [/table]
[table] Table 3: Guiding Statement for Patient Triage During Tier 3 (60%-80% Inpatient COVID-19 Load, Severe Reduction in Operative Capacity) [/table]
[table] Table 2: Guiding Statement for Patient Triage During Tier 2 (30%-60% Inpatient COVID-19 Load, Moderate Reduction in Operative Capacity) Essential Services Deferred All inpatients waiting for surgery, including emergency services Outpatients with progressive symptoms who have demonstrated failure to medical management [/table]
[table] Table 4: Guiding Statement for Patient Triage During Stage 4 (>80% Inpatient COVID-19 Load, Minimal Operative Capacity) [/table]