Prioritizing surgery during the COVID-19 pandemic: the Quebec guidelines



## Process
A literature review served as the basis for discussion. The criteria of the prioritization system were identified by consensus. Those involved in the process were surgeons (n = 5), radiation oncologists (n = 1), oncologists (n = 1), the national director of a cancer program, patients (n = 6), intensivists (n = 1), ethicists (n = 3), and research professionals (n = 2). These 20 people were divided into 3 groups, including a working group that developed a first draft of the system (n = 9), a review group that revised and enhanced the system to a final version (n = 5) and a patient group (n = 6) that also reviewed and commented on the draft. Several iterations were necessary before achieving consensus among all groups. In many countries, health care institutions have ramped down nonemergent activities in order to free up hospital and critical care beds in anticipation of a wave of patients with coronavirus disease 2019 (COVID-19). Medical activities were reduced to a minimum, leaving operating rooms to run semiurgent and urgent surgeries only. The status quo of systematically prioritizing resources away from surgical care to patients with COVID-19 may lead to unintended long-term outcomes. We propose a 4-step prioritization system based on resource availability and clinical criteria, as well as supplemental triage criteria for instances where multiple patients have equal claims to priority. The algorithm aims to guide clinicians and decision-makers toward allocating resources to surgical patients while still optimizing pandemicspecific benefits to the population.

## The prioritization system
The system aims to support the orientation of each patient. Its ethical principles are benefit maximization, proportionality, nonmaleficence, equity, reciprocity, agility and protection of stakeholders and the public. Continuous communication between the surgeon and the patient transcends this system. Continuous follow-up is required and provides an opportunity to reassure and respond to the questions and concerns of patients and family members.The system contains 4 sequential steps based on resource availability, clinical criteria and supplemental triage criteria when needed as tie-breakers.
Step 1: maximize the daily capacity of the OR Institutions determine their daily OR capacity. They negotiate an equitable distribution of resources, aiming to maximize benefits, proportional to current demand, across patient populations. Once agreement is reached on the distribution of resources, the OR capacity is finalized .

## Step 2: pretriage by specialty
Individual surgeons within each specialty pretriage all their patients. The goal of pretriage is to identify patients for whom the surgery is essential and for whom alternative care is not an acceptable equivalent .

## Step 3: overall prioritization
Final prioritization of surgical cases across specialties is a dynamic and continuous process that adapts to various changes in OR capacity and patient condition. First, a list is produced by each surgeon within each specialty. Second, a single list combines all the p a t i e n t s ( r e g a r d l e s s o f s u r g e o n ) w i t h i n e a c h specialty.
Decisions are then made by a local committee that applies the proposed prioritization criteria across specialties [fig_ref] Figure 3: Step 3 [/fig_ref]. This algorithm proposes more stringent clinical criteria as capacity decreases, but demands frequent reassessment as resources become available again, until the backlog is empty. If 2 or more patients have equal claims to priority, 2 supplemental criteria are proposed to choose fairly. The "fair innings" criterion favours intergenerational equity and therefore gives priority to the person who is at an earlier stage of life. [bib_ref] Scarce resource allocation during disasters. a mixed-method community engagement study, Biddison [/bib_ref] If this criterion is not applicable, randomization will be carried out to best respect equality of opportunity between patients. [bib_ref] Identifying prioritization criteria to supplement critical care triage protocols for the allocation..., Winsor [/bib_ref] Step 4: determining the OR schedule
The operating schedule is constructed by combining the daily OR capacity (step 1) and the prioritized lists of patients (result of step 2 and 3) [fig_ref] Figure 4: Step 4 [/fig_ref].

## Recommendations
This prioritization system can only be justified on the basis of equity if it is applied in the larger context of prioritizing the care needs of the entire population. To that Priority list of patients for all specialties (with resources required for each patient) 30% to 50% of the operating room capacity Prioritize patient according to: Those whose survival is most at risk Those nearest to or beyond the maximum surgery date Those requiring the least amount of operating time and resources possible (considering the cases most at risk and requiring more operating time.) Those most likely to recover quickly (low ASA classification)

## From
Step 2
Ensure that the patient list considers the capacity of other clinical services e.g., radiotherapy, rehabilitation
Step 3: overall prioritization of patients awaiting surgery The prioritization is done in two stages using the same decision-making process:
- By specialty - All specialties combined end, 3 recommendations emerge for maximizing population benefit during the COVID-19 pandemic. First, a system for prioritizing access to surgery during a pandemic should be applied immediately to identify patients across specialties who should have access to surgery, even when resources are limited. Otherwise, people suffering from life-threatening clinical conditions other than COVID-19 may be disproportionately disadvantaged, resulting in indirect morbidity and deaths from the pandemic beyond those caused by COVID-19 directly. Second, implementation of this protocol should be uniform across jurisdictions so that the entire population can have equitable access to scarce resources. Finally, many patients will not be selected and will continue to wait for their surgery, most likely with increasing anxiety and stress over time. Maintenance of the therapeutic relationship between patients and surgeons is important to assess the clinical and emotional consequences of delays.

# Conclusion
Our group advocates for the regionalization of resource allocation. This can be achieved with standardized surgical triage criteria based on clinical relevance. We submit that such a system will minimize the harm of the COVID-19 pandemic to the countless patients on surgical waiting lists. Step 4: determine a surgical program and the follow-up Step 1

## From
Step 3
Choice of rooms and patients
Evaluation of the consequences of the delay in surgery
[fig] Figure 3: Step 3: overall prioritization of patients awaiting surgery. ASA = American Society of Anesthesiologists. [/fig]
[fig] Figure 4: Step 4: determining the operating room schedule.Daily surgical capacity by specialty [/fig]
[table] , 4: Fig. 1.Step 1: determine the capacity of the operating room. Step 2: pretriage of patients, by specialty. Alternative treatment refers to a treatment that may not be the best curative option, but an alternative to the standard of care. Intermediate care refers to care units for patients who are more stable than those in intensive care, but who require specialized care that is not available in acute care medical and surgical units. Palliative care refers to care focused on the patient's quality of life, without the objective of curing the patient. COVID-19 = coronavirus disease 19.Do not perform the surgery and assess whether alternative care is required. Assess whether the patient should remain on the waiting list. [/table]