The new timing in acute care surgery (new TACS) classification: a WSES Delphi consensus study
Authors: De Simone Belinda , Kluger Yoram , Moore Ernest E. , Sartelli Massimo , Abu-Zidan Fikri M. , Coccolini Federico , Ansaloni Luca , Tebala Giovanni D. , Di Saverio Salomone , Di Carlo Isidoro , Sakakushev Boris E. , Bonavina Luigi , Sugrue Michael , Galante Joseph M. , Ivatury Rao , Picetti Edoardo , Chirica Mircea , Wani Imtiaz , Bala Miklosh , Sall Ibrahima , Kirkpatrick Andrew W. , Shelat Vishal G. , Pikoulis Emmanouil , Leppäniemi Ari , Tan Edward , Broek Richard P. G. ten , Gurmu Beka Solomon , Litvin Andrey , Chouillard Elie , Coimbra Raul , Cui Yunfeng , De’ Angelis Nicola , Sganga Gabriele , Stahel Philip F. , Agnoletti Vanni , Rampini Alessia ,   WSES TACS panel of experts, Shelat Vishal , Damaskos Dimitrios , Carcoforo Paolo , Biffl Walter L. , Bonavina Luigi , Hecker Andreas , Di Carlo Isidoro , Abu-Zidan Fikri M. , Galante Joseph M. , Kirkpatrick Andrew , Sartelli Massimo , Picetti Edoardo , Coimbra Raul , Di Salomone Salomone , Balogh Zsolt , Beka Solomon Gurmu , Broek Richard Ten , Velmahos Georges , Sakakushev Boris , Tan Edward , Ceresoli Marco , Chiara Osvaldo , Stahel Philip , Agnoletti Vanni , Pikoulis Emmanouil , Leppaniemi Ari , Marzi Ingo , Tebala Giovanni D. , Sall Ibrahima , Inaba Kenji , Khokha Vladimir , Wani Imtaz , Reva Viktor , Moore Ernest E. , Ansaloni Luca , Khan Mansoor , Toro Adriana , Litvin Andrey , de’ Angelis Nicola , Malangoni Mark , Kluger Yoram , Scozzafava Emanuele , Chirica Mircea , Civil Ian , Maier Ron , Weber Dieter , Chiarugi Massimo , Ivatury Rao , Soreide Kjetil , Sganga Gabriele , Cui Yunfeng , Testini Mario , Bravi Francesca , Maier Ronald V. , Biffl Walter L. , Catena Fausto 
Published: April 2023

Abstract
Background
Timely access to the operating room for emergency general surgery (EGS) indications remains a challenge across the globe, largely driven by operating room availability and staffing constraints. The “timing in acute care surgery” (TACS) classification was previously published to introduce a new tool to triage the timely and appropriate access of EGS patients to the operating room. However, the clinical and operational effectiveness of the TACS classification has not been investigated in subsequent validation studies. This study aimed to improve the TACS classification and provide further consensus around the appropriate use of the new TACS classification through a standardized Delphi approach with international experts.

Methods
This is a validation study of the new TACS by a selected international panel of experts using the Delphi method. The TACS questionnaire was designed as a web-based survey. The consensus agreement level was established to be ≥ 75%. The collective consensus agreement was defined as the sum of the percentage of the highest Likert scale levels (4–5) out of all participants. Surgical emergency diseases and correlated clinical scenarios were defined for each of the proposed classes. Subsequent rounds were carried out until a definitive level of consensus was reached. Frequencies and percentages were calculated to determine the degree of agreement for each surgical disease.

Results
Four polling rounds were carried out. The new TACS classification provides 6 colour-code classes correlated to a precise timing to surgery, defined scenarios and surgical condition. The WHITE colour-code class was introduced to rapidly (within a week) reschedule cancelled or postponed surgical procedures. Haemodynamic stability is the main tool to stratify patients for immediate surgery or not in the presence of sepsis/septic shock. Fifty-one surgical diseases were included in the different colour-code classes of priority.

Conclusion
The new TACS classification is a comprehensive, simple, clear and reproducible triage system which can be used to assess the severity of the patient and the surgical disease, to reduce the time to access to the operating room, and to manage the emergency surgical patients within a “safe” timeframe. By including well-defined surgical diseases in the different colour-code classes of priority, validated through a Delphi consensus, the new TACS improves communication among surgeons, between surgeons and anaesthesiologists and decreases conflicts and waste and waiting time in accessing the operating room for emergency surgical patients.

Graphical Abstract