Coronavirus disease 2019 pandemic: staged management of surgical services for gynecology and obstetrics.

The widespread COVID-19 epidemic in China showed a high rate of infection in healthcare personnel, up to 63% in Wuhan (1080 of 1716), with 14.8% cases classified as severe or critical (247 of 1668) and 5 deaths. 12 , 13 This can quickly overwhelm resources and make it very challenging to provide adequate care for ill COVID-19 patients. Minimizing all unnecessary patient contact through proactive systematic postponement of elective surgical cases and all nonessential outpatient visits is key to channeling all healthcare resources to overcoming this COVID-19 pandemic.

The World Health Organization (WHO) provides an all-hazards list of key actions to be considered by hospitals in response to any disaster event. 1 This tool provides guidance on establishing a command center, consistent and effective communication, prioritization of safety and security, the logistics of triage and supply management in light of surge capacity while maintaining essential services, and postdisaster recovery planning. In 2014, the WHO hospital emergency response checklist was used as an evaluation tool kit in a cross-sectional study to assess the preparedness of 15 hospitals in Italy. It showed that most had adequate command and control response operations but had insufficient communication systems for potential disaster. 2 Although there is some correlation between the level of hospital care and preparedness, there was a poor level of readiness to implement strategic and logistical plans. In fact, some hospitals successfully anticipated infrastructure needs, such as water, sanitation, and electricity, but failed to demonstrate a coordinated and strategic plan for surge capacity. Inpatient surge capacity is the ability to generate staffed beds in response to a surge in demand for inpatient healthcare services. In times of emergent increase in healthcare demand, the goal is to increase capacity between 10% and 20%, although the target may vary based on specific circumstances. 2 , 3 Financial demands have traditionally prompted hospitals to maintain a high inpatient census to meet tighter budgets. Naturally, this limits their ability to respond to a sudden large surge in demand over the typical occupancy of 90%–95%. 4 This is particularly true for times of high occupancy during natural surge cycles as can be seen with the influenza or respiratory syncytial virus. These large (sometimes academic), nonprofit, and safety-net hospitals with level I trauma centers depend on the financial security of maintaining a high patient census and large surgical volumes. These sites will also be relied on for expertise in caring for nonsurgical patients with critical illness resulting from an emerging pathogen, in addition to the ongoing demands of high-level surgical services.

Despite these conflicts, 1 strategy to free up capacity within a hospital system is through cancellation of nonessential surgical cases that most commonly occurs in an unstructured and decentralized manner. 5 As seen previously, nonsystematic modifications of procedural schedules and adjusting admission and discharges were shown to reduce occupancy and demand of nonurgent hospital resources after the New York attacks in 2001 and after the severe acute respiratory syndrome Toronto outbreak in 2003 by 9% and 12%, respectively. 6 In 2016, researchers reported a structured system of categorizing surgical procedures based on the potential impact on inpatient surge capacity if a procedure was to be canceled or delayed. 5 Using chart review, all planned procedures over a 4-week period (n=2821) were categorized based on their impact on inpatient capacity and the safety of their delay into 1 of 4 groups: (A) procedures with no impact on inpatient capacity, (B) procedures that could be delayed indefinitely, (C) procedures that could be delayed by 1 week, and (D) procedures that could not be delayed. This strategy of delaying scheduled cases in categories B and C most effectively (especially on Mondays) led to a reduction of inpatient occupancy by 8% (65 beds). Although category A cases, such as outpatient procedures and same-day procedures, do not impact inpatient occupancy, they do require other equipment and staffing resources, thus limiting potential surge capacity during a healthcare crisis requiring intensive patient care. An important element of managing surgical services in the setting of a healthcare emergency is planned coordination throughout the hospital system, including various surgical departments, anesthesia, and nursing services. In the current COVID-19 crisis, the American College of Surgeons issued the following recommendation: “Each health system and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone or cancel elective [cases] until we can be confident that our health care infrastructure can support [an increase] in critical patient care needs.” 7 A joint statement from leading societies in gynecologic surgery and the US Surgeon General encouraged hospitals to consider modifying surgical scheduling in areas where COVID-19 is prevalent. 8 , 9 Effective rescheduling of surgeries should involve engagement of the entire hospital system with specific attention to the unique demands of the crisis at hand. Also of importance, many surgeries are performed in settings outside of hospital systems through either free-standing outpatient surgical centers or clinical offices. These entities are usually excluded from planning considerations since they are often removed, both operationally and financially, from the larger hospital systems. This creates a potential conflict of interest when making decisions about surgery reductions. Communication during a healthcare emergency is critical, and differences in the management of elective cases can interfere with consistent messaging across an institution and to the public. Community practices and nonaffiliated surgical facilities should be included in this process and have similar expectations for adjusting care. In the event of widespread COVID-19 infection, all resources may be severely strained and should be conserved to care for life-threatening infections rather than elective surgical procedures. The wide spectrum of clinical manifestations seen in COVID-19 complicates predictions of the impact on healthcare. Therefore, it is difficult to anticipate when the epidemic will peak and introduce further difficulty in the detection of cases. 10 Current data suggest that the risk for developing acute respiratory distress syndrome (ARDS, 17%–29%) and death (1%) are most commonly seen in the elderly (older than 70 years) and those with underlying respiratory illness. 11 Clinically recognized infection in children seems less frequent (2%), and limited data suggest that pregnant women are not particularly vulnerable to contracting the illness and have similar maternal complications to other populations. 12 There appears to be an increased risk for preterm birth, fetal distress, and cesarean delivery with infection. 11 Nevertheless, 1:1 obstetric and pediatric staffing and the resultant personal protective equipment (PPE) needs offer additional strains on resources.

Preparing for COVID-19 community spread requires emergency response planning as outlined by the WHO. Additional preparedness actions can be elucidated from the Italian experience, which provides guidance on forecasting ICU surge capacity and promoting containment measures once the outbreak has begun. 13 However, there is little guidance for managing scheduled, elective surgical services while awaiting the onslaught of COVID-19 cases. While hospital leadership is engaged in logistical planning, the maintenance of some limited surgical services may provide a financial balance to hospitals and allow physicians and staff to remain focused on providing high-quality care. Utilizing the principles from Soremekun et al 5 , it is possible to develop specialty-specific case categories and establish a schedule for tiered, coordinated case cancellation/postponement. Table 1 shows the staged reduction considerations for gynecologic and obstetric surgeries used at the University of Florida to guide decision making. Category I includes elective cases of any type performed on a patient at high risk of complications associated with COVID-19 infection. In the setting of COVID-19, category I was designed to identify all patients across all services whose mere presence in a densely populated hospital with COVID-19 community transmission would pose a greater risk to the patient than to postpone their surgery. For example, urogynecology largely serves older patients who are also at high risk of morbidity and mortality resulting from COVID-19 infection but whose surgical treatment can usually be delayed for patient protection. Table 1 General guidance to assist gynecologists and obstetricians with staged cancellation or postponement of surgical cases in response to the COVID-19 pandemic. Individual case-specific characteristics may modify category assignment for a given patient Category: I II III IV V Trigger(s) to cancel or delay - Community transmission - Community transmission - Inpatient bed availability limited - PPE supply limited - Community transmission - Inpatient bed availability limited - Case-by-case basis with team review - Community transmission - PPE supply limited Never canceled COVID-19 morbidity and mortality risk High Vulnerable population Average Average Average All risk levels Urgency level Low Low Moderate (can delay up to 14 d) Low High Impact on bed capacity Variable by procedure (possible inpatient) Variable by procedure (possible inpatient) Variable by procedure (possible inpatient) No impact (same-day surgery) High (inpatient, emergency department) Examples of patient characteristics and/or surgical case types Benign gynecology For all surgical groups - Immunocompromised - Elderly (older than 70 y) - Respiratory disease - Other comorbidities - Excision of pelvic masses without high suspicion of malignancy - Hysterectomy for benign disease - Major minimally invasive surgery (excision of advanced endometriosis or adhesions) - Excision of benign mass affecting health (causing ureteral obstruction) - Missed abortion - Interval tubal ligation - Hysteroscopy - D&C - Minor adnexal surgery - Minor laparoscopy - Minor vaginal surgery - Ectopic pregnancy - Ovarian torsion - Tuboovarian abscess requiring surgery - Uncontrollable uterine bleeding; no cancer - Incomplete abortion Urogynecology - Hysterectomy (with overnight stay) - Major pelvic floor repairs - Sacral colpopexy - Mass resulting in urinary obstruction - Minor pelvic floor repairs - Minimally invasive surgery - Hysterectomy (same-day discharge) - Irreducible procidentia resulting in acute urinary retention Gynecologic oncology - Hysterectomy for complex benign disease - Prophylactic surgery heritable cancer risk - Cysts followed for long periods without change and negative serum markers (Benign Gyn or Gyn Onc) - Excision of malignant mass - Hysterectomy for early endometrial cancer - Surgery for preinvasive disease: EIN, VIN, VAIN, CIN - Bowel obstruction - Uncontrollable uterine bleeding from cancer - Pelvic mass causing severe symptoms Reproductive endocrinology and infertility - Abdominal myomectomy N/A - Hysteroscopy, D&C - Septoplasty - Adnexal surgery - Minor laparoscopy - IVF retrievals and transfers - IUIs and office procedures - Ectopic pregnancy - Ovarian torsion - Treatment of ovarian hyperstimulation Obstetrics - Considered a vulnerable population and should only have indicated procedures to preserve maternal and fetal health - Delayed postpartum tubal ligation (separate anesthesia episode) - Ovarian cystectomy - Scheduled cesarean - Scheduled labor induction - History-indicated cerclage - Amniocentesis - Chorionic villous sampling N/A - Emergent cesarean - Emergent cesarean hysterectomy - Rescue cerclage - Incarcerated uterus - Ovarian torsion - Intrauterine transfusion - Tubal ligation at cesarean or with delivery CIN , cervical intraepithelial neoplasia; COVID-19 , coronavirus disease 2019; D&C , dilation and curettage; EIN , endometrial intraepithelial neoplasia; IUI , intrauterine insemination; IVF , in vitro fertilization; N/A , not applicable; PPE , personal protective equipment; VIN , vulvar intraepithelial neoplasia; VAIN , vaginal intraepithelial neoplasia. Weber LeBrun. COVID-19 pandemic: staged management of surgical services for gynecology and obstetrics. Am J Obstet Gynecol 2020. General guidance to assist gynecologists and obstetricians with staged cancellation or postponement of surgical cases in response to the COVID-19 pandemic. Individual case-specific characteristics may modify category assignment for a given patient Community transmission Community transmission Inpatient bed availability limited PPE supply limited Community transmission Inpatient bed availability limited Case-by-case basis with team review Community transmission PPE supply limited Immunocompromised Elderly (older than 70 y) Respiratory disease Other comorbidities Excision of pelvic masses without high suspicion of malignancy Hysterectomy for benign disease Major minimally invasive surgery (excision of advanced endometriosis or adhesions) Excision of benign mass affecting health (causing ureteral obstruction) Missed abortion Interval tubal ligation Hysteroscopy D&C Minor adnexal surgery Minor laparoscopy Minor vaginal surgery Ectopic pregnancy Ovarian torsion Tuboovarian abscess requiring surgery Uncontrollable uterine bleeding; no cancer Incomplete abortion Hysterectomy (with overnight stay) Major pelvic floor repairs Sacral colpopexy Mass resulting in urinary obstruction Minor pelvic floor repairs Minimally invasive surgery Hysterectomy (same-day discharge) Irreducible procidentia resulting in acute urinary retention Hysterectomy for complex benign disease Prophylactic surgery heritable cancer risk Cysts followed for long periods without change and negative serum markers (Benign Gyn or Gyn Onc) Excision of malignant mass Hysterectomy for early endometrial cancer Surgery for preinvasive disease: EIN, VIN, VAIN, CIN Bowel obstruction Uncontrollable uterine bleeding from cancer Pelvic mass causing severe symptoms Abdominal myomectomy Hysteroscopy, D&C Septoplasty Adnexal surgery Minor laparoscopy IVF retrievals and transfers IUIs and office procedures Ectopic pregnancy Ovarian torsion Treatment of ovarian hyperstimulation Considered a vulnerable population and should only have indicated procedures to preserve maternal and fetal health Delayed postpartum tubal ligation (separate anesthesia episode) Ovarian cystectomy Scheduled cesarean Scheduled labor induction History-indicated cerclage Amniocentesis Chorionic villous sampling Emergent cesarean Emergent cesarean hysterectomy Rescue cerclage Incarcerated uterus Ovarian torsion Intrauterine transfusion Tubal ligation at cesarean or with delivery CIN , cervical intraepithelial neoplasia; COVID-19 , coronavirus disease 2019; D&C , dilation and curettage; EIN , endometrial intraepithelial neoplasia; IUI , intrauterine insemination; IVF , in vitro fertilization; N/A , not applicable; PPE , personal protective equipment; VIN , vulvar intraepithelial neoplasia; VAIN , vaginal intraepithelial neoplasia. Weber LeBrun. COVID-19 pandemic: staged management of surgical services for gynecology and obstetrics. Am J Obstet Gynecol 2020. Categories II and IV are similar except for the postoperative hospital-care burden. Category II cases require overnight hospitalization or potential intensive care and can be postponed if the hospital resources are overstretched. In contrast, category IV cases occur in an off-site or independent ambulatory care center and therefore could continue without straining hospital-based resources (since some health systems do not maintain separate locations or surgical environments, categories II and IV may not be distinct for those centers). Although individuals in categories II and IV may be at lower risk for viral morbidity (such as most patients with benign and pediatric gynecology needs), consideration should be given to postponement if their surgery is nonessential and their potential exposure places the community at greater risk. In contrast, before the evidence of COVID-19 community spread, early completion of category IV cases will serve the low-risk population without expending significant resources and reduce additional hospital burden once the crisis resolves. Thus, both the specific community environment and COVID-19 risk must be considered. Category III describes urgent procedures (or cases) that need to be performed within the next 7–14 days, but which can be scheduled strategically on the basis of hospital resources. In the COVID-19 setting, terminal cleaning of an operating room, preparation of adequate PPE, or mobilization of staff may be prioritized to strategically delay a category III case. For example, surgical oncology cares for patients at the highest risk for contracting COVID-19 and, simultaneously, for experiencing devastating outcomes with a delay in cancer care. These cases best fit into category III, prompting a case review and individualized risk assessment. Finally, category V cases are emergent and should not be delayed for any reason. Emergent cases such as ovarian torsion and ectopic pregnancies fall into category V, for which a careful risk assessment is undertaken and the case performed urgently with mobilization of available resources. This categorization strategy depends heavily on surgeons to fairly identify several key factors about the patient and the planned surgery, to weigh the relative impacts of those factors on the overall health of the patient, and to seek peer review when confounding factors are involved. When considering symptomatic or COVID-19–positive surgical patients, we suggest that a multidisciplinary team must balance the various risks and benefits to the patient and to the entire healthcare system. There are a number of considerations for triggering a staged reduction in surgical services ( Table 2 ). Nevertheless, for COVID-19, the emergence of local or regional community transmission is the most important. Because pregnancy care (antenatal, intrapartum, and postpartum) is not optional, it is particularly important to conserve and protect this highly specialized workforce and assigned PPE resources to safely ensure the ability to provide services during the outbreak. This may mean an earlier reduction of benign gynecologic surgeries than in other specialties. Table 2 Selected considerations important for guiding decisions surrounding a staged reduction in surgical services during the COVID-19 pandemic Public health concerns Patient concerns Healthcare system concerns • Extent of community transmission • Risk for mortality for nosocomial infection • Comorbidities confounding screening (eg, tracheostomy) • Urgency of surgical indication • Health impact(s) if procedure postponed/canceled • Availability of PPE, both general surgical masks and COVID-19–resistant air-purifying masks/head coverings • Availability of blood bank resources • Availability and health of surgical teams • Surgeon • Anesthesiologist • Specialty consultative clinicians • Surgical assistance • Nursing support • Custodial and sterile-processing staff • Room capacity • Operating suites with negative pressure capabilities • Preoperative areas • Postoperative areas • Inpatient rooms • Emergency department COVID-19 , coronavirus disease 2019; PPE , personal protection equipment. Weber LeBrun. COVID-19 pandemic: staged management of surgical services for gynecology and obstetrics. Am J Obstet Gynecol 2020 . Selected considerations important for guiding decisions surrounding a staged reduction in surgical services during the COVID-19 pandemic Extent of community transmission Risk for mortality for nosocomial infection Comorbidities confounding screening (eg, tracheostomy) Urgency of surgical indication Health impact(s) if procedure postponed/canceled Availability of PPE, both general surgical masks and COVID-19–resistant air-purifying masks/head coverings Availability of blood bank resources Availability and health of surgical teams Surgeon Anesthesiologist Specialty consultative clinicians Surgical assistance Nursing support Custodial and sterile-processing staff Room capacity Operating suites with negative pressure capabilities Preoperative areas Postoperative areas Inpatient rooms Emergency department COVID-19 , coronavirus disease 2019; PPE , personal protection equipment. Weber LeBrun. COVID-19 pandemic: staged management of surgical services for gynecology and obstetrics. Am J Obstet Gynecol 2020 . Although each hospital or healthcare system must evaluate their own capabilities and surge capacity, this approach can be applied across all surgical departments allowing for a consistent and measured management of resources. We have provided an expanded table with additional categorized examples from other procedural specialties that might be useful for guiding decisions including general surgery, pediatric surgery, neurosurgery, otolaryngology, and psychiatry ( Appendix ).