This forthcoming medical journal article, authored by a group of acute care surgeons with diverse expertise in disaster management and public health, outlines a tiered approach to surgical department planning, including deployment of Acute Care Surgeons (ACS), utilization of infrastructure and transfers, triage principles, and deployment of faculty, resident, and advanced care practitioners.
The article notes that pandemic response differs significantly from other typical mass casualty plans because a pandemic presents a prolonged course of resource and personal exhaustion, rather than an acute event followed by an acute and relatively short response.
The authors recommend a tiered approach (Alert, Level 2, Level 1, Condition Zero) based on confirmed COVID19 cases, facility capacity, and resource/staff depletion.
The recommendations address surge capacity, personnel attrition, novel infrastructure utilization, and resource exhaustion. At the most severe tier (“Condition Zero”) the authors recommend steps for surgery departments that include:
- Cancellation of all non-emergent cases
- Transfer of urgent cases to outlying facilities
- General surgeons assist with trauma and emergency general surgery coverage
- All additional staff, residents, fellows, and Advanced Practice Providers flex as needed to cover non-surgical COVID-19 patients
- Application of triage criteria for emergency operations, trauma patients, and mechanical ventilation
- Futility policy for Code Blue Activation in COVID patients and futility policy for trauma activations and admissions
- Remaining ACS faculty transition to focus on ICU only.
At Condition Zero, the authors recommend steps for facilities that include:
- Daily sitrep huddles
- ICU expansion
- OR conversion to 4 ICU beds
- Anesthesia reassignment to critical care
- Use of tandem or novel ventilator approaches
- Possible intubation with family manual ventilation using bag valve mask
- Limiting to urgent/emergent surgical cases only.
The recommendations incorporate March 2020 guidance from the American College of Surgeons for triage of non-emergent operations during the COVID-19 outbreak.