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The START (Surgical Triage And Resource Allocation Tool) of Surgical Prioritization During the COVID-19 Pandemic

      To the Editor: Guidelines on deferring surgeries during the COVID-19 pandemic have been based primarily on disease urgency, without addressing resource allocation specifically.
      • Goldman HB
      • Haber GP
      Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 Era.
      • Stensland KD
      • Morgan TM
      • Moinzadeh A
      • et al.
      Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
      • Ficarra V
      • Novara G
      • Abrate A
      • et al.
      Urology practice during COVID-19 pandemic.
      • Ribal MJ
      • Cornford P
      • Briganti A
      • et al.
      European Association of Urology Guidelines Office Rapid Reaction Group: an organisation-wide collaborative effort to adapt the European Association of Urology guidelines recommendations to the coronavirus disease 2019 era.

      Urological Society of Australia and New Zealand. Urological prioritisation during COVID-19. 2020. Accessed date: 15 May 2020. Available at:https://usanz.org.au/publicassets/3fdf1dd5-5d6e-ea11-90fb-0050568796d8/Pol-020-Guidelines-Urol-Prioritisation-During-COVID-19–25-3-2020.pdf.

      We highlight resource stewardship issues, and share an easily administered and highly adaptable tool for surgical prioritization depending on surgical acuity and resource utilization, 2 key determinants of resource allocation in a pandemic.

      RESOURCE STEWARDSHIP DURING A PANDEMIC

      It is imperative that surgeons consider broader resource utilization and allocation, beyond individual patients’ needs. Doctors are trained to consider disease severity as the most important factor in prioritizing treatment. Yet, in a pandemic, considering overall resource utilization is essential.
      Each country exists at different timepoints on their pandemic curves. Blanket recommendations for postponing all elective surgeries would be relevant in resource-scarce states, but inefficient in resource-sufficient states. Dynamic resource allocation decision-making is necessary.
      The COVID-19 pandemic would likely be prolonged, with unpredictable waves of infection. Hospitals need to balance risks of overloading current capacity, vs the inevitable backlog of deferred cases. Mismanagement of demand and supply would lead to unsustainable deferment of services, excessive built-up demand, causing an overly protracted recovery.

      OVERVIEW OF THE SURGICAL TRIAGE AND RESOURCE ALLOCATION TOOL (START)

      START is an easily administered and highly adaptable tool for surgical prioritization, developed by our tertiary academic center. The START Score is derived from the Surgical Triage (ST) and Resource Utilization (RU) Scores of each case (Table 1).
      Table 1The Surgical Triage and Resource Utilization Tool (START) and Suggested Classification of Urological Procedures
      Surgical Triage ScoreResource Utilization Score(× Multiplication Factor)START Score
      Life-threatening/Emergency

      (0 points)

      Organ-threatening or Oncologically

      Urgent (1 point)

      Organ-threatening or Oncologically

      Semiurgent

      (2 points)

      Elective procedures

      (4 points)

      Nonessential procedures

      (8 points)


      Need for Intensive Care or High Dependency Unit care

      (× 1.4 points)

      Need for hospital stay > 2 days

      (× 1.2 points)

      Need for involvement of other medical or surgical disciplines

      (× 1.1 points)

      Need for blood transfusions

      (× 1.1 points)

      None of the above

      (× 1.0 point)
      Calculated START Score: __________Examples for illustration (lower START scores represent a combination of more urgent cases and less resources consumed)
      • Laparotomy and Nephrectomy for Major Trauma requiring ICU care, prolonged hospital stay, multi-disciplinary surgical involvement, blood transfusions
        • -
          0 × (1.4 × 1.2 × 1.1 × 1.1 points) = START Score 0
      • Radical Cystectomy for MIBC requiring HDU care and prolonged hospital stay
        • -
          1 × (1.4 × 1.2 points) = START Score 1.68
      • Radical Nephrectomy for RCC with IVC thrombus requiring ICU care, prolonged hospital stay, cardiothoracic surgery involvement and blood transfusions
        • -
          1 × (1.4 × 1.2 × 1.1 × 1.1 points) = START Score 2.03
      • Diagnostic Ureteroscopy for suspected high-grade UTUC as a day surgery case with no other resources utilized
        • -
          2 x (1.0 point) = START Score 2.00
      Surgical Triage ScoreLife-threatening/ EmergencyOrgan-threatening or

      Oncologically Urgent
      Organ-threatening or

      Oncologically Semiurgent
      Elective proceduresNonessential procedures
      ONCOLOGY
      Prostate cancerRadical Prostatectomy for high risk prostate cancerRadical Prostatectomy for intermediate risk prostate cancer

      Radiation therapy procedures (ADT can be given with deferred RT)
      Orchidectomy for surgical castration

      Procedures for treatment of low risk prostate cancer
      Bladder cancerRadical Cystectomy for MIBC

      TURBT for high risk/symptomatic NMIBC or MIBC as part of bladder sparing protocol
      Radical Cystectomy for high risk/recurrent NMIBCBladder biopsies/TURBT for low-risk lesions

      Surveillance cystoscopy for high and intermediate NMIBC
      Surveillance cystoscopy for low risk NMIBC
      Upper tract urothelial carcinomaNephroureterectomy for high risk or symptomatic UTUCDiagnostic Procedures for high risk UTUCDiagnostic and Therapeutic Procedures for low risk UTUC
      Renal cell carcinomaLaparotomy for ruptured RCC with hemodynamic instabilityRadical Nephrectomy for RCC with IVC thrombus or symptomatic RCCRadical Nephrectomy for T2-T4 RCCPartial/Radical Nephrectomy for RCC or SRM >4cm, or progression on imagingPartial Nephrectomy and Ablative Therapies for stable Small Renal Masses
      Adrenal tumorsAdrenalectomy for suspected adrenocortical cancer (>6cm)Adrenalectomy for functioning adenomas with failed medical therapy, suspected cancer <6cmAdrenalectomy for functioning adenomas controlled by medical therapy
      Testicular cancerRadical Orchidectomy for Testicular cancerRPLND postchemotherapy or primary RPLNDRPLND postchemotherapy for suspected slow growing teratomaInsertion of testicular implant
      Penile cancerPenectomy for Penile cancerBiopsy for suspected Penile cancer
      ENDO-UROLOGY
      HematuriaCystodiathermy for intractable lower tract bleedingCystoscopy for evaluation of hematuria with abnormal imaging findingsCystoscopy for evaluation of gross hematuria without abnormal imaging findingsCystoscopy for evaluation of microscopic hematuria
      Lower tract urinary obstructionSPC insertion or Cystoscopy for catheter insertion with failure to insert catheter per urethraCystoscopy for evaluation of stable/chronic obstructive LUTS
      Urethral strictureProcedures for urethral strictures if diversion has been achieved
      Benign prostatic enlargementTransurethral Resection of Prostate and other related procedures for BPE
      Upper tract urinary obstructionUreteric stenting or nephrostomy tube insertion for infected hydronephrosis, solitary functioning kidney or bilateral obstructionUreteric stenting or nephrostomy tube insertion for symptomatic/high-grade obstructionUreteric stenting or nephrostomy tube insertion for obstruction without infection or symptomsRegular change of long-term ureteric stentDefinitive procedures for stable ureteric strictures with existing diversion, eg, ureteric stents
      UROLITHIASIS
      Ureteric calculiUreteric stenting or nephrostomy tube insertion for infected hydronephrosis

      Ureteric stenting or nephrostomy tube insertion for solitary functioning kidney or bilateral calculi
      Ureteric stenting or nephrostomy tube insertion for symptomatic/high-grade obstructionTherapeutic ureteroscopy for obstructing ureteric calculus with hydronephrosis

      Ureteric stenting or nephrostomy with deferred ESWL/ ureteroscopy for obstructing ureteric calculus with hydronephrosis
      Therapeutic ureteroscopy or ESWL for ureteric calculus with no hydronephrosis or when urinary diversion for obstruction has been achieved
      Renal calculiProcedures for staghorn calculi with obstructionProcedures for symptomatic calculus without obstructionProcedures for asymptomatic calculus
      Bladder calculiProcedures for bladder calculi with recurrent obstruction or infectionProcedures for asymptomatic bladder calculi
      Urethral calculiCystoscopy for calculus with urinary obstruction
      KIDNEY TRANSPLANT AND DIALYSIS ACCESS
      Kidney transplantDeceased Donor TransplantLiving Donor Transplant
      Transplanted kidney managementGraft nephrectomy for fulminant graft sepsisLymphocele drainage procedures for symptomatic lymphocelesGraft nephrectomy for chronic graft failure
      Dialysis accessPeritoneal dialysis catheter removal for peritonitis

      Peritoneal dialysis catheter insertion
      Peritoneal dialysis catheter removal

      Vascular access surgeries
      MISCELLANEOUS CONDITIONS
      Urogenital traumaProcedures for patients with hemodynamic instabilityProcedures to salvage organ functionPost trauma reconstructive surgery
      InfectionsUreteric stenting or nephrostomy tube insertion for infected hydronephrosis

      Wound debridement for Fournier's Gangrene

      Drainage of abscesses in septic patients
      Drainage of abscesses in nonseptic patientsRepair of urogenital fistulas with recurrent infections
      Testicular/scrotal disordersScrotal exploration for suspected testicular torsionExcision of cutaneous malignancyScrotal exploration for suspected intermittent torsion

      Orchidopexy for undescended testes
      Hydrocele Repair

      Varicocele surgery

      Excision of

      benign lesions
      Penile disordersPenile Exploration for Penile Fracture

      Shunt procedures for

      Priapism

      Removal of infected penile prosthesis

      Excision of cutaneous malignancy
      Circumcision for BXOProcedures for Peyronie's Disease

      Penile implants

      Circumcision for phimosis/social reasons

      Excision of benign skin lesions
      Fertility and contraception proceduresDiagnostic and therapeutic fertility procedures

      Vasectomy
      Functional urology/incontinenceIntravesical Botox for OAB

      Continence surgeries, eg, slings, AUS, TVT

      Urogenital prolapse surgeries
      The ST Score is dependent on an intuitive color-coded 5-tier system (Life-threatening/Emergency, Oncologically/Organ-Threatening Urgent, Oncologically/Organ-threatening Semiurgent, Elective, and Nonessential. We classified Urology surgeries (Table 1) based on consensus opinion from an expert panel of subspecialists. The ST Score was designed to be incremental (Score = 2n), to ensure cases in each Tier will not have a higher final START score (and lower priority) than the following less-acute Tier, unless the surgery would be highly resource-intensive with all 4 key resources utilized. As Life-threatening cases were intentionally assigned a score of 0, the START score of all emergency cases would be 0, indicating the default highest priority, regardless of the RU score.
      The RU Score is determined by 4 hospital resources that are scarce in the COVID-19 pandemic. These were the need for Intensive/High-Dependency Care, hospital stay >2-days, involvement of other medical/surgical disciplines, and blood transfusions. For every resource consumed, a cumulative score is derived by multiplying the multiplication factors which applies.
      The ST score is multiplied by the RU score to calculate the final START score. START scores range from 0 to 16.3. Lower START scores indicate more urgent and less resource intense cases, which should be accorded higher priorities. START proved effective with table-top-exercises based on different scenarios. Its ease of administration reduces stress associated with complex decision-making during the pandemic. It is also highly applicable to other surgical disciplines. With any given amount of resources, and as local pandemic situations change, surgeons can prioritize surgeries based on START scores. It is our hope that sharing this easily administered tool would enable Urologists worldwide to dynamically prioritize surgeries, tailored to their local prevailing pandemic circumstances.

      AUTHORS’ CONTRIBUTIONS

      Yi Quan Tan: Conceptualization, Writing - original draft. Ziting Wang, Ho Yee Tiong, Wei Jin Chua, Qing Hui Wu: Conceptualization, Writing - review & editing. Edmund Chiong: Conceptualization, Writing - review & editing, Supervision.

      References

        • Goldman HB
        • Haber GP
        Recommendations for tiered stratification of urologic surgery urgency in the COVID-19 Era.
        J Urol. 2020; (; Apr 21:101097JU0000000000001067)
        • Stensland KD
        • Morgan TM
        • Moinzadeh A
        • et al.
        Considerations in the triage of urologic surgeries during the COVID-19 pandemic.
        Eur Urol. 2020; 77: 663-666https://doi.org/10.1016/j.eururo.2020.03.027
        • Ficarra V
        • Novara G
        • Abrate A
        • et al.
        Urology practice during COVID-19 pandemic.
        Minerva Urol Nefrol. 2020; https://doi.org/10.23736/S0393-2249.20.03846-1
        • Ribal MJ
        • Cornford P
        • Briganti A
        • et al.
        European Association of Urology Guidelines Office Rapid Reaction Group: an organisation-wide collaborative effort to adapt the European Association of Urology guidelines recommendations to the coronavirus disease 2019 era.
        Eur Urol. 2020; https://doi.org/10.1016/j.eururo.2020.04.056
      1. Urological Society of Australia and New Zealand. Urological prioritisation during COVID-19. 2020. Accessed date: 15 May 2020. Available at:https://usanz.org.au/publicassets/3fdf1dd5-5d6e-ea11-90fb-0050568796d8/Pol-020-Guidelines-Urol-Prioritisation-During-COVID-19–25-3-2020.pdf.