American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures

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In response to the rapidly evolving challenges faced by hospitals related to the Coronavirus Disease 2019 (COVID-19) outbreak, and broad calls to curtail “elective” surgical procedures, the American College of Surgeons (ACS) provides the following guidance on the management of non-emergent operations.

It is not possible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. While some cases can be postponed indefinitely, the vast majority of the cases performed are associated with progressive disease (such has cancer, vascular disease and organ failure) that will continue to progress at variable, disease-specific rates. As these conditions persist, and in many cases, advance in the absence of surgical intervention, it is important to recognize that the decision to cancel or perform a surgical procedure must be made in the context of numerous considerations, both medical and logistical. Indeed, given the uncertainty regarding the impact of COVID-19 over the next many months, delaying some cases risks having them reappear as more severe emergencies at a time when they will be less easily handled. Following careful review of the situation, we recommend the following:

  • Hospitals and surgery centers should consider both their patients’ medical needs, and their logistical capability to meet those needs, in real time.
  • The medical need for a given procedure should be established by a surgeon with direct expertise in the relevant surgical specialty to determine what medical risks will be incurred by case delay.
  • Logistical feasibility for a given procedure should be determined by administrative personnel with an understanding of hospital and community limitations, taking into consideration facility resources (beds, staff, equipment, supplies, etc.) and provider and community safety and well-being.
  • Case conduct should be determined based on a merger of these assessments using contemporary knowledge of the evolving national, local and regional conditions, recognizing that marked regional variation may lead to significant differences in regional decision-making.
  • The risk to the patient should include an aggregate assessment of the real risk of proceeding and the real risk of delay, including the expectation that a delay of 6-8 weeks or more may be required to emerge from an environment in which COVID-19 is less prevalent.

In general, a day-by-day, data-driven assessment of the changing risk-benefit analysis will need to influence clinical care delivery for the foreseeable future. Plans for case triage should avoid blanket policies and instead rely on data and expert opinion from qualified clinicians and administrators, with a site-specific granular understanding of the medical and logistical issues in play. Finally, although COVID-19 is a clear risk to all, it is but one of many competing risks for patients requiring surgical care. Thus, surgical procedures should be considered not based solely on COVID-associated risks, but rather on an assimilation of all available medical and logistical information.

To further assist in the surgical decision-making process to triage non-emergent operations, ACS suggests that surgeons look at the Elective Surgery Acuity Scale (ESAS) from St. Louis University (below).  Each surgical specialty has specific guidelines that are pertinent to the procedures within that specialty. We gratefully acknowledge and thank Allan Kirk, MD, PhD, FACS, and Sameer Siddiqui, MD, FACS, for their contributions and recommendations to this document.

ACS will continue to follow up with additional recommendations and refinements, as needed. 

Elective Surgery Acuity Scale (ESAS)

Reprinted with permission: Sameer Siddiqui MD, FACS, St Louis University






Tier 1a Low acuity surgery/healthy patient
Outpatient surgery
Not life threatening illness
Hospital with low/no COVID- 9 census
Carpal tunnel release
Penile prosthesis
Postpone surgery or perform at ASC
Tier 1b Low acuity surgery/unhealthy patient HOPD
Hospital with low/no COVID-19 census
Postpone surgery or perform at ASC
Tier 2a Intermediate acuity surgery/healthy patient
Not life threatening but potential for future morbidity and mortality.
Requires in hospital stay
Hospital with low/no COVID-19 census
Low risk cancer
Non urgent spine
Ureteral colic
Postpone surgery if possible or consider ASC
Tier 2b Intermediate acuity surgery/unhealthy patient HOPD
Hospital with low/no COVID-19 census
Postpone surgery if possible or consider ASC
Tier 3a High acuity surgery/healthy patient Hospital Most cancers
Highly symptomatic patients
Do not postpone
Tier 3b High acuity surgery/unhealthy patient Hospital Do not postpone

HOPD – Hospital Outpatient Department
ASC – Ambulatory Surgery Center


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