To make these decisions easier for providers, Arizona Community Surgeons (ACS), a multispecialty surgery group serving the Tucson area, built a checklist to help providers assess a patient's risk and inform scheduling. To learn more, we spoke to ACS President George Bradbury, MD, about how he created and rolled out the checklist across their group.
Inside ACS's risk scoring for scheduled procedures
ACS started to bring scheduled cases back online in early May and soon realized they needed a way to assess patients' risk before setting a procedure date. Their board considered a range of approaches to evaluate patient risk—from asking physicians to rely on their professional judgment to forming a committee to oversee each scheduled surgery case. In the end, the board settled on a simple yet efficient approach: a one-page checklist that providers can use to calculate a patient's clinical risk score for surgery.
ACS's clinical risk score takes multiple factors into account, including:
- The patient's attitude toward surgery
- The disease or condition progression over the next four weeks without surgery
- The patient's Risk Assessment and Prediction Tool (RAPT) score, which predicts if they'll need discharge to post-acute care
- The likelihood the patient will need a ventilator or ICU care post-op
- The patient's expected length of stay
- The patient's existing clinical risk factors, including BMI, age, and underlying conditions
If a patient has a clinical risk score higher than two, it's recommended that the provider postpone the procedure if possible and communicate how they made that decision to the patient. If the patient has a score of two or below, they can move forward with surgery if and both the patient and provider agree that it's appropriate.
In addition to the clinical risk score, the checklist includes steps the provider should take before the surgery, including patient education, Covid-19 testing, and verifying the patient's financial details are still accurate.
Helping providers—and patients—make informed decisions about their care
It was important to ACS that patients, not just providers, understand the risks associated with scheduling their surgery. In addition to developing the scheduled surgery checklist for providers, Bradbury compiled a patient education document that every patient receives before surgery. The document outlines what patients should know about their elevated risk due to Covid-19 and steps they can take to protect themselves. The document also sets the expectation that a patient's care might look different than normal due to staffing and workflow changes such as pre-procedure Covid testing and visitor restrictions. In addition to the education materials, patients sign an "enhanced" consent form that addresses the additional risks Covid-19 poses to their surgery.
To keep everyone informed, ACS also sent a letter to referring providers about the safety precautions they're taking in their facilities and how they're assessing patients' risk for scheduled surgeries.
ACS's lessons learned from rolling out their scheduled procedure checklist
Bradbury said the checklist's implementation has been relatively smooth. A key reason is that ACS secured provider buy-in early. In a world of ever-changing Covid-19 guidance, providers view the checklist as helpful, instead of burdensome. Below, we outline a few aspects of the checklist—and its rollout—that made it effective.
Underscore that guidance exists to support providers' decision-making, not monitor behavior
When rolling out the checklist, Bradbury emphasized that the purpose of the tool is to hone, rather than override, clinical judgment. Although providers have the ultimate decision-making power, the goal is for the checklist to support them as they make quick decisions in a rapidly evolving clinical environment.
Partner with providers to inform risk criteria, and keep them up to date
During rollout, Bradbury made it clear that ACS's scheduled surgery checklist is a living document and encouraged providers to raise questions and suggest changes as needed. In response, providers offered feedback that made the wording in the document clearer and more accurate. For example, Bradbury realized that there was confusion about how a patient's RAPT score factored into the final risk score since the two scores were on different scales. To eliminate confusion, he made changes to the document so that it was clear how to integrate RAPT into the final calculation.
As the Covid-19 environment evolves, Bradbury will continue to turn to providers for guidance and input on how their organization can best keep patients and providers safe.
Keep it simple, user-friendly, and iterative
There's an overwhelming amount of information on Covid-19 out there, and it can be difficult for providers to know how to stay up to date. Bradbury notes that having a one-page resource that lays out key considerations is a huge help to providers as they bring cases back online. It's likely that evidence will continue to emerge about Covid-19 and surgical outcomes. And although it's nearly impossible to capture all the available information, providing a distilled, actionable source of information is an important first step.