The Forum

One Swiss hospital's "3 bucket" approach to rescheduling planned procedures

by Rebecca Soistmann and Rachel Zuckerman

Around the world, hospitals are slowly attempting to return to 'normal' with regular caseloads, filled surgery schedules, and in-person appointments when they're appropriate. But as we've seen over the past few weeks, a new normal is emerging—and even that is proving difficult to achieve.

Ready to restart elective surgeries? Here are 3 steps to prioritize your services.

Background

Different organisations are using different criteria to decide how to reschedule planned procedures that were cancelled during the initial Covid-19 surge. In many jurisdictions around the world, hospitals must consider the financial implications brought on by Covid-19 and seek to recoup losses by rescheduling more profitable surgeries as quickly as possible. This is forcing many providers to strike a delicate balance between clinical urgency and financial importance as they begin to bring back patients.

But in other states and countries—particularly where providers receive greater economic support from the government and financial losses are less of a concern—clinical necessity outweighs all other factors.

Many organisations have published guidance to help hospitals reschedule planned procedures according to clinical necessity, including the American College of Surgeons, the National Health Service in England, and the Australian Health Protection Principal Committee. While many clinical and national associations have offered guidance, in most jurisdictions it is ultimately up to hospitals to design their own criteria.

How a Swiss hospital uses 3 buckets of criteria to assess clinical necessity

We spoke with Anne-Claude Griesser, Deputy Medical Director at Centre Hospitalier Universitaire Vaudois (CHUV) in Switzerland, to understand how they're approaching this process. Though CHUV is facing budgetary challenges, the hospital is a public facility and is prioritising elective procedures based on clinical necessity above all else. But 'clinical necessity' can mean different things to different people. CHUV is using three buckets of criteria to assess clinical necessity and prioritise procedures:

  1. Emergence: Patients for whom surgery will have a demonstrated positive impact on patient survival such as oncology or for whom surgery provides necessary palliation will receive the highest weight in rescheduling.

  2. Fragility: Patients who do not have immunological problems or many comorbidities will be prioritised ahead of more complex patients. CHUV has taken extensive protective measures to limit the transmission of Covid-19, but the hospital still wants to decrease any possible chance of transmission to immunocompromised patients while they're in the hospital for a procedure. If these patients can delay a procedure until the threat of Covid-19 has mostly passed, it's less likely that they'll catch the virus while in the hospital.

  3. Covid-19 status: Covid-19 patients will not undergo surgery unless it's absolutely necessary for survival. CHUV not only has been very proactive in protecting patients from viral transmission, but it's also been extremely protective of its clinicians and staff. Performing surgery presents numerous routes for coronavirus transmission from patient to clinician. CHUV's strategy is to delay procedures until the patient's viral load has decreased.

CHUV plans to use this criteria to prioritise procedures at least until September, at which point Griesser estimates the hospital will return to its pre-Covid surgery schedule.

Even as CHUV begins to ramp up care, the hospital is continuing to rapidly prepare for the second wave of Covid-19 and develop plans to care for both Covid-19 patients and minimise care disruptions as much as possible.

Your checklist for resuming elective procedures

As state officials begin lifting elective procedure restrictions, health system strategy leaders should prepare plans to resume procedures. This guide outlines important factors to consider when developing those plans to help you pinpoint potential gaps in strategy.

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