Medically Necessary, Time-Sensitive Procedures: Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic

Abstract

Hospitals have severely curtailed the performance of nonurgent surgical procedures in anticipation of the need to redeploy healthcare resources to meet the projected massive medical needs of patients with coronavirus disease 2019 (COVID-19). Surgical treatment of non-COVID-19 related disease during this period, however, still remains necessary. The decision to proceed with medically necessary, time-sensitive (MeNTS) procedures in the setting of the COVID-19 pandemic requires incorporation of factors (resource limitations, COVID-19 transmission risk to providers and patients) heretofore not overtly considered by surgeons in the already complicated processes of clinical judgment and shared decision-making. We describe a scoring system that systematically integrates these factors to facilitate decision-making and triage for MeNTS procedures, and appropriately weighs individual patient risks with the ethical necessity of optimizing public health concerns. This approach is applicable across a broad range of hospital settings (academic and community, urban and rural) in the midst of the pandemic and may be able to inform case triage as operating room capacity resumes once the acute phase of the pandemic subsides.

Figure 1

Use of the cumulative medically necessary time-sensitive (MeNTS) score. Upper and lower threshold MeNTS scores can be assigned and dynamically adjusted to respond to the immediate and anticipated availability of resources and local conditions while preserving operating room capacity for trauma, emergency, and highly urgent cases.

Figure 2

Proof of concept of the medically-necessary time-sensitive (MeNTS) scoring system. Cumulative MeNTS scores of a sample of MeNTS procedures performed after ad hoc case review (n = 35, green bars) and procedures cancelled (n = 6, red bars) between March 20 and March 26, 2020, after initial cessation of all MeNTS procedures on March 16 were calculated. Y-axis represents the number of cases with a specific MeNTS score. MeNTS cases that were performed had generally lower MeNTS scores than those of cancelled procedures, demonstrating concordance with the ad hoc decisions made before creation of the MeNTS scoring system.