Prof Gordon Carlson CBE FRCS
In light of the need to assess priorities of surgical treatment in a resource-limited environment, NHS England have set out clinical priorities for cancer surgery. However, these priorities do not take into account the vulnerability of the patient to excess morbidity and mortality in the event of Covid-19 infection. It seems evident that, particularly when undertaking elective surgery, the vulnerability of a patient to Covid-19 related morbidity and mortality might be equally important to considerations of the timing of surgery as the underlying disease for which surgery is proposed.
The resource allocation system currently in use at Salford Royal NHS Foundation Trust (which has since been adopted throughout other hospitals at Northern care Alliance) takes both of these factors into account, by producing a score based upon the need to prioritise treatment on purely disease related grounds and also the vulnerability of the patient to Covid-19. The aim is to generate a score which can be used to determine the overall surgical treatment priority of a group of patients, possibly from different surgical subspecialties, when surgical resources have become limited as a result of the Covid-19 pandemic. The score allows different groups of surgeons and hospital management to objectively determine how temporarily limited resources might be allocated. It is meant to help guide collective discussions, not to be a rigid indicator of those patients for whom surgical treatment should be deferred, and it should be used to support, not to replace MDT discussions.
Cancer Surgery Priority
The NHS England Suggested Priority for Cancer surgery is summarised in table 1 below.
|Priority level 1a||• Emergency: operation needed within 24 hours to save life|
|Priority level 1b||• Urgent:operation needed with 72 hours|
Based on: urgent/emergency surgery for life threatening conditions such as obstruction, bleeding and regional and/or localised infection permanent injury/clinical harm from progression of conditions such as spinal cord compression
|Priority level 2||Elective surgery with the expectation of cure, prioritised according to: |
• Surgery within 4 weeks to save life/progression of disease beyond operability.
Based on:urgency of symptoms, complications such as local compressive symptoms, biological priority (expected growth rate) of individual cancers
NB. Local complications may be temporarily controlled, for example with stents if surgery is deferred and /or interventional radiology.
|Priority level 3||Elective surgery can be delayed for 10-12weeks with no predicted negative outcome.|
However we could make resource allocation easier if we devised a simple, objective and consistent way of summarising the two variables which influence decision making – clinical treatment priority and risk of COVID-related adverse outcome, into one numerical score;
The “Salford Score” simplifies this to:
- Priority 1a = score (P)1
- Priority 1b = score (P)2
- Priority 2 = score (P)3
- Priority 3 = score (P)4
A second component of this relates to vulnerability of the patient in case of a COVID infection (see table 2).
|Vulnerability score||Outcome in case of COVID infection|
|Vulnerability level 1||• Unlikely to have excess mortality (compared to a completely fit individual < 70 years old) in the event of Covid infection|
|Vulnerability level 2||• Likely to have significant excess mortality compared to a completely fit individual < 70 years old in the event of Covid-19 infection, but would ordinarily receive invasive ventilation in that eventuality|
|Vulnerability level 3||• Extremely likely to succumb to Covid-19 infection and would not ordinarily receive invasive ventilation in that eventuality|
A resource allocation score of PxV, is then calculated so that a fit patient at high risk of imminent death of underlying disease (P1or 2) and unlikely to have excess Covid mortality (V1) would score 1 or 2 (and get urgent surgical treatment), whereas a patient with a non-immediately life threatening condition (P4) for which surgical treatment could be safely be delayed for 12 weeks and who would not, as a result of severe pre-existing medical comorbidity, be intubated etc. should they develop Covid and respiratory failure (V3) would score 12 and we would not proceed to offer surgery until the current resource position changes.