Emory’s surgery adjudicators must make complex decisions during COVID-19

May 2020

With Atlanta being the epicenter of the COVID-19 pandemic in Georgia, the responsibilities of surgery adjudicators on the front lines in Emory's hospitals are not dissimilar to those of physicians performing triage in combat zones. At this stage, our adjudicators' duties may not be as intensely concentrated as those of surgeons at field hospitals, but our physicians and their teams certainly feel the weight and associated stress their obligations carry, particularly since they must determine when, where, and how patients that absolutely need surgery to survive can receive it, and how long those that don't can wait.

"As with the rest of the world, we've tried to balance patient and staff safety from COVID-19 with the imperative of providing active surgical care for patients who require it, and I am honored and humbled to serve as part of the great team at Emory navigating the turbulent waters of the past few months," says surgical oncologist Dr. David Kooby, chief of surgery in the Northern Arc and surgeon adjudicator at Emory Saint Joseph's Hospital. "While we have learned that it is easier to shut things down than it is to open them back up, we have also learned that we can care for our patients safely and thoughtfully during this pandemic."

As of this writing, all elective procedures remain postponed at all Emory Healthcare (EHC) facilities, but the decision has been made to progressively increase the volume of time sensitive, urgent, emergent, and essential surgery through a phased implementation based on hospital capacity and resources as well as clinical importance by specialty, and the adjudication process that was initiated in early March remains essential for this transition to run smoothly. The preliminary goal is to reach 50% of Emory's historical clinical volume.

The surgery adjudicator teams at each EHC surgical facility consists of surgeons, anesthesiologists, and nursing leaders who work together to manage the day-to-day flow and allocation of resources for urgent cases that need to be completed within 24 hours, and emergent procedures that have to be completed immediately due to the threat of loss of life. These teams then consider the timing and scheduling of essential interventions, which are critical for preventing premature death, disease progression, and long term disability, as well as time sensitive cases, which should be done within four weeks.

To make these decisions, the adjudicator teams must calculate the availability of anesthesia and nursing personnel required for a particular case, the availability of ICU/beds if either are needed, the length of the procedure, the risk of prolonged hospitalization/ICU or use of critical supplies such as blood and/or PPE, the degree of patient-likely survival if surgery is successful, and the potential for adverse clinical outcomes if surgery or intervention is delayed.

"These are the types of issues our surgical teams have always had to evaluate before moving forward," says cardiothoracic surgeon Dr. Allan Pickens, director of EHC's minimally invasive thoracic surgery and thoracic oncology services and surgeon adjudicator for Emory University Hospital Midtown. "But since the pandemic began, we have had to cautiously schedule operations while being mindful of the limited resources available every day, and always be ready to adjust the schedule to do urgent and emergent cases with short notice. Our surgeons and staff have been very accommodating during this crisis."

At this stage in the pandemic, one prevailing constant is that modifications and revisions of policies and procedures can happen at any time, as evidenced by the recent expansion of pre-procedural and preoperative COVID-19 testing for surgical patients across EHC for reasons related to patient and staff safety, thus giving adjudicators another component to slot into their deliberations.

"The fluidity of the pandemic makes for a dynamic clinical environment where projections and associated plans can shift at a moment's notice, so you really have to be on your toes and hyper alert," says Dr. John Sweeney, chair of Emory Surgery and lead surgeon adjudicator for the entire EHC system. "But it helps me rest a little easier knowing that we have the best people possible on the job in the adjudicator teams."

In addition to Dr. Pickens and Dr. Kooby, Emory Surgery hereby acknowledges the commitment to our clinical mission and to our patients during this unprecedented time shown by the following surgeon adjudicators: laparoscopic surgeon Dr. Scott Davis and endoscopy specialist Dr. Field Willingham at Emory University Hospital, colorectal surgeon and surgical robotics expert Dr. Seth Rosen at Emory Johns Creek Hospital, orthopaedic surgeon Dr. Scott Boden at Emory University Orthopaedics & Spine Hospital, general surgeon Dr. Tyler Reynolds at Emory Decatur Hospital, orthopaedic surgeon Dr. Augustine Conduah at Emory Hillandale Hospital, and Dr. Charles Staley, chief of the Emory Division of Surgical Oncology, at Emory Ambulatory Surgery Center.