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What is an Elective Case? Making the American College of Surgeons “Guidance for Triage of Non-Emergent Surgical Procedures” work in Your Hospital

Posted by Dr. Tom Blasco on Mar 25, 2020 12:20:34 PM

What is an elective case? This relatively simple question used to be easily answered, but now that it relates to containing COVID-19 versus getting a case on the schedule or not – the answer has gotten much more complicated.

In this rapidly changing COVID-19 environment, hospitals are being asked to undertake a rapid transition in their operating rooms and procedural areas to urgent-only care.

The key issue with urgent-only, or ‘high-acuity’ surgical care, is defining and managing this group versus lower acuity, elective patients. On March 17th, the American College of Surgeons (ACS), amongst many other organizations, published a thoughtful and relatively comprehensive guide for patient triage. The table here is pulled from that guide:

Elective Surgery Acuity Scale (ESAS) [1]






Tier 1a

Low acuity surgery/healthy patient
Outpatient surgery
Not life-threatening illness

Hospital with low/no COVID- 9 census

Carpal tunnel release
Penile prosthesis

Postpone surgery or perform at ASC

Tier 1b

Low acuity surgery/unhealthy patient

Hospital with low/no COVID-19 census


Postpone surgery or perform at ASC

Tier 2a

Intermediate acuity surgery/healthy patient
Not life threatening but potential for future morbidity and mortality.
Requires in hospital stay

Hospital with low/no COVID-19 census

Low risk cancer
Non urgent spine
Ureteral colic

Postpone surgery if possible or consider ASC

Tier 2b

Intermediate acuity surgery/unhealthy patient

Hospital with low/no COVID-19 census


Postpone surgery if possible or consider ASC

Tier 3a

High acuity surgery/healthy patient


Most cancers
Highly symptomatic patients

Do not postpone

Tier 3b

High acuity surgery/unhealthy patient



Do not postpone

Source: American College of Surgeons, March 17, 2020 (see footnote)

HOPD – Hospital Outpatient Department

ASC – Ambulatory Surgery Center

However, as stated in this guide, there are many nuances to triaging the appropriate cases that require a hospital to work closely with its proceduralists and patients. 

Surgical Directions, having worked with nearly 400 hospitals, has spent more than two decades refining optimum approaches to hospital-based procedural patient preparation and triage. With this experience, we have some suggestions on how best to implement these ACS guidelines:

  • Communicate: Appropriate hospital clinical and administrative leadership should alert the proceduralist and their offices that all future procedures will be screened for their acuity/urgency, and that for the near term, only high acuity cases will be scheduled.
  • Start Early: Initial triage in this urgent-only environment should begin at the time of booking, separating the high-acuity cases that need immediate surgery from procedures that can be delayed.  
  • Get together: A multi-disciplinary Daily Huddle Group should be formed. This groups needs to be administration-sponsored and empowered, and should include surgeons, anesthesia, nursing, and administrative leadership. Using the ACS guidelines and working closely with scheduling and surgeons’ offices, this group should assess acuity and any special circumstances influencing patient triage. This group should meet daily, typically in the afternoon, and, when possible, review these high acuity procedures in advance of the scheduled day of surgery. It should also be reviewing and addressing any current or recent operational issues.
  • Be hyper responsive: It is important that the Scheduling Office have immediate decision backup support from the Daily Huddle Group. From our recent experience, it is inevitable that this triage system will require this high-level decision support for procedures that require further discussion.

It is expected that many urgent cases will come either directly from the Emergency Department, or from within the hospital. Prioritizing these patients’ care should use the same ACS triage guidelines managed under the direction of the Daily Huddle Group. 

Surgical Directions’ highly experienced team is available to help you and your hospital prepare and manage patient care during and following this crisis. Proactively addressing issues and creating a plan to respond and recover operationally is critical to hospital viability. Please do not hesitate to contact us at info@surgicaldirections.com, or at 312-870-5600 if you are looking for help or for more information.


[1] American College of Surgeons, March 17, 2020. Retrieved from: https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage

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