Abstract
BackgroundThe COVID-19 pandemic halted non-emergency surgery across Scotland. Measures to mitigate the risks of transmitting COVID-19 are creating significant challenges to restarting all surgical services safely. We describe the development of a risk stratification tool to prioritise patients for cataract surgery taking account both specific risk factors for poor outcome from COVID-19 infection as well as surgical ‘need’. In addition we report the demographics and comorbidities of patients on our waiting list.MethodsA prospective case review of electronic records was performed. A risk stratification tool was developed based on review of available literature on systemic risk factors for poor outcome from COVID-19 infection as well as a surgical ‘need’ score. Scores derived from the tool were used to generate 6 risk profile groups to allow prioritised allocation of surgery.ResultsThere were 744 patients awaiting cataract surgery of which 66 (8.9 %) patients were ‘shielding’. One hundred and thirty-two (19.5 %) patients had no systemic comorbidities, 218 (32.1 %) patients had 1 relevant systemic comorbidity and 316 (46.5 %) patients had 2 or more comorbidities. Five hundred and ninety patients (88.7 %) did not have significant ocular comorbidities. Using the risk stratification tool, 171 (23 %) patients were allocated in the highest 3 priority stages. Given an aging cohort with associated increase in number of systemic comorbidities, the majority of patients were in the lower priority stages 4 to 6.ConclusionsCOVID-19 has created an urgent challenge to deal safely with cataract surgery waiting lists. This has driven the need for a prompt and pragmatic change to the way we assess risks and benefits of a previously regarded as low-risk intervention. This is further complicated by the majority of patients awaiting cataract surgery being elderly with comorbidities and at higher risk of mortality related to COVID-19. We present a pragmatic method of risk stratifying patients on waiting lists, blending an evidence-based objective assessment of risk and patient need combined with an element of shared decision-making. This has facilitated safe and successful restarting of our cataract service.
Highlights
The COVID-19 pandemic halted non-emergency surgery across Scotland
The risk stratification and patient prioritisation protocol we describe was designed with several aims; (1) quantify the risk factors that were known at the time to be predictors of poor outcomes in patients with COVID-19 infection in our patients waiting for cataract surgery, (2) categorise patients by need and from this, (3) derive an approach to cataract surgery resumption that is efficient and pragmatic [20]
The prioritisation stages we developed based on systemic ‘risk’ and ‘need’ demonstrate that a significant number of patients awaiting cataract surgery are, as expected, of high risk of poor outcome from COVID-19 and every effort to reduce the risk of these patients contracting COVID-19 should be considered and used to inform prioritisation for surgery
Summary
Measures to mitigate the risks of transmitting COVID-19 are creating significant challenges to restarting all surgical services safely. We describe the development of a risk stratification tool to prioritise patients for cataract surgery taking account both specific risk factors for poor outcome from COVID-19 infection as well as surgical ‘need’. Visual impairment and age-related cataract is known to be associated with increased mortality [6,7,8,9]. Visual impairment is associated with increased risk of depression after adjusting for confounding factors [10]. Improved quality of life with improved independence with less need for hospital and community care makes cataract surgery service restart a priority for NHS Scotland in the COVID-19 era [12,13,14,15]
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