How to Prioritise and Optimise Access to Elective Surgery in the COVID-19 Pandemic: An Interhospital Alliance Pathway Based on the SWALIS 2020 Model. A Single-Cohort Feasibility & Pilot Study

Background: Surgical capacity is reduced due to COVID-19; and actions are required to optimise access, as the waiting patients’ needs dramatically exceed the available resources. The Italian Liguria Regional Health Trust (ALiSa) commissioned a pathway for all cancer/urgent cases from the metropolitan area of Genoa (840,000 inhabitants). Methods: The 6-week single-cohort feasibility-pilot of a software-aided, inter-hospital, collaborative multidisciplinary pathway covering all specialities in the Genoa Departments of Surgery. It modifies the Surgical Waiting List InfoSystem (SWALIS 2020) prioritisation model based on waiting time and clinical urgency by implicit criteria. We have introduced three new urgent subcategories: A1-15 days (certain rapid disease progression), A2-21 days (probable progression), and A3-30 days (potential progression). Findings: 295 referrals were evaluated in 6 weeks without major criticalities from 12 Surgical Units. Waiting lists were weekly monitored, and theatres allocated based on the existing demand. Their urgency category frequencies differed between week 3 and week 4 (p = 0·031). The SWALIS priority score (% of the waited against maximum time) in the operated patients was 88•7 ± 45•2 at week 1 and then persistently over 100% (efficiency), spread over a controlled variation (equity), with a difference between the A3 (153•29 ± 103•52) vs. A1 (97•24 ± 107•93) (p <0•001), and A3 vs. A2 (88•05 ± 77•51) (p <0•001). 222 patients eventually underwent surgery. Neither pathway-related perioperative complications, nor delayed/failed discharges. Interpretation: The pathway has allowed selecting the patients with the greatest need, optimising access even with rapid capacity modifications (+30% weekly). We will continue using the pathway in the COVID-19 “phase 2” and its scheduling policy to finely manage active, backlog, and hidden waiting lists. We are looking for collaboration for a multi-centre Service Improvement Research. Trial Registration: Registration: ISRCTN11384058. Funding Statement: The study has not received any external or ad hoc funding. Declaration of Interests: Dr. Valente reports other from BLIR, outside the submitted work; In addition, Dr. Valente and Dr. Di Domenico have a patent on cumulative linear prioritisation method pending. None of the authors has any other competing or conflicting interests with the submitted study. Ethics Approval Statement: The Regional Ethic Committee approved the project framework and publication, waiving the patient consent form, given no change was made to the current clinical practice and governance. The study design was confirmed.