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Surgical Resource Management during the COVID-19 Pandemic – Insights from Global Surgery

A guest blog by:

Joshua S. Ng-Kamstra, Fellow in Adult Critical Care Medicine – Department of Critical Care Medicine, University of Calgary,

Dhruvin H. Hirpara, Resident in General Surgery – Department of Surgery, University of Toronto,

John Meara, Professor of Global Surgery and Social Medicine – Program in Global Surgery and Social Change, Harvard Medical School, Boston & Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, &

Julie Hallet, Assistant Professor – Department of Surgery, Sunnybrook Health Sciences Centre & Department of Surgery, University of Toronto

Background

The COVID-19 pandemic poses an acute threat to human health that is unprecedented in our lifetimes. Many health systems still continue to grapple with the volume of critically ill patients suffering from the virus.. The impacts of this crisis on surgical systems are being felt worldwide by patients and surgical providers. The estimated 30% of the global burden of disease caused by surgical conditions does not pause during a pandemic.1 Each year, 16.9 million people die due to surgically treatable conditions,2 and 15.2 million new cancers are diagnosed, 80% of which will require surgery.3 The magnitude and immediacy of the threat from COVID-19 has led many jurisdictions to cancel elective surgery to preserve precious hospital and critical care beds and limit nosocomial spread of the virus. As local trajectories of the pandemic become clear, surgeons and policymakers need to determine an optimal approach to meet population-level surgical needs to avoid additional pandemic-related morbidity and mortality.

Surgical systems are logistically demanding and interconnected networks of services: adaptation to the realities of limited operating theater availability is therefore complex. Human resources will also be threatened;4 safeguarding healthcare workers despite finite availability of personal protective equipment further adds to service delivery challenges. High-volume surgical systems must have the flexibility to systematically scale back provision of surgical care in a way that makes optimal use of resources while minimizing impacts on patients, providers, and systems. Looking at structured ways to operationalize sudden reductions in resources quickly, all countries can learn from existing principles and frameworks in the global surgery literature. Indeed, in addition to advocating for the health and economic benefits of investment in surgical systems,2 the global surgery literature recognizes and addresses the challenge of working under constraint. 

Prioritization of Surgical Services 

Surgical societies have provided guidance to surgeons as to which procedures are essential during this crisis.5,6 Such determinations are based on acuity, complexity, and population burden of disease. In a “must do, should do, can do” procedural framework,2 most surgeons have found themselves limited to providing only the first category: high value procedures (i.e. some cancer surgery) where long-term outcomes may hinge on timely surgical intervention, and urgent life- or limb-saving procedures. Should-do procedures are important but not vital procedures that may be amenable to a temporary workaround and still add value in the long run. Finally, can-do procedures are ones that are often desirable but not necessary—they could be deprioritized first with a relatively smaller impact on patient outcomes. These categories ought to be reassessed as resources change, but this framework can support discussions at the system, institution, and service levels. Non-operative management of traditionally surgical conditions (eg. antibiotics for uncomplicated appendicitis or endoscopic management of an early-stage esophageal cancer) may also aid in resource conservation. Finally, trauma prevention campaigns can be implemented or scaled up to minimize the need for emergency surgery.7  

Mitigating Harm from Delays to Care 

Globally, increased delays in access to surgical care are likely. Breaking these delays down into their three constituent components may help to mitigate them.2,8 First, is the delay in seeking care. With travel restrictions or residential lockdowns, the threshold to seek answers to concerns unrelated to the pandemic will increase. Creating easy access to primary care and surgical expertise, via telehealth for example, will give populations a venue to triage health concerns. Barriers to telehealth including finance, technical considerations, and confidentiality should be addressed collectively by providers, payers, government, and regulatory colleges. Second, the delay in reaching care at an appropriate center where diagnostics and therapeutics can be applied is less amenable to a technological solution. Maintaining separate health facilities as designated non-COVID-19 centers is one strategy to allow surgical work to continue or resume shortly after the pandemic peaks. As the pandemic progresses, the number of non-COVID-19 centres are reduced proportional to need as more patients present with viral illness, expanding again once the pandemic’s initial peak has passed. Finally, mitigating the delay in receiving surgical care requires adaptive waitlist management at the hospital level when progressively narrower bottlenecks in operating room time are encountered. Managing staffing constraints and pandemic-related supply chain disruptions will be critical to ensure that the appropriate personnel and disposables are available to use operating theaters as efficiently as possible.

Stuff, staff, space, and systems and the perils of reopening

Governments are struggling to balance the devastating economic consequences of ongoing stay-at-home orders with the risk of an overwhelming second wave of infections.9 While the optimal timing and strategy for reopening the economy remain unclear, strategies to mitigate the hazard of disease resurgence include widespread testing, serological surveys to better understand community-level exposure, staged relaxation of distancing measures, and bolstering hospital capacity to manage potential new cases. What these strategies all require are staff, stuff, space, and systems, an alliterative list of necessities for global health delivery coined by Dr. Paul Farmer.10

When public health officials deem it safe to resume some elective surgery, surgical leaders can also use this model to ensure that surgery again becomes available. Staff may need to be remarshaled from deployments to other acute care services; ensuring their mental and physical health during a period of significant stress will be critical. Stuff includes not only robust supplies of the necessary personal protective equipment to safely assess, operate on, and provide postoperative care for patients, but also medications and other operating room disposables that may become scarce due to supply chain disruptions. Space implies not only physical operating room space, but also appropriate spacing between postoperative patients, ideally in individual rooms, to prevent outbreaks of COVID-19 on wards. Finally, systems are required to ensure that care pathways for infected and uninfected patients are developed, staff are trained in their implementation, and their logistics are feasible.

Integrating surgery and other acute care services into global health security

Global health security (GHS) implies global collaboration to ensure that all health systems are prepared to manage public health threats and emergencies. Historically, the GHS discourse has been focused on infectious diseases as the primary public health threat born of globalization.11 The Global Health Security Agenda is a growing community of nations and organizations formed in 2014 to respond to infectious disease threats.12 By strengthening public health systems and stopping outbreaks at their point of origin, the GHSA aimed to decrease the risk of global pandemic disease. When it comes to a pandemic, the aphorism that prevention is better than cure is true. But it is an aphorism that historically excluded surgery from the global health discourse—why invest in surgery when some surgical disease is preventable?

The Lancet Commission on Global Surgery demonstrated the scale of human suffering that results when prevention is preached to the exclusion of treatment, with five billion individuals unable to access safe, affordable surgical care when needed.2 Not all surgical disease is preventable, and not every pandemic is stopped. GHS must evolve to include health services like critical care and surgery to plan for effective treatment of patients after a pandemic has emerged. If plans to address global critical care needs were in place before COVID-19, would countries have better mobilized to support beleaguered hospitals in China, Italy, or New York? If countries had anticipated the impacts of a pandemic on surgical care, would the cancellation of all elective surgery have been necessary? While these counterfactuals are unknowable, what is clear is that health services leaders must sit at the global health security table alongside infectious disease epidemiologists and public health professionals.

Summary

COVID-19 has reached almost every country on earth, and many surgical systems have already responded to the challenges it poses. The choices made in surgical system design, both historically and recently, will determine patient outcomes in the coming weeks and months. The shock to surgical systems will not be a short one—until the majority of the population has been exposed to the virus via vaccine or illness,13 the virus will pose a unique barrier to accessing safe surgical care.

Now more than ever, we must emphasize interdisciplinary collaboration, knowledge exchange, and health equity in order to maximize the efficiency of surgical access in all jurisdictions.14 Global surgery frameworks can support adaptation to rapid shifts in resource availability. More importantly, they can be used to plan the post-pandemic delivery of surgical services, serve to reconceive routine surgical care delivery systems, and plan resource scaling strategies to build more flexibility into surgical delivery in the future.

National surgical crisis planning must become part of the health systems lexicon. Mitigating acute threats to surgical systems including natural disasters, economic downturns, workforce declines, supply chain disruptions, military conflicts, and pandemic disease is not optional: our patients’ lives depend on it.


References

1.         Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. The Lancet Global health 2015; 3 Suppl 2: S8-9.

2.         Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015.

3.         Sullivan R, Alatise OI, Anderson BO, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2015; 16(11): 1193-224.

4.         Bundu I, Patel A, Mansaray A, Kamara TB, Hunt LM. Surgery in the time of Ebola: how events impacted on a single surgical institution in Sierra Leone. J R Army Med Corps 2016; 162(3): 212-6.

5.         Mock CN, Donkor P, Gawande A, et al. Essential surgery: key messages from Disease Control Priorities, 3rd edition. Lancet 2015; 385(9983): 2209-19.

6.         American College of Surgeons. Guidance for Triage of Non-Emergent Surgical Procedures. 2020. https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage?MessageRunDetailID=1509048893&PostID=12687687&utm_medium=email&utm_source=rasa_io (accessed March 20 2020).

7.         Kotagal M, Agarwal-Harding KJ, Mock C, Quansah R, Arreola-Risa C, Meara JG. Health and economic benefits of improved injury prevention and trauma care worldwide. PLoS One 2014; 9(3): e91862.

8.         Thaddeus S, Maine D. Too far to walk: maternal mortality in context. Soc Sci Med 1994; 38(8): 1091-110.

9.         Kissler SM, Tedijanto C, Goldstein E, Grad YH, Lipsitch M. Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period. Science 2020.

10.       Farmer P. Diary: Ebola. London Review of Books 2014; 36(20).

11.       Karan A. How Should Global Health Security Priorities Be Set in the Global North and West? AMA J Ethics 2020; 22(1): E50-4.

12.       Osterholm M. Global Health Security—An Unfinished Journey. Emerg Infect Dis 2017; 23(Suppl 1): S225-S7.

13.       Ferguson N, Laydon D, Nedjati-Gilani G, et al. Report 9: Impact of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcare demand: Imperial College, 2020.

14.       Dare AJ, Grimes CE, Gillies R, et al. Global surgery: defining an emerging global health field. Lancet 2014; 384(9961): 2245-7.

My first time.

Claire Donohoe (@clairedonohoe6), Editorial Assistant BJS, Consultant Oesophagogastric surgeon, Dublin

(a follow-on to “With the End in Mind”1)

Who was the first patient you discussed their own death with? 

For me, it was my grandmother. I was a medical student and she was slowly declining from heart and renal failure. During her last admission to hospital, she was clearly fearful of impending death – she told me that she felt better when I sat with her as she slept – which she did more frequently than, previously  – as she feared that she might not wake up from her nap. 

I assume that the medical staff noted our relationship. It was suggested to me that I might discuss resuscitation orders with her. I agreed that this was a timely discussion for her. Having participated in resuscitation during my rotation in the Emergency Department wanted to spare her this futile treatment.

I can only imagine how bumbling I was in that conversation. My mother had noted when I started medical school that I would have to work on my “bedside manner”.

On reflection

I definitely lacked the requisite vocabulary to not frighten her more. However, I do remember trying to reassure her that this was to prevent harmful treatment, that wouldn’t help her. And I would have loved to have had the phrase “It’s an order so that we hold your hand when you are dying rather than pound your chest”( see here2 and here3 for more).

I would have loved to have known better to narrate the process of dying to her; to relieve her of her fear that slipping away would be painful and something that she should fight. That her increasing need for sleep was normal and it differed from slipping into unconsciousness so that she could sleep more easily.

An ending

In the end, I failed her. As her medical team predicted, she had a cardiac arrest watching a soap on TV a few weeks later. And I failed her, because I hadn’t had that delicate conversation with her wider family. In my naïve medical student approach, she was the patient and I and the medical team knew her wishes. But I forgot that she existed surrounded by a devoted family who wanted to keep her forever. 

She arrested, panic ensued, an ambulance was called, CPR was commenced and she had cardiac compressions en route to the hospital where she was pronounced dead. Family members arrived to the resus bay to sit with her and hold her hand. With better communication, we could have done that in her own home. 

What I wish I’d known

In the world of surgery, we are always learning4. I regularly wish that I had already mastered all of the communication skills that I need. In a recent blog post1 I wrote about an approach to end of life communication entitled “Difficult Conversations – Why we need to talk about dying”. Dr Lara Mitchell has produced resource materials with Open Change, an educational design company, to give healthcare professionals a visual approach to support these difficult conversations  around dying with compassion and honesty. It aims to give framework, concepts and phrases to support these conversations for health and social care.

She has now produced a video discussing the framework in more detail and with references to other sources5. I found it useful and hope that you do too. In the meantime, I’ll continue to work on my bedside manner, aiming to communicate with openness, compassion and empathy.

References

1. Donohoe C. With the End in Mind. 2020.

2. Mannix K. 2020. Available at: https://ne-np.facebook.com/DrKathrynMannix/posts/today-i-was-asked-a-great-question-about-deciding-whether-or-not-a-ventilator-is/2949195348436749/. 

3. Mannix K. Dot MD talk. 2019.

4. Chamberlain C, Blazeby JM. A good surgical death. BJS (British Journal of Surgery) 2019; 106(11):1427-1428.5. Mitchell L. Difficult conversations- we need to talk about dying. 2020.

Visual abstract blog

As Monty Python would say…

Time for an upbeat blog!

The BJS ‘how to write a paper’ session is a fixture at many UK surgical meetings. This covers lots of the ‘nuts and bolts’ of writing a paper. We delivered a short version of this course at the Association of Surgeons in Training Meeting in Birmingham.

One of the fun and developing parts of publishing is the promotion of material on social media. Visual abstracts have emerged as a concise way of sharing the key points of a manuscript online. Therefore it shouldn’t come as a surprise that we cover making visual abstracts in this course.

We discuss things like picking out key points and the use of icons and images. We then give the participants a choice of two abstracts and invite them to submit a visual abstract to our competition. This year we chose this paper on peripheral vascular disease and this paper on oesophageal cancer as subjects for the exercise.

We were pleased to receive a number of visual abstracts, which were of a really high standard. Most participants opted for the peripheral artery disease abstract. The team were really impressed by the abstracts that were submitted to us. Dr Jia Ying Lim (blue background) was the winner, and Dr Rucira Ooi (red background) was awarded the runner up prize. You can see these below.

Please keep an eye out for the course at future meetings. If you would like us to deliver this course at your meetings, please get in touch!

Guest post: CovidSurg – The impact of COVID-19 on surgical patients and the provision of surgical services

Constantine Halkias on behalf of COVIDSurg

The chance to learn about this disease & impact on surgical patients is in our hands.
Photo by Valentin Antonucci from Pexels

Surgery in a pandemic

Policies and public health efforts have not addressed the impact of pandemics on the provision of surgical services and the effects on health-related outcomes on surgical patients. This also applies to the response to Coronavirus disease 2019 (COVID-19). There hasn’t been any related research or analysis despite the impact of the pandemic so far. Understanding the effects of COVID-19 on patients undergoing surgery along with the effects of this pandemic on the provision of surgical services is a fundamental step to understanding the various different effects of a healthcare emergency of that magnitude and to implement policies from the lessons learned.

Impact on surgical patients

Undoubtedly despite the global focus to encounter the pandemic itself and the need to improve provision of services and treatments related to the immediate effects of COVID-19, with intensive care playing a major role, there are still millions of patients who will need surgical treatment. Major focus should be the provision of emergency surgical care, cancer surgery and transplant surgery. There is little or no knowledge on the outcomes of surgical patients with COVID-19 related disease.

Low quality data from a case series of patients who underwent cardiac surgery and acquired Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) did show very high mortality of 83.33% (1). This has major direct implications on the management of emergency surgical patients during the pandemic as well as on the ongoing provision of organ transplantation and cancer related operations. Whether major cancer surgery and organ transplantation should be delayed and for how long, in view of the possible worse outcomes during the pandemic is one of the issues that should be investigated.

Impact on surgical services

We also need to address the effects of the current pandemic on surgical services provision. It is an unprecedented situation that has already changed the way surgeons and health systems worldwide are offering surgical services. There is also very low quality evidence available from the 2003 Hong Kong Severe Acute Respiratory Syndrome (SARS) epidemic that showed significant reduction in the colorectal surgical caseload that had a major negative impact on waiting times and training (2). Although it’s certain that the impact of the current COVID-19 pandemic will be of unprecedented severity, it’s actual consequences and the implications on resources, staff allocation and training are still uncertain. Understanding the effect of the pandemic would also inform future global policy around cancer and transplantation surgery during pandemics, and the provision of surgical services in general.

A new project

There is an urgent need to understand the outcomes of COVID-19 infected patients who undergo surgery. To address the above issues we designed CovidSurg, an international group of surgeons and anaesthetists, with representation from Canada, China, Germany, Hong Kong, Italy, Korea, Singapore, Spain, United Kingdom, and the United States. Our aim is to capture real-world data and share international experience that will inform the management of this complex group of patients who undergo surgery throughout the COVID-19 pandemic, improving their clinical care and to understand the effects of the pandemic on the provision of surgical services. 

References

  1. Outbreak of Middle East Respiratory Syndrome-Coronavirus Causes High Fatality After Cardiac Operations. Nazer RI, Ann Thorac Surg. 2017 Aug;104(2):e127-e129. doi: 10.1016/j.athoracsur.2017.02.072.
  1. Tales from the frontline: the colorectal battle against SARS. Bradford IM Colorectal Dis. 2004 Mar;6(2):121-3. doi: 10.1111/j.1462-8910.2004.00600.x

With the end in mind

Post by Claire Donohoe (@clairedonohoe6), Editorial Assistant BJS, Consultant Oesophagogastric surgeon, Dublin

We need to talk

A critical role of the surgeon is having difficult conversations with patients and their families. Continuously improving our communication skills is as important an aspect of professional development as staying abreast of technological changes. Recent papers in BJS have highlighted the importance of clear decision making at the end of life regarding when to operate1, 2. Recent global events bring the matter in sharper focus.

One potential barrier to making appropriate decisions is engagement with patients, in a time critical manner, to determine their core values and preferences regarding end of life treatment. In “Learning from Regret” the authors noted that perceived communication barriers, regarding poor prognosis with little prospect of ultimate survival, lead to surgeons undertaking emergency surgery and subsequently regretting this decision when they reviewed their patient’s death retrospectively2. In their leader on a “good surgical death” Chamberlain and Blazeby note the importance of early identification of patient’s goals and warned of the rescue culture and death denial that can results in the surgical arena1. Joliat et al. could only identify seven studies in their systematic review which addressed the impact of patient death on surgeons, none of which included interventions to reduce negative impacts3.

Approaching a difficult conversation

Story telling is a powerful tool for enhancing reflection and a potential way of promoting practice change4. “With the End in Mind” is written by a palliative care specialist Dr Kathryn Mannix. In it, she utilises a series of composite accounts of deaths of patients during her career, to illustrate how the experience of death can be managed, symptoms palliated and people comforted5. This book is available for free download in the UK and Ireland until April 6th through this link.  This book aims to give us permission to directly discuss dying.

From a personal perspective, some of the important themes which led me to reflect on my personal practice included how to address the potential collusion of silence between patients, families and healthcare professionals by ensuring that knowledge is shared and exploring what barriers may exist to a shared understanding of what is happening. This can help promote mutual support within families and facilitate open communication by setting the tone.

By taking the lead on broaching difficult conversations, the healthcare professional can take some of the power of un-named worries away and relieve some of the burden of the taboo. Similarly, by directly addressing the usual trajectory of the decline to death in the metastatic cancer setting as well as the well-recognised in the last days and hours of night as described eloquently by Dr Mannix, I have found a sense of control can be imparted to the dying patient and their supporters.

Infographic prepared by Scottish Quality Safety Fellowship Cohort and Open Change on approaching discussions about dying. Reproduced with authors permission.

How to put it into practice?

Some of the lessons from this book and others have been incorporated into an infographic by cohort 12 of the Scottish Quality Safety Fellowship working with design partner Open Change to illustrate an approach to end of life communication entitled “Difficult Conversations – Why we need to talk about dying”. The focus is on breaking down an approach to end of life conversations using honesty and compassion. It provides a framework for the novice and an opportunity to reflect for the more experienced practitioner.

Mastery can enhance a personal sense of control. Mastering communication skills in fraught situations is fundamental to the provision of high quality surgical care and might perhaps, reduce some of the effects of secondary victimhood experience as we care for our dying patients6.

Acknowledgements

With thanks to Dr Lara Mitchell (@laramitchdr), Consultant Geriatrician and Clinical Lead, and Hazel White, Director Open Change (@openchangeuk) for their insight and providing access to their communication resource.

1.            Chamberlain C, Blazeby JM. A good surgical death. BJS 2019; 106(11):1427-1428.

2.            Boyle FM, Allen J, Rey-Conde T, et al. Learning from regret. BJS 2020; 107(4):422-431.

3.            Joliat GR, Demartines N, Uldry E. Systematic review of the impact of patient death on surgeons. British Journal of Surgery 2019.

4.            Zaharias G. What is narrative-based medicine?: Narrative-based medicine 1. Canadian Family Physician 2018; 64(3):176-180.

5.            Mannix K. With the End in Mind: Dying, Death and Wisdom in an Age of Denial. London: Harper Collins, 2017.

6.            Pellino G, Pellino I. Deaths, errors and second victims in surgery: an underestimated problem. BJS 2020; 107(1):152-152.

Prioritising Surgical Treatment in Coronavirus Pandemic “Salford Score”

Prof Gordon Carlson CBE FRCS

Background

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.

PriorityDescription
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 2Elective 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 3Elective surgery can be delayed for 10-12weeks with no predicted negative outcome.
Table 1: NHS England Suggested Priority for Cancer surgery

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

Vulnerability

A second component of this relates to vulnerability of the patient in case of a COVID infection (see table 2).

Vulnerability scoreOutcome 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
Table 2: Vulnerability score

Salford Score

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.

Guest post: Lessons in preparedness – the response to the COVID-19 pandemic by a surgical department in Singapore

Min-Hoe Chew1, Lester WL Ong1, Frederick H Koh1, Aven Ng1, YHA Tan1, Biauw-Chi Ong2

1 Department of General Surgery, Sengkang General Hospital, Singapore

2 Department of Anaesthesiology, Chairman Medical Board, Sengkang General Hospital, Singapore

Background

On 11th March 2020, World Health Organization declared the coronavirus disease (COVID-19) outbreak a pandemic. [1] Over 509,164 people have been infected worldwide with 23,335 deaths [2]. (case fatality-rate 4.6%)

The first imported case of COVID-19 in Singapore occurred on 23rd January 2020. [3] Local transmission was confirmed on 4th February 2020 and the Disease Outbreak Response System Condition (DORSCON) was raised (Orange) on 7th February 2020 [4-5]. As of 27th March 2020, there have been 732 cases in Singapore and 2 deaths. [6] Sengkang General Hospital (SKH) is a 1,400-bed hospital serving a population of 900,000. SKH confirmed its first case on 26th January 2020 and has managed 32 cases to date. [7] SKH Department of General Surgery (GS) has developed response measures to ensure all staff were ready to perform surgery for COVID-19 cases, reduce risks of nosocomial infection, and ensure continuity of care for patients. We describe the Preparation Phase in the initial outbreak, the Evolution Phase (DORSCON Orange), and Crisis Phase planning norms (DORSCON Red). [8-9]

Preparation Phase

Preparation Phasebegan before the first case was reported in Singapore. Cases were initially limited to China [10].  Information was limited; thus, planning was based on experience with Severe Acute Respiratory Syndrome (SARS) outbreak in 2002 [11-12]. A departmental task force was formed to enforce measures implemented by the hospital and develop knowledge specific workflows. Importantly, besides fever and upper respiratory tract symptoms, COVID-19 patients could mimic surgical conditions and have diarrhoea and abdominal pain [13-15].

Communication

The task force ensured accuracy of information disseminated. This suppressed falsehood from social media and maintained morale. This also allowed rapid and effective communication between junior and senior staff, and obtained feedback regarding policies.

Internal surveillance measures

Staff conducted twice daily temperature monitoring. Temperatures were entered into web-based forms via personal smartphones. All staff had Radiofrequency Identification tags facilitating contact tracing should there be exposure. Staff who developed symptoms were to only seek medical consultation within the hospital staff clinic. This enabled symptomatic staff to be identified promptly. 

Training and rehearsals

Hospital-wide refresher training on the use of Personal Protective Equipment (PPE) was conducted. This included N95 mask fitting as well as training on Powered Air-Purifying Respirators (PAPR) (CleanSpace® HALOTM, CleanSpace Technology Pty Ltd, Artarmon, NSW, Australia).

Business Continuity Plan (BCP)

The GS department split into two working teams. One team handled all inpatient services, which included emergency admissions, elective and emergency surgeries and ward rounds; the other team managed outpatient clinics and endoscopy procedures. Every seven days, teams would exchange duties.

The segregation of teams ensured that the department would remain functional should any team member fall ill. Under Singapore guidelines, close contacts of confirmed COVID-19 cases without adequate PPE, will serve a 14-day quarantine. [16] A seven-day cycle was appropriate in view of the reported mean incubation period of 5 days. [10]

Evolution phase

This BCP was executed when Singapore raised the DORSCON level (Orange) on 7th Feb 2020.

Elective and emergency surgeries

Non-urgent, non-cancer surgeries were postponed. Time-sensitive surgeries, such as cancer-related work and limb salvage procedures, could proceed. Surgeons performed elective surgeries during designated weeks.

Outpatient clinics and endoscopy

Outpatient clinic patient volume was reduced by 30%. Non-urgent endoscopy procedures were postponed. Patients attending appointments had temperature checks and performed declarations of travel history and symptoms. Ill patients were diverted to the Emergency Department (ED).

Operational demands

There was a spontaneous reduction in hospital attendances. ED admissions to the surgical department fell 11% (from a median of 156 per week) initially. (Figure 1) OR utility for surgeries reduced by 13% (from a median of 155 per week). (Figure 2) Median outpatient clinic attendances also decreased by 22% compared to the same period (1674 per week in 2019), without any hospital-initiated postponement. (Figure 3)

However, between the fifth and seventh week, the number of emergency admissions increased by 7 to 14% compared to the past year. OR utility returned to normal and outpatient clinic numbers surpassed previous year numbers by 24% in the seventh week.  This was likely due to increased public confidence in Singapore’s response. [17]

Team segregation was subsequently stopped for junior staff to meet manpower demands. Team segregation for senior staff continued.

Crisis Phase (Preparing for DORSCON Red)

In a Crisis phase, it would necessitate expansion of departments such as ED and Intensive Care Unit (ICU). The objective of Crisis Phase planning was to facilitate manpower allocation while maintaining essential surgical capabilities. (Figure 4)

Key aspects of the Crisis Phase plan are:

  1. Reducing OR workload to allow anesthetists to support ICU
  2. Reducing outpatient clinic and endoscopy workload to free staff for deployment
Figure 4. DORSCON escalation planning norms for Department of General Surgery, Sengkang General Hospital

Discussion

The course for the COVID-19 pandemic is likely to be protracted. [18] A surgical department must plan a stepwise reduction of elective work to allow for sustained deployment of manpower to frontline departments, and team segregation to allow for continuity of essential services.

The protection of healthcare staff is vital. Ng et al. reported 85% of 41 healthcare workers were exposed to a COVID-19 patient during an aerosol generating procedure [19]. None acquired the infection even though not all were in N95. Standard hand hygiene practices remain important.

Our department statistics provide a snapshot of Singapore’s health-seeking behaviors. Postponing elective surgeries did not reduce workload and more patients were admitted as emergency cases.

We acknowledge that we have had a very controlled increase in the number of COVID-19 cases; much of this is a result of a national strategy of rapid detection and isolation of cases and aggressive contact tracing. [20] Nonetheless, it is challenging to strike a balance between complacency and overreaction. Premature implementation of drastic measures can lead to staff burnout and resource wastage. Indecisive action however, may result in nosocomial spread and a loss of confidence in hospital leadership. The department has benefitted from the hindsight of the SARS outbreak in 2002.

Conclusion

In the COVID-19 pandemic battle, there are multiple considerations in how a surgical unit functions. Phases of Preparation, Evolution and Crisis will require hard decisions, strong leadership and decisive communication. A robust BCP is essential to ensure that surgical patients continue to have quality care.

References

1. Ghebreyesus TA. World Health Organization. Coronavirus disease 2019 (COVID-19).  WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March 2020. March 11, 2020. Available at:  https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19—11-march-2020. Accessed March 11, 2020.

2. WHO Coronavirus Situation Report 67. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200327-sitrep-67-covid-19.pdf?sfvrsn=b65f68eb_4. Accessed 28th March, 2020.

3. Abdullah Z, Salamat H. Singapore confirms first case of Wuhan virus. January 23, 2020. Available at:  https://www.channelnewsasia.com/news/singapore/wuhan-virus-pneumonia-singapore-confirms-first-case-12312860. Accessed March 14, 2020.

4. Ministry of Health, Singapore. Confirmed cases of local transmission of novel coronavirus infection in Singapore. February 4, 2020. Available at: https://www.moh.gov.sg/news-highlights/details/confirmed-cases-of-local-transmission-of-novel-coronavirus-infection-in-singapore. Accessed March 14, 2020.

5. Ministry of Health, Singapore. Risk assessment raised to DORSCON Orange. February 7, 2020. Available at: https://www.moh.gov.sg/news-highlights/details/risk-assessment-raised-to-dorscon-orange. Accessed March 15, 2020.

6. Ministry of Health Singapore Updates on COVID-19 Local situation. Available on: https://www.moh.gov.sg/covid-19. Accessed March 28, 2020.

7. Channelnewsasia. 4th confirmed case of Wuhan virus in Singapore: MOH. January 26, 2020. Available at:  https://www.channelnewsasia.com/news/singapore/4th-confirmed-case-of-wuhan-pneumonia-virus-in-singapore-moh-12339912. Accessed March 14, 2020.

8. Yeo C, Kaushal S, Yeo D. Enteric involvement of coronaviruses: is faecal-oral transmission of SARS-CoV-2 possible? Lancet Gastroenterol Hepatol. 2020 Apr;5(4):335-337.

9. Ministry of Health, Singapore. Ministry of Health Singapore pandemic readiness and response plan for influenza and other acute respiratory disaeses (revised April 2014). April, 2014. Available from: https://www.moh.gov.sg/docs/librariesprovider5/diseases-updates/interim-pandemic-plan-public-ver-_april-2014.pdf. Accessed on March 20, 2020.

10. Li Q, Guan X, Wu P, et al. Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia. N Engl J Med. 2020 Jan 29. doi: 10.1056/NEJMoa2001316. [Epub ahead of print]

11. Tan CC. SARS in Singapore–key lessons from an epidemic. Ann Acad Med Singapore. 2006 May;35(5):345-9.

12. Chow KYLee CELing ML, et al. Outbreak of severe acute respiratory syndrome in a tertiary hospital in Singapore, linked to an index patient with atypical presentation: epidemiological study. BMJ. 2004 Jan 24;328(7433):195.

13. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; 395: 507-13.

14. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease, (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648. [Epub ahead of print]

15. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan. China. Lancet 2020; 395: 497-506.

16. Ministry of Health, Singapore. Multiple lines of defence to guard against local spread of COVID-19. March 13, 2020. Available from: https://www.gov.sg/article/multiple-lines-of-defence-to-guard-against-local-spread. Accessed on March 22, 2020.

17. Ipsos. Singaporeans are confident in the Government amidst fears of the COVID-19 outbreak. March 16, 2020. Available from: https://www.ipsos.com/en-sg/singaporeans-are-confident-government-amidst-fears-covid-19-outbreak. Accessed on March 22, 2020.

18. Tan A. Covid-19 likely to last till end-2020 at least: Experts. March 9, 2020. Available from: https://www.straitstimes.com/singapore/health/coronavirus-covid-19-likely-to-last-till-end-2020-at-least-experts. Accessed on March 22, 2020.

19. Ng K, Poon BN, Kiat Puar TH, et al. COVID-19 and the risk to health care workers: a case report. Ann Intern Med 2020 Mar 16. Doi:10.7326/L20-0175 (Epub ahead of print)

20. Wong JEL, Leo YS, Tan CC. COVID-19 in Singapore-Current Experience: Critical Global Issues That Require Attention and Action. JAMA. 2020 Feb 20. doi: 10.1001/jama.2020.2467. [Epub ahead of print]

BJSOpen April 2020 issue published.

BJSOpen is a fully-online and open access journal & is proud to publish high-quality surgical research. This month, papers span surgical oncology, methdology, benign disease, and global surgery. The full table of contents is here.

We would also like to draw your attention to the EHS/AHS guidelines on primary hernias in rare locations or special circumstances.

images from this months BJS open
Some of the key images from this months papers

Methodology

Anyone submitting papers to a journal will be familiar with the role of checklists. These are intended to improve the quality of reporting of publications. This review has assessed how well benefits and harms of treatments are reported in surgical trials. It shows that the surgical community needs to do better; outcomes were poorly described, or presented in a manner where it was not possible to interpret effect sizes with any degree of precision.

Randomised trials

Whilst breast cancer surgery aims to conserve breast tissue, mastectomy is still an important tool for the breast surgeon. One of the problems seen here is with bleeding from this typically vascular area. This Norwegian trial randomised 208 patients to either topical tranexamic acid or topical saline to wound edges for haemostasis. There was reduced drain output in the TXA group. There was also a non-significant (but interesting) reduction in the rate of haematomas. 

The pilonidal sinus is a sadly unloved condition. This is despite being a constant presence for the colorectal surgeon. This RCT compared alginate vs DACC (hydrophobic-type) dressings in wound healing after excision of pilonidal sinus. There was no difference in wound healing at 75 days on the per-protocol analysis. The trial needed 222 patients to complete to reach power calculations and managed to retain 200 patients. There might be other things to learn about trial management. This population is quite young and may pose problems with recruiting to trials

Surgical oncology

Other surgical oncology papers this month include a review of outcomes of immediate and delayed autologous breast reconstruction in post-mastectomy radiotherapy. This is a well conducted review and highlights the issues with the literature. On a related note, this patient survey on immediate breast reconstruction is interesting. It looks at some of the important socioeconomic factors that drive patient decision making around this treatment.

For the HPB surgeons, a cohort study shows the outcomes of resection for HCC with tumour thrombus extending into the IVC. In practice, this is a small group with advanced disease and this is shown by a 20 year case series. And not forgetting the oesophagogastric surgeons, we have a retrospective cohort study comparing laparoscopic proximal gastrectomy with double‐flap technique versus laparoscopic subtotal gastrectomy for proximal early gastric cancer. This study was intended to assess the impact on nutrition between these two approaches. No difference in these outcomes were seen.

Advanced cancer

This is a growing field, and this growth is reflected in the many submissions we receive on this topic.Two of the big questions are on the prediction of development of peritoneal disease, and the role of chemotherapy dosing in HIPEC.

A large cohort study from the Danish Colorectal Database has tried to answer the first of these questions. Rates of metastatic peritoneal disease were low, but factors such as advanced tumour or node stage were associated with early presentations, whereas R1 resection was associated with recurrence at 3 years.

The second question was addressed by the PRODIGE 7 trial, which suggested cytoreductive surgery was key in treatment of peritoneal disease. This is reflected in a cohort study of ‘real world’ experience from the Netherlands. This has compared intraperitoneal chemotherapy outcomes based on agents used and adjusted for body surface area. It doesn’t seem to disagree with PRODIGE 7… 

On a related note, the introduction of new technology demands robust assessment. For surgeons this typically follows the IDEAL framework. This review has looked at reports on the development of Pressurized intraperitoneal aerosol chemotherapy (PIPAC), which is based on laparoscopy to deliver intraperitoneal chemotherapy for peritoneal metastases. We now know that we are following the rules with this technology. However, progress is slow and we need bigger definitive studies to understand efficacy.

Global surgery

There are two papers on global surgery this month. One highlights the challenges related to deployment of electrosurgical and laparoscopic kit in LMICS. This shows that equipment is available, but surgeons still had problems using or maintaining it. The second paper shows that traumatic brain injury is common in Uganda, with a male preponderance. The mortality rate in this group is 33%. The authors suggest this may be influenced by limited access to CT and ICP monitoring.

Summary

These are just some of the papers published in this issue of BJSOpen. We welcome direct submissions to the journal. If you think your work would fit in here, please have a look at the instructions for authors page.