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 6ththrough 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.
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.
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.
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.
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 2
Elective 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 3
Elective 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
A second component of this relates to vulnerability of the patient in case of a COVID infection (see table 2).
Outcome 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
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.
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
On 11th March 2020, World Health Organization declared the coronavirus disease (COVID-19) outbreak a pandemic.  Over 509,164 people have been infected worldwide with 23,335 deaths . (case fatality-rate 4.6%)
The first imported case of COVID-19 in Singapore occurred on 23rd January 2020.  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.  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.  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 Phasebegan before the first case was reported in Singapore. Cases were initially limited to China . 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].
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.  A seven-day cycle was appropriate in view of the reported mean incubation period of 5 days. 
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).
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. 
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:
Reducing OR workload to allow anesthetists to support ICU
Reducing outpatient clinic and endoscopy workload to free staff for deployment
The course for the COVID-19 pandemic is likely to be protracted.  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 . 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.  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.
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.
12. Chow KY, Lee CE, Ling 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.
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.
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.
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.
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.