Maria Picciochi (@MariaPicciochi), Hospital Prof Doutor Fernando Fonseca, Portugal
Dmitri Nepogodiev (@dnepo), University Hospital Birmingham, UK
Virtually all elective surgical services around the world suffered some form of shutdown due to the COVID-19 pandemic1. Now, patients and surgeons are desperately looking to re-start services. Efforts to re-start after the first waves faced multifactorial challenges, including patient safety and ensuring enough staff along the whole patient pathway to support operating theatre availablity.2,3
The impact of the reduction in surgical capacity is likely to be staggering. Initial estimates of 28 million cancelled operations likely escalated to 50 million towards Autumn 2020, and may now be in excess of 100 million. That is only one part of the story, since the many undiagnosed patients with surgical conditions sitting in the community over the last 12 months may never make it to a surgeon or waiting list. Without adequate surgical capacity, there will be a major global decline in population health due to the burden of a full range of inadequately treated non-communicable diseases.
There is no single factor or solution that will enable surgery to re-start at scale, quickly. There is no single set of solutions that will work across every region. Since every single hospital around the world functions differently, context specific and whole system solutions are needed.
Vaccination will hopefully provide solutions to the current pandemic, although the global rollout is occurring at different paces globally, meaning surgical recoveries will differ. Cultural challenges across countries are adding to this variation. Unlike acute major incidents which disable elective surgical but are quickly over (e.g. major trauma or bombings), this pandemic has exposed specific, longer-term weaknesses of current systems. Post-pandemic planning will now happen across all spectrums of society. Surgeons need to lead efforts to create resilient elective surgical services that are pandemic resistant for the future, advocating for hospital and political awareness.
The COVIDSurg collaborative has taken a data driven approach to supporting safe surgery, and for 2021-2022 will provide further data to support re-starts globally. Data is needed across the whole system and patient pathway, that includes referrals, preoperative selection, perioperative testing and safety, postoperative risk reduction, and structural organisation of hospitals4–6.
Figure 1 – Centres enrolled in COVIDSurg studies
Learning from other non-medical disciplines, surgeons have little barometer of how secure their elective surgical services are compared to everyone else’s. COVIDSurg will deliver a validated Elective Surgery Resilience Index in the first half of 2021, allowing surgeons to test their systems and identify areas for immediate strengthening.
Re-starting surgery safely will be a complex interplay of these multiple factors. Not all resources will be available across all regions, and in some resource limited settings, surgery is at risk of being seen as a burden. To further support the re-start, an easily accessible, digital, online toolkit is needed that will provide key take-home messages and downloadable pathways for surgical teams to take and adapt. This will include the ability to self-certify individual department and hospital level of COVID Secure Surgery. This will provide the building blocks to provide ring-fenced, pandemic secure surgery by 2030.
Conflicts of interest: We have no conflicts of interest to declare.
Funding: No funding was received for this blog article.
1. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020;107(11):1440-1449. doi:10.1002/bjs.11746
2. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative sars-cov-2 infection: An international cohort study. Lancet. 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-X
3. COVIDSurg Collaborative. COVID-19-related absence among surgeons: development of an international surgical workforce prediction model. BJS Open. doi:10.1093/BJSOPEN/ZRAA021
4. COVIDSurg Collaborative. Outcomes from elective colorectal cancer surgery during the SARS‐CoV‐2 pandemic. Color Dis. December 2020:codi.15431. doi:10.1111/codi.15431
5. COVIDSurg Collaborative. Elective cancer surgery in COVID-19–Free surgical pathways during the SARS-cov-2 pandemic: An international, multicenter, comparative cohort study. J Clin Oncol. 2021;39(1):66-78. doi:10.1200/JCO.20.01933
6. COVIDSurg Collaborative. Preoperative nasopharyngeal swab testing and postoperative pulmonary complications in patients undergoing elective surgery during the SARS-CoV-2 pandemic. Br J Surg. 2021;108(1):88-96. doi:10.1093/bjs/znaa051
Yongbo An (@an_yongbo), Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
Vittoria Bellato (@vittoriabellat0), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
Gianluca Pellino (@GianlucaPellino), Department of Advanced Medical and Surgical Sciences, Universita degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy; Department of Colorectal Surgery, Vall d’Hebron University Hospital, Barcelona, Spain
Tsuyoshi Konishi (@yoshi_konishi), Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, 1400 Pressler Street, Unit 1484, Houston, Texas 77030
Giuseppe S Sica (@sigisica), Department of Surgery, Minimally Invasive Unit, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
on behalf of S-COVID Collaborative Group
The epicentre of the SARS-CoV2 outbreak has been shifting from place to place, hitting many countries in the world. The feelings of angst, distress and desperation have also spread along with the virus among healthcare workers (HCW). It is hard to forget the early voices from the frontline HCW, the rapidly worsening situation during the escalating phase,1which seems to be occurring again in countries that are being hit by the second wave.2
1/ I may be repeating myself, but I want to fight this sense of security that I see outside of the epicenters, as if nothing was going to happen “here”. The media in Europe are reassuring, politicians are reassuring, while there’s little to be reassured of. #COVID19#coronavirus
The early working experience originally narrated by an Italian doctor Daniele Macchini. English translation by Silvia Stringhini on twitter.
Surgeons’ fear of getting infected by SARS-CoV-2 and developing COVID-19, as well as the change of their daily surgical practice, has been described since the early stage of the pandemic.3 Despite the varying rates of infected people among countries, surgeons have experienced globally a common angst about the virus due to their high-risk job.
China, as the first country facing the virus, had limited previous knowledge and experience about COVID-19 to refer to. The HCW were immediately frightened by what they witnessed: emergency rooms filled with patients infected by an unfamiliar type of virus, followed by overwhelmed intensive care units. Since the escalation of the epidemic in Wuhan was so rapid, most elective surgeries in China were cancelled and not resumed until mid-March 2020.4 The fear of the unknown had forced most hospitals to stop surgical practice, leading to a serious backlog of surgical patients. Due to lack of staff, many surgeons were frequently re-employed to work in intensive care unit or fever clinic, causing a feeling of inadequacy to work in a medical area for which they were not trained. During the post-epidemic period, the mental stress among surgical staff persisted due to the extensive surgical backlog and the additional work involved in ensuring a safe environment for newly hospitalized patients through creation of selective safe routes and adequate personal protective equipment (PPE) adoption.5
Surgeons in Europe have probably suffered even worse situations. Fear of getting infected has led HCW to feel a threat to their life because of their work. In the early phase, a vascular surgeon from the UK spoke out about such dreads, and acknowledged the importance of looking after surgeon’s mental well-being.6 Otolaryngology-ENT, and maxillofacial specialties were regarded as those at highest risk, therefore, a team from the Head and Neck Unit of the Royal Marsden NHS Foundation Trust and Lewisham Child and Adolescent Mental Health Services analysed the impact of COVID-19 on the mental health of surgeons. The fear of contracting the virus and transmitting to family members represented important factors affecting mental health of HCW during the pandemic.7 Many HCW were self-isolating from their family and many decided to left their homes, while others moved into their garages and basements.8, 9
In US, where the pandemic hit in the summer, surgeons also expressed their angst during work. Shortage of PPE and lack of a coordinated pandemic plan from the central government further exacerbated the fear. During the early phase of the pandemic, surgeons from US declared “guilt and fear are to some extent pervasive in medical practice”, “any provider during this time that says they aren’t impacted is not being truthful with themselves”.10, 11
Another key element that has generated stress among doctors has been the uncertainty of how to treat a completely unknown disease. Data were lacking and indications were changing frequently, causing confusion and misinformation. An explicative example is given by guidelines on use of surgical masks: WHO and many governments initially banned the use of adequate PPE in hospital daily practice when dealing with asymptomatic people, due to lack of scientific evidence and lack of stock of PPE.
Surveys among HCW have become a fast and effective way to provide updated data to guide medical choices during this unprecedented time.12, 13 A survey from Mexico investigated personal feelings among 150 vascular surgeons; with ten short but detailed questions, the results of the survey showed that the greatest fear was to infect their families. More than half of the respondents thought that PPE supply was inadequate and 61% of the respondents did not agree with the way government and the Health secretary have handled the pandemic.14
A survey among 150 vascular surgeons from Mexico, investigating their feelings and life during COVID-19 pandemic.
Another regional survey from a tertiary academic centre in Singapore investigated psychological health condition among 45 surgical providers during the pandemic. The results revealed that 77.8% of respondents were experiencing fear of contracting COVID-19, and 88.9% reported fear of spreading the virus to their families. Doctors in training suffered worse mental health condition than other colleagues;15 a national survey explored factors associated mental health disorders among 1001 young surgical residents and fellows in France, finding that enough PPE supply and sufficient training on preventing COVID-19 could decrease the possibility of developing anxiety, depression and insomnia.16During early April 2020, the S-COVID Collaborative conducted a global survey among surgeons from 71 countries, revealing that the fear of getting infected by COVID-19 or infecting others was indeed very common among the respondents from all over the world. Furthermore, the analysis showed that shortage of surgical masks, dissatisfaction towards hospital’s preventive measures and experiencing in-hospital infections were associated with surgeon’s fear.17
A global survey of surgeons’ fear of getting infected by COVID-19, conducted by S-COVID group
Indeed, factors associated with surgeons’ fear, elicited from the above global survey, are preventable. Since comprehensive meta-analysis and reviews have clarified the effectiveness of face masks,18 and additional supply strategies have been established,19 the shortage of face masks and other PPE could be fully managed. Another action which could reduce anxiety and stress of the HCW would be intensive SARS-CoV-2 screening. In Wuhan, universal screening for all 10 million residents was completed in May. “The physical lockdown on the city was lifted on April 8, and after the testing campaign was finished, the psychological lockdown on Wuhan people has also been lifted.” Such universal screening would also reassure the surgeons as well as other HCW.20, 21
Unfortunately, before the normal life and work could be resumed (even if known as “new normality”), the second wave of the pandemic started. Sentiments of fear, angst, anxiety are likely to impact heavily citizens and HCW. The surgical staff is already facing heavier workload due to the backlog of surgical patients during the pandemic – which might be even worse, as many did not have enough time to recover from the first wave. If one takes into account that more than 28 million elective surgeries have been cancelled or postponed worldwide,22 the resulting picture is extremely worrisome. Besides the upcoming enormous workload, asymptomatic COVID-19 patients are still acting as threats for hospitals, making the daily work of surgeons harder than usual.23
It is well acknowledged that surgeons are always working under great pressure, burnout due to work is a common finding among surgeons.24 However, the pandemic has generated an unprecedented situation, in which HCW are being overwhelmed by their angst and fears. Medical litigations are also likely to increase in the next months, adding to HCW sense of uncertainty and inappropriateness.25 It is mandatory that the public opinion, the press and social media contribute to offer a balanced and realistic overview of the conditions in which HCW are being forced to work; and that societies and entities collaborate to create strategies to prevent such conditions,26 and to help HCW who are struggling, left alone.
13. Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS. Screening policies, preventive measures and in-hospital infection of COVID-19 in global surgical practices. Journal of global health 2020;10(2): 020507.
15. Tan YQ, Chan MT, Chiong E. Psychological health among surgical providers during the COVID-19 pandemic: a call to action.n/a(n/a).
16. Vallée M, Kutchukian S, Pradère B, Verdier E, Durbant È, Ramlugun D, Weizman I, Kassir R, Cayeux A, Pécheux O, Baumgarten C, Hauguel A, Paasche A, Mouhib T, Meyblum J, Dagneaux L, Matillon X, Levy-Bohbot A, Gautier S, Saiydoun G. Prospective and observational study of COVID-19’s impact on mental health and training of young surgeons in France.n/a(n/a).
17. An Y, Bellato V, Konishi T, Pellino G, Sensi B, Siragusa L, Franceschilli M, Sica GS, Group S-CC. Surgeons’ fear of getting infected by COVID19: A global survey.n/a(n/a).
18. Chu DK, Akl EA, Duda S, Solo K, Yaacoub S, Schünemann HJ. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet (London, England) 2020.
19. Zeidel ML, Kirk C, Linville-Engler B. Opening Up New Supply Chains. New England Journal of Medicine 2020: e72.
23. Bellato V, Konishi T, Pellino G, An Y, Piciocchi A, Sensi B, Siragusa L, Khanna K, Pirozzi BM, Franceschilli M, Campanelli M, Efetov S, Sica GS, Group S-CC. Impact of asymptomatic COVID-19 patients in global surgical practice during the COVID-19 pandemic.n/a(n/a).
25. Pellino G, Pellino IM, Pata F. Uncovering the Veils of Maya on defensive medicine, litigation risk, and second victims in surgery: care for the carers to protect the patients. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.
26. Pellino G, Vaizey CJ, Maeda Y. The COVID-19 pandemic: considerations for resuming normal colorectal services. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2020.