Impact of COVID-19 on access and availability of radiological imaging and surgical intervention at the East Midlands Major Trauma Centre: An ICON Trauma StudySeehra, J K; Lewis-Lloyd, C; Gida, G; Adiamah, A; Brooks, A; , ; ,
doi: 10.1093/bjs/znab014pmid: 33723581
Dear Editor The novel coronavirus SARS-CoV-2 disease (COVID-19) was declared a pandemic in March 2020. There became an urgent necessity to redistribute resources, optimize care flow pathways and reorganize staff, systems and space within all UK hospitals1. Major trauma services adjusted to reduced access to CT and had to restructure operative flow due to limited intensive care beds. Current best practice, as outlined by the Royal College of Radiologists, recommends CT to be available within 15 minutes of a major trauma admission2. The National Emergency Laparotomy Audit (NELA) suggests a door to theatre time for immediate surgery as less than 2 hours and 2–6 hours for urgent surgery3. Additionally, the Trauma Audit and Research Network (TARN) advises that time to theatre should be less than 60 minutes for injuries with significant haemorrhage4. The Impact of COVID‐19 on Major Trauma workload (ICON Trauma) initiative was extended to investigate the availability and timeliness of CT and emergency operating during the COVID-19 national lockdown5. An observational study from the East Midlands Major Trauma Centre (EM-MTC) compared two cohorts of patients admitted over a 10-week period during COVID-19 (March–May 2020) and the same time period in 2019 (March–May 2019). Hospital record data were collated to a secure online platform (REDCap Cloud; https://www.redcapcloud.com) and analysed using STATA® v16 (StataCorp, College Station TX, USA). Variables included demographics, time to CT and surgery, management approaches, and operative characteristics. Data normality was assessed by visualizing distribution plots, with non-parametric data presented as median (i.q.r.) values. Statistical comparison was undertaken using Mann–Whitney U, Fisher’s exact and χ2 tests as appropriate, and P <0.050 was deemed statistically significant. Of 642 patients, 405 were admitted in 2019 and 237 in 2020, representing a 41.5 per cent absolute reduction in trauma admissions during the COVID-19 period (Table 1). No statistical differences were noted between arrival in the emergency department and time to CT, with a median of 42 minutes from admission. Within subgroup analysis of surgical patients, there were significant differences in the time to surgery(P = 0.019) and duration of surgery (P = 0.014). We found a 31.2 per cent increase in patients operated on within 24 hours of admission and a 42.9 per cent reduction in surgery lasting more than 120 minutes during the COVID-19 pandemic. There was more than a twofold increase in night-time operations occurring between 22.00 and 08.00 hours during COVID-19. No differences in type or time of surgery, surgical approach or level of postoperative care were observed. Table 1 Comparison of 2019 and 2020 cohorts . 2019 cohort (n = 405) . 2020 COVID-19 cohort (n = 237) . P . Age (years)* 40 (24–59) 46 (28–60) 0.050** Sex ratio (F : M) 120 : 285 62 : 175 0.347†† Time to CT (min)* From arrival in ED† 42 (24–112) 42 (24–75) 0.259** From CT decision‡ 28 (16–70) 32 (17–77) 0.667** Definitive management Conservative 274 (67.7) 175 (73.8) Interventional radiology 2 (0.5) 0 (0) 0.112‡‡ Surgical§ 129 (31.9) 62 (26.2) COVID-19 diagnosis Negative 405 (100) 233 (98.3) 0.018§§ Positive 0 (0) 4 (1.7) Type of primary surge n = 129 n = 62 General and vascular surgery/laparotomy 14# (10.9) 9 (15) 0.145†† Thoracic surgery/thoracotomy 3 (2.3) 2 (3) Neurosurgery 15 (11.6) 3 (5) Orthopaedic/spinal 81 (62.8) 33 (53) Other¶ 16 (12.4) 15 (24) Primary surgical approach Open 126 (97.7) 60 (97) 0.728§§ Laparoscopic converted to open 1 (0.8) 0 (0) Laparoscopic 2 (1.6) 2 (3) Time to primary surgery (h) <24 65 (50.4) 41 (66) 0.019‡‡ 24 to <48 42 (32.6) 16 (26) 48 to <72 11 (8.5) 4 (6) ≥72 11 (8.5) 1 (2) Time of primary surgery 0800–18.00 hours (day) 93 (72.1) 41 (66) 0.058†† 18.00–22.00 hours (evening) 21 (16.3) 6 (10) 22.00–08.00 hours (night) 15 (11.6) 15 (24) Duration of primary operation (min) <30 4 (3.1) 6 (10) 0.014‡‡ 30–60 18 (14.0) 8 (13) 61–90 21 (16.3) 16 (26) 91–120 24 (18.6) 15 (24) >120 62 (48.1) 17 (27) Postoperative level of care Ward (level 1) 92 (71.3) 44 (71) 0.788§§ HDU (level 2) 5 (3.9) 1 (2) ICU (level 3) 32 (24.8) 17 (27) . 2019 cohort (n = 405) . 2020 COVID-19 cohort (n = 237) . P . Age (years)* 40 (24–59) 46 (28–60) 0.050** Sex ratio (F : M) 120 : 285 62 : 175 0.347†† Time to CT (min)* From arrival in ED† 42 (24–112) 42 (24–75) 0.259** From CT decision‡ 28 (16–70) 32 (17–77) 0.667** Definitive management Conservative 274 (67.7) 175 (73.8) Interventional radiology 2 (0.5) 0 (0) 0.112‡‡ Surgical§ 129 (31.9) 62 (26.2) COVID-19 diagnosis Negative 405 (100) 233 (98.3) 0.018§§ Positive 0 (0) 4 (1.7) Type of primary surge n = 129 n = 62 General and vascular surgery/laparotomy 14# (10.9) 9 (15) 0.145†† Thoracic surgery/thoracotomy 3 (2.3) 2 (3) Neurosurgery 15 (11.6) 3 (5) Orthopaedic/spinal 81 (62.8) 33 (53) Other¶ 16 (12.4) 15 (24) Primary surgical approach Open 126 (97.7) 60 (97) 0.728§§ Laparoscopic converted to open 1 (0.8) 0 (0) Laparoscopic 2 (1.6) 2 (3) Time to primary surgery (h) <24 65 (50.4) 41 (66) 0.019‡‡ 24 to <48 42 (32.6) 16 (26) 48 to <72 11 (8.5) 4 (6) ≥72 11 (8.5) 1 (2) Time of primary surgery 0800–18.00 hours (day) 93 (72.1) 41 (66) 0.058†† 18.00–22.00 hours (evening) 21 (16.3) 6 (10) 22.00–08.00 hours (night) 15 (11.6) 15 (24) Duration of primary operation (min) <30 4 (3.1) 6 (10) 0.014‡‡ 30–60 18 (14.0) 8 (13) 61–90 21 (16.3) 16 (26) 91–120 24 (18.6) 15 (24) >120 62 (48.1) 17 (27) Postoperative level of care Ward (level 1) 92 (71.3) 44 (71) 0.788§§ HDU (level 2) 5 (3.9) 1 (2) ICU (level 3) 32 (24.8) 17 (27) Values in parentheses are percentages unless indicated otherwise; * values are median (i.q.r.). ED, emergency department; HDU, high dependency unit. † 2019, n = 296; 2020, n = 151. ‡ 2019, n = 231; 2020, n = 117. § Includes patients who had interventional radiological embolization before surgery (2 in 2019, 1 in 2020). ¶ Includes plastic, oral and maxillofacial, and ear, nose and throat surgery. # Includes one patient who underwent laparotomy and thoracotomy. ** Mann–Whitney U test; †† χ2 test; ‡‡ χ2 test for trend; §§ Fisher's exact test. Open in new tab Table 1 Comparison of 2019 and 2020 cohorts . 2019 cohort (n = 405) . 2020 COVID-19 cohort (n = 237) . P . Age (years)* 40 (24–59) 46 (28–60) 0.050** Sex ratio (F : M) 120 : 285 62 : 175 0.347†† Time to CT (min)* From arrival in ED† 42 (24–112) 42 (24–75) 0.259** From CT decision‡ 28 (16–70) 32 (17–77) 0.667** Definitive management Conservative 274 (67.7) 175 (73.8) Interventional radiology 2 (0.5) 0 (0) 0.112‡‡ Surgical§ 129 (31.9) 62 (26.2) COVID-19 diagnosis Negative 405 (100) 233 (98.3) 0.018§§ Positive 0 (0) 4 (1.7) Type of primary surge n = 129 n = 62 General and vascular surgery/laparotomy 14# (10.9) 9 (15) 0.145†† Thoracic surgery/thoracotomy 3 (2.3) 2 (3) Neurosurgery 15 (11.6) 3 (5) Orthopaedic/spinal 81 (62.8) 33 (53) Other¶ 16 (12.4) 15 (24) Primary surgical approach Open 126 (97.7) 60 (97) 0.728§§ Laparoscopic converted to open 1 (0.8) 0 (0) Laparoscopic 2 (1.6) 2 (3) Time to primary surgery (h) <24 65 (50.4) 41 (66) 0.019‡‡ 24 to <48 42 (32.6) 16 (26) 48 to <72 11 (8.5) 4 (6) ≥72 11 (8.5) 1 (2) Time of primary surgery 0800–18.00 hours (day) 93 (72.1) 41 (66) 0.058†† 18.00–22.00 hours (evening) 21 (16.3) 6 (10) 22.00–08.00 hours (night) 15 (11.6) 15 (24) Duration of primary operation (min) <30 4 (3.1) 6 (10) 0.014‡‡ 30–60 18 (14.0) 8 (13) 61–90 21 (16.3) 16 (26) 91–120 24 (18.6) 15 (24) >120 62 (48.1) 17 (27) Postoperative level of care Ward (level 1) 92 (71.3) 44 (71) 0.788§§ HDU (level 2) 5 (3.9) 1 (2) ICU (level 3) 32 (24.8) 17 (27) . 2019 cohort (n = 405) . 2020 COVID-19 cohort (n = 237) . P . Age (years)* 40 (24–59) 46 (28–60) 0.050** Sex ratio (F : M) 120 : 285 62 : 175 0.347†† Time to CT (min)* From arrival in ED† 42 (24–112) 42 (24–75) 0.259** From CT decision‡ 28 (16–70) 32 (17–77) 0.667** Definitive management Conservative 274 (67.7) 175 (73.8) Interventional radiology 2 (0.5) 0 (0) 0.112‡‡ Surgical§ 129 (31.9) 62 (26.2) COVID-19 diagnosis Negative 405 (100) 233 (98.3) 0.018§§ Positive 0 (0) 4 (1.7) Type of primary surge n = 129 n = 62 General and vascular surgery/laparotomy 14# (10.9) 9 (15) 0.145†† Thoracic surgery/thoracotomy 3 (2.3) 2 (3) Neurosurgery 15 (11.6) 3 (5) Orthopaedic/spinal 81 (62.8) 33 (53) Other¶ 16 (12.4) 15 (24) Primary surgical approach Open 126 (97.7) 60 (97) 0.728§§ Laparoscopic converted to open 1 (0.8) 0 (0) Laparoscopic 2 (1.6) 2 (3) Time to primary surgery (h) <24 65 (50.4) 41 (66) 0.019‡‡ 24 to <48 42 (32.6) 16 (26) 48 to <72 11 (8.5) 4 (6) ≥72 11 (8.5) 1 (2) Time of primary surgery 0800–18.00 hours (day) 93 (72.1) 41 (66) 0.058†† 18.00–22.00 hours (evening) 21 (16.3) 6 (10) 22.00–08.00 hours (night) 15 (11.6) 15 (24) Duration of primary operation (min) <30 4 (3.1) 6 (10) 0.014‡‡ 30–60 18 (14.0) 8 (13) 61–90 21 (16.3) 16 (26) 91–120 24 (18.6) 15 (24) >120 62 (48.1) 17 (27) Postoperative level of care Ward (level 1) 92 (71.3) 44 (71) 0.788§§ HDU (level 2) 5 (3.9) 1 (2) ICU (level 3) 32 (24.8) 17 (27) Values in parentheses are percentages unless indicated otherwise; * values are median (i.q.r.). ED, emergency department; HDU, high dependency unit. † 2019, n = 296; 2020, n = 151. ‡ 2019, n = 231; 2020, n = 117. § Includes patients who had interventional radiological embolization before surgery (2 in 2019, 1 in 2020). ¶ Includes plastic, oral and maxillofacial, and ear, nose and throat surgery. # Includes one patient who underwent laparotomy and thoracotomy. ** Mann–Whitney U test; †† χ2 test; ‡‡ χ2 test for trend; §§ Fisher's exact test. Open in new tab The EM-MTC was able to make early preparations in 2020, anticipating the expected disruptions of COVID-19. The present results show a significant reduction in major trauma admissions, similar to observations reported elsewhere5. Interestingly, there was no difference in time to radiological imaging when 2020 was compared with 2019. This was achieved by streamlining CT scanning for COVID-suspected and non-suspected patients, and facilitated by having two CT rooms within the emergency department and 24-hour reporting availability. Overall, during the COVID-19 pandemic, most medical and surgical specialties reported a decreased workload. In addition, there was a curtailing of the elective workload to free up bed availability for patients with COVID-196. The unintended beneficial consequence from a trauma perspective was the prompt availability of theatre spaces and personnel, potentially explaining the shorter duration to surgical intervention during the 2020 period. Additionally, the presence of a 24-hour dedicated trauma surgeon, supported by senior surgical trainees, encouraged single-stage definitive operations with a shift towards quicker surgical technique. Importantly, having this dedicated workforce ensured more operations were undertaken overnight (22.00 to 08.00 hours) during the COVID-19 period than in 2019. Early robust restructuring of staff, space and services in the COVID-19 period allowed the EM-MTC to maintain excellence in patient care. Improvements to the major trauma pathway have become ingrained into daily practice and optimized for future outbreaks. Collaborators ICON Trauma Study Group members: A. Adiamah, F. Anis, L. Blackburn, H. Brewer, A. Brooks, R. Brailsford, S. Boardman, A. Dahaley, E. Dickson, Z. Draper, R. Friej, W. Gaskin, S. Gida, L. Hutchinson, J. Jackman, A. Kapeleris, A. Koh, C. Lamb, C. Lewis-Lloyd, A. La Valle, R. Lee, S. McSweeney, Y. Nassif, A. Navarro, R. O’Connor, C. O’Sullivan, O. Oyende, J.-J. Reilly, JK. Seehra, J. Saunders, S. Sanderson, A. Thompson, E. Theophilidou, S. Walsh, R. Winter. Members of the ICON Trauma Study Group may be found under the heading Collaborators Acknowledgements JK.S., C.L.-L. and G.G. are joint first authors of this publication. Disclosure: The authors declare no conflict of interest. References 1 Tahmassebi R , Bates P , Trompeter A , Bhattacharya R , El-Daly I , Jeyaseelan L et al. Reflections from London’s level-1 major trauma centres during the COVID crisis . Eur J Orthop Surg Traumatol 2020 ; 30 : 951 – 954 Google Scholar Crossref Search ADS PubMed WorldCat 2 Royal College of Radiologists. Standards of Practice and Guidance for Trauma Radiology in Severely Injured Patients . London : Royal College of Radiologists , 2011 Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 3 National Emergency Laparotomy Audit. National Emergency Laparotomy Audit (NELA): Participant Manual; 2015 . https://www.nela.org.uk/NELADocs (accessed 26 January 2021) 4 Trauma Audit and Research Network. Major Trauma Dashboard; 2016 . https://www.tarn.ac.uk/content/downloads/53/Example%20TU%20dashboard.pdf (accessed 26 January 2021) 5 Adiamah A , Moody N , Blackburn L , Dickson E , Thompson A , Reilly JJ et al. ICON Trauma (Impact of COVID-19 on Major Trauma workload) study . Br J Surg 2020 ; 107 : e412 – e413 Google Scholar Crossref Search ADS PubMed WorldCat 6 Søreide K , Hallet J , Matthews JB , Schnitzbauer AA , Line PD , Lai PBS et al. Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services . Br J Surg 2020 ; 107 : 1250 – 1261 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. 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COVID-19 restrictions on multidisciplinary team meeting decision-making: service evaluation in a major UK cancer centreTo, N; Bekker, H L; Henry, K; Melling, P; Turley, J; Lodge, J P A; Young, A L
doi: 10.1093/bjs/znab009pmid: 33778851
Dear Editor COVID-19 has caused significant disruption to National Health Service (NHS) services, with resources redirected to combat the virus pandemic1. This has had a knock-on effect on other patient groups, such as those with cancer. There are reports of an increase in the number of avoidable deaths from cancer during the pandemic2. Cancer multidisciplinary team (MDT) meetings form a crucial part of the cancer care pathway. The effects of the pandemic on MDT function need to be explored as this may have direct implications for the quality of a patient’s cancer care. A service evaluation was used to assess the impact of COVID-19 on cancer MDT function at Leeds Teaching Hospitals NHS Trust in the UK. This is a cancer care provider to 4.5 million people. Mixed methods were employed for analysis of both routinely collected MDT activity data and questionnaires of staff experiences. Three time frames were assessed: period 1, before any impact of COVID-19 (January to February 2020); period 2, full lockdown owing to COVID-19 (April to May 2020); and period 3, recovery when NHS functioning had been reinstated (July to August 2020). The transition intervals between these time periods (March and June) were excluded to ensure clear separation of data. Thirty-one different cancer MDTs were included. Analysis demonstrated a 37 per cent reduction in total number of patients discussed weekly between period 1 (874) and period 2 (548) (Fig. 1). An increase in numbers of patients discussed was observed in period 3 (679), although these were still only 78 per cent of pre-COVID levels. Marked differences were observed between teams, which may reflect different challenges in terms of diagnostic availability, clinical teams or patient groups (Fig. 1). Fig. 1 Open in new tabDownload slide Total number of patients discussed each week in cancer multidisciplinary team meetings CUP, cancer of unknown primary; ACE, accelerate, coordinate evaluate. Fig. 1 Open in new tabDownload slide Total number of patients discussed each week in cancer multidisciplinary team meetings CUP, cancer of unknown primary; ACE, accelerate, coordinate evaluate. A total of 90 MDT members completed the survey (response rate 35 per cent). The results demonstrated a drop in the number of MDTs continuing with face-to-face meetings (63 per cent), with the majority making changes including limiting attendees, social distancing, use of face masks, and use of virtual software. Feedback on the experience of virtual MDT meetings was that 79 per cent of respondents found them less interactive and 80 per cent reported that communication was disadvantaged. Some 63 per cent of those surveyed believed that IT support was inadequate. Indeed, half of respondents felt that a virtual MDT hampered the decision-making process and 66 per cent believed that COVID-19 had resulted in delays in the diagnosis or management of patients with cancer. The pandemic also affected MDT members directly, with 62 per cent of respondents reporting a drop in meeting attendance because of members self-isolating or COVID-related sickness. This study provides further insight into the effect of the COVID-19 pandemic on the delivery of cancer services. It represents a service evaluation in one region; implementation of COVID-19 restrictions in other regions and indeed countries may have a different impact. The authors have, however, demonstrated that COVID-19 has had a substantial impact on the cancer MDT meeting process, which is of concern, considering its key role in the provision of cancer care in the NHS. Not only has there been a fall in the numbers of patients discussed, but also the quality of discussion has been hampered. The medium–longer-term impact of this damage to diagnostic and therapeutic interprofessional decision-making in terms of cancer survival has yet to be fully ascertained. Promisingly, actions in the authors’ hospital Trust have led to upgrades of IT systems and technology in MDT meeting rooms, and also further efforts from the cancer care teams to increase patient support. Further improvements and innovations are, however, needed throughout the NHS and other healthcare systems to mitigate some of the current deficits. The changes to healthcare provision owing to COVID-19 can also be seen as an opportunity to improve patient care and efficiency while maintaining high quality of care3,4. Disclosure. The authors declare no conflict of interest. References 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 : 1440 – 1449 PubMed OpenURL Placeholder Text WorldCat 2 Maringe C Spicer J Morris M Purushotham A Nolte E Sullivan R et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study . Lancet Oncol 2020 ; 21 : 1023 – 1034 Google Scholar Crossref Search ADS PubMed WorldCat 3 Wallis C Catto J Finelli A Glaser A Gore J Loeb S et al. The impact of the COVID-19 pandemic on genitourinary cancer care: re-envisioning the future . Eur Urol 2020 ; 78 : 731 – 742 Google Scholar Crossref Search ADS PubMed WorldCat 4 Nunoo-Mensah J Giordano P Chung-Faye G. COVID-19: an opportunity to reimagine colorectal cancer diagnostic testing—a new paradigm shift . Clin Colorectal Cancer 2020 ; 19 : 227 – 230 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. 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Impact of COVID-19 on treatment modalities and short-term outcomes of rectal cancer following neoadjuvant chemoradiotherapy: a retrospective studyDong, D -Z; Dong, Q -S; Zhang, F -N; Li, C -L; Wang, L; Li, Y -H; Wang, W -H; Wu, A -W
doi: 10.1093/bjs/znab011pmid: 33793768
Dear Editor Since December 2019, coronavirus (COVID-19) has spread rapidly, with 25.8 million confirmed cases worldwide at 31 August 20201. To control transmission of SARS-CoV-2, Beijing established a first-level response with policies such as cancellation of public activities, restriction of public transportation, and suspension of school2. Even so, Beijing experienced two waves of the COVID-19 pandemic, greatly influencing people’s daily lives and hospitalization. Articles have been published to share the impact of the COVID-19 pandemic3,4. However, evidence of its impact on patients with rectal cancer is sparse. Patients with rectal cancer who underwent neoadjuvant chemoradiotherapy (nCRT) at Peking University Cancer Hospital between January 2019 and February 2020 were assigned to a routine (last radiotherapy before 1 September 2019) or COVID-19 (last radiotherapy 1 September 2019 or later) group. The treatment modality of nCRT was as described previously5. No patient was infected by SARS-CoV-2 during the treatment process. A total of 265 patients were included in the study: 114 patients in the routine group and 151 in the COVID-19 group. A significantly lower proportion of patients in the COVID-19 group (91, 60.3 per cent) underwent surgical resection compared with the routine group (86, 75.4 per cent) (P = 0.009) (Table S1). Patients were more likely to have surgery at a local hospital during the COVID-19 pandemic (P < 0.001). The COVID-19 pandemic significantly prolonged the mean interval between surgery and the last radiation session (13.0 weeks in the routine group versus15.4 weeks in the COVID-19 group, P = 0.001). The corresponding pathological compete resection (pCR) rate showed an increasing trend, from 14.0 to 20.9 per cent (P = 0.242). Open surgery was more likely to be performed in the COVID-19 group (P = 0.026). Duration of surgery, surgical approach, laparoscopic application, ileostomy, sphincter-preserving rate and intraoperative blood loss were no different between the groups, and no differences in pathological parameters, such as tumour regression grade, were observed (Table S2). Postoperative complications occurred in 33 patients (20.8 per cent) in the whole group, most commonly surgical-site infection (16 patients, 10.1 per cent) and ileus (9, 5.7 per cent). The COVID-19 group had more postoperative complications than the routine group (27.6 versus 14.5 per cent respectively; P = 0.041) and more Clavien–Dindo grade I–IIIa complications (P = 0.046) (Table 1). Table 1 Postoperative complications in patients who had surgical resection . Total (n=159) . Routine (n=83) . COVID-19 (n=76) . P† . Hospital stay (days)* 11.2 (3.8) 10.8 (2.4) 0.769‡ Duration of surgery (min)* 196.2 (75.6) 176.0 (64.8) 0.082‡ Blood loss (ml)* 104.0 (116.3) 96.7 (88.8) 0.663‡ No. of surgical complications 33 (20.8) 12 (14) 21 (28) 0.041 Anastomotic leakage 1 (0.6) 1 (1) 0 (0) Ileus 9 (5.7) 4 (5) 5 (7) Urological tract infection 1 (0.6) 0 (0) 1 (1) Bleeding 1 (0.6) 0 (0) 1 (1) Surgical-site infection 16 (10.1) 5 (6) 11 (14) 0.077 Pulmonary infection 1 (0.6) 0 (0) 1 (1) Other† 4 (2.5) 2 (2) 2 (3) Clavien–Dindo grade 0.046 I–IIIa 31 (19.5) 10 (12) 21 (28) IIIb 2 (1.3) 2 (2) 0 (0) IV–V 0 (0) 0 (0) 0 (0) . Total (n=159) . Routine (n=83) . COVID-19 (n=76) . P† . Hospital stay (days)* 11.2 (3.8) 10.8 (2.4) 0.769‡ Duration of surgery (min)* 196.2 (75.6) 176.0 (64.8) 0.082‡ Blood loss (ml)* 104.0 (116.3) 96.7 (88.8) 0.663‡ No. of surgical complications 33 (20.8) 12 (14) 21 (28) 0.041 Anastomotic leakage 1 (0.6) 1 (1) 0 (0) Ileus 9 (5.7) 4 (5) 5 (7) Urological tract infection 1 (0.6) 0 (0) 1 (1) Bleeding 1 (0.6) 0 (0) 1 (1) Surgical-site infection 16 (10.1) 5 (6) 11 (14) 0.077 Pulmonary infection 1 (0.6) 0 (0) 1 (1) Other† 4 (2.5) 2 (2) 2 (3) Clavien–Dindo grade 0.046 I–IIIa 31 (19.5) 10 (12) 21 (28) IIIb 2 (1.3) 2 (2) 0 (0) IV–V 0 (0) 0 (0) 0 (0) Values in parentheses are percentages unless indicated otherwise; * values are mean(s.d.). † One patients with fever and one with rectovaginal leak in routine group; one patient with delayed gastric emptying and one with urinary retention in COVID-19 group. † χ2 or Fisher’s exact test, except ‡ Student’s t test, unpaired. Open in new tab Table 1 Postoperative complications in patients who had surgical resection . Total (n=159) . Routine (n=83) . COVID-19 (n=76) . P† . Hospital stay (days)* 11.2 (3.8) 10.8 (2.4) 0.769‡ Duration of surgery (min)* 196.2 (75.6) 176.0 (64.8) 0.082‡ Blood loss (ml)* 104.0 (116.3) 96.7 (88.8) 0.663‡ No. of surgical complications 33 (20.8) 12 (14) 21 (28) 0.041 Anastomotic leakage 1 (0.6) 1 (1) 0 (0) Ileus 9 (5.7) 4 (5) 5 (7) Urological tract infection 1 (0.6) 0 (0) 1 (1) Bleeding 1 (0.6) 0 (0) 1 (1) Surgical-site infection 16 (10.1) 5 (6) 11 (14) 0.077 Pulmonary infection 1 (0.6) 0 (0) 1 (1) Other† 4 (2.5) 2 (2) 2 (3) Clavien–Dindo grade 0.046 I–IIIa 31 (19.5) 10 (12) 21 (28) IIIb 2 (1.3) 2 (2) 0 (0) IV–V 0 (0) 0 (0) 0 (0) . Total (n=159) . Routine (n=83) . COVID-19 (n=76) . P† . Hospital stay (days)* 11.2 (3.8) 10.8 (2.4) 0.769‡ Duration of surgery (min)* 196.2 (75.6) 176.0 (64.8) 0.082‡ Blood loss (ml)* 104.0 (116.3) 96.7 (88.8) 0.663‡ No. of surgical complications 33 (20.8) 12 (14) 21 (28) 0.041 Anastomotic leakage 1 (0.6) 1 (1) 0 (0) Ileus 9 (5.7) 4 (5) 5 (7) Urological tract infection 1 (0.6) 0 (0) 1 (1) Bleeding 1 (0.6) 0 (0) 1 (1) Surgical-site infection 16 (10.1) 5 (6) 11 (14) 0.077 Pulmonary infection 1 (0.6) 0 (0) 1 (1) Other† 4 (2.5) 2 (2) 2 (3) Clavien–Dindo grade 0.046 I–IIIa 31 (19.5) 10 (12) 21 (28) IIIb 2 (1.3) 2 (2) 0 (0) IV–V 0 (0) 0 (0) 0 (0) Values in parentheses are percentages unless indicated otherwise; * values are mean(s.d.). † One patients with fever and one with rectovaginal leak in routine group; one patient with delayed gastric emptying and one with urinary retention in COVID-19 group. † χ2 or Fisher’s exact test, except ‡ Student’s t test, unpaired. Open in new tab Among those who did not have surgical treatment, there were 30 (11.3 per cent of 265) who chose ‘deferral of surgery’ without achieving a clinical complete response (cCR) or near cCR: five (4.4 per cent) of 114 in the routine group and 25 (16.6 per cent) of 151 in COVID-19 group (P = 0.002) (Table S3). Based on these results and the speculation that the COVID-19 pandemic will last a long time, the authors present several suggestions for the treatment of rectal cancer. Medical professionals should inform patients of the risks of deferring surgery and advise them to consult regularly. Preventive measures should be taken during the perioperative period to reduce complications, especially surgical-site infection. Although delay to surgery after nCRT has been shown to increase cCR6, if this is not reached by 16 weeks after nCRT, surgery should be performed as soon as possible. This was a single-centre retrospective study, and may be subject to selection bias. The median follow-up time was shorter for the COVID-19 group, which may impact upon the results of local and distant progression. Moreover, as all patients included in the study were free from infection by SARS-CoV-2, experience of treating patients with rectal cancer who were infected with the virus was not included. Supplementary material Supplementary material is available at BJS online. Acknowledgements D.-Z.D., Q.-S.D. and F.-N.Z. contributed equally to this manuscript. The authors thank Y.-L. Xu and Y. Zhang for case management support, and Y. Cai, Y.-F. Yao, J. Zhao, S. Li, Y.-F. Peng, T.-C. Zhan and J.-H. Geng for providing data on patients with rectal cancer from Peking University Cancer Hospital. This work was supported by Science Foundation of Peking University Cancer Hospital (18-03), Clinical Technology Innovation Project of Beijing Hospital Authority (XMLX201842), Beijing Municipal Science and Technology Commission (Z151100004015105 and Z181100001718192), Beijing Natural Science Foundation (7182028), Clinical Medical Development Project of Beijing Hospital Authority (ZYLX202116) and National Natural Science Foundation of China (81902371). Disclosure: The authors declare no conflict of interest. References 1 World Health Organization. Coronavirus disease (COVID-19) Pandemic . https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (accessed 31 August 2020) 2 Zhao S , Zhuang Z, Cao P, Ran J, Gao D, Lou Y et al. Quantifying the association between domestic travel and the exportation of novel coronavirus (2019-nCoV) cases from Wuhan, China in 2020: a correlational analysis . J Travel Med 2020 ; 27: taaa022 Google Scholar Crossref Search ADS PubMed WorldCat 3 O'Leary MP , Choong KC, Thornblade LW, Fakih MG, Fong Y, Kaiser AM. Management considerations for the surgical treatment of colorectal cancer during the global COVID-19 pandemic . Ann Surg 2020 ; 272: e98 – e105 Google Scholar Crossref Search ADS PubMed WorldCat 4 PelvEx Collaborative . The impact of the COVID-19 pandemic on the management of locally advanced primary/recurrent rectal cancer . Br J Surg 2020 ; 107: e547 – e548 PubMed OpenURL Placeholder Text WorldCat 5 Wu A , Cai Y, Li Y, Wang L, Li Z, Sun Y, Ji J. Pattern and management of recurrence of mid-low rectal cancer after neoadjuvant intensity-modulated radiotherapy: single-center results of 687 cases . Clin Colorectal Cancer 2018 ; 17: e307 – e313 Google Scholar Crossref Search ADS PubMed WorldCat 6 Ryan EJ , O’Sullivan DP, Kelly ME, Syed AZ, Neary PC, O’Connell PR et al. Meta-analysis of the effect of extending the interval after long-course chemoradiotherapy before surgery in locally advanced rectal cancer . Br J Surg 2019 ; 106 : 1298 – 1310 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Powered air-purifying respirators: a solution to shortage of FFP3 filtering facepiece respirators in the operating theatreRees, P A; Watson, S; Corcoran, J; Slade, D A J; Pathmanaban, O; Bibi, A; Carlson, G L
doi: 10.1093/bjs/znab008pmid: 33778849
Dear Editor The ongoing COVID-19 pandemic has resulted in significant challenges to the safe delivery of both elective and emergency surgery1. Filtering facepiece respirators (FFP3) are recommended for use in high-risk areas such as operating theatres to protect healthcare professionals. However, they require ‘fit testing’, should be worn for only short periods, and are subject to availability. In comparison, powered air-purifying respirators (PAPRs) offer superior protection2 and improved comfort3. They can be worn universally without fit testing, allow the unhindered wearing of corrective spectacles, and are not compromised by facial hair. However, PAPRs employing reusable hoods are expensive, have limited availability, and may themselves pose infection-control challenges. Although PAPRs reduce contamination into a sterile field effectively4 and have proven to be acceptable to surgical teams in simulated settings5, they are yet to be optimized for use in the operating theatre environment. PAPR units can become occluded when placed under surgical gowns5. The ESAB PAPR unit (Elektriska Svetsnings Aktiebolaget Group, Gothenburg, Sweden) was here adapted with a custom cowl placed over the air intake fans (Fig. 1a). Air intake is redirected such that it is drawn from underneath the device, preventing occlusion. The cowl does not decrease air flow through the PAPR unit (mean(s.d.) 150.5(0.7) l/min without cowl versus 150.1(0.7) l/min with cowl) when measured with a VT mobile medical gas flow analyser (Fluke Biomedical, Everett, WA, USA). Fig. 1 Open in new tabDownload slide Use and testing of the powered air-purifying respirator a Elektriska Svetsnings Aktiebolaget Group (EASB) powered air-purifying respirator (PAPR) unit (left) and with the addition of custom cowl (right), demonstrating direction of airflow (red arrows). b PAPR system including PAPR unit, hose pipe and novel disposable hood (left). In use in theatre (right) c Digital fit-testing was performed on five subjects using a PortaCount 8040. Measurements were repeated using a second hood for each individual. Data are presented as absolute values for subjects 1–5, followed by the mean(s.d.) value. The red dashed line represents a fit factor of 100 (standard required for an FFP3 mask). d Example of real-time fit-testing performed while subject carried out exaggerated movements. e Example of real-time fit-testing when PAPR unit was switched off. *Indicates the time point at which the unit was switched off. f Powered storage rack, able to store and charge up to 14 PAPR units at any one time. Fig. 1 Open in new tabDownload slide Use and testing of the powered air-purifying respirator a Elektriska Svetsnings Aktiebolaget Group (EASB) powered air-purifying respirator (PAPR) unit (left) and with the addition of custom cowl (right), demonstrating direction of airflow (red arrows). b PAPR system including PAPR unit, hose pipe and novel disposable hood (left). In use in theatre (right) c Digital fit-testing was performed on five subjects using a PortaCount 8040. Measurements were repeated using a second hood for each individual. Data are presented as absolute values for subjects 1–5, followed by the mean(s.d.) value. The red dashed line represents a fit factor of 100 (standard required for an FFP3 mask). d Example of real-time fit-testing performed while subject carried out exaggerated movements. e Example of real-time fit-testing when PAPR unit was switched off. *Indicates the time point at which the unit was switched off. f Powered storage rack, able to store and charge up to 14 PAPR units at any one time. Moreover, novel disposable single-use hoods were designed in collaboration with a local engineering company (Chemsplash, Manchester, UK). They are composed of a Tyvek® (DuPont, Wilmington, DE, USA) hood with a thin acetate screen (Fig. 1b). Spectacles, surgical loupes and three-dimensional glasses can be worn simultaneously. The hose connecting the PAPR unit to the hood can be immersed fully in disinfectant for cleaning. The manufacturing costs of the hoods per unit are less than £10 (approximately €11) (August 2020), offering the basis of a cost-effective supply of these consumables. Five individuals (3 men and 2 women) with varying body shapes and degrees of facial hair were fit-tested digitally using a PortaCount 8040 (TSI, Shoreview, MN, USA) while wearing the PAPR system. Each individual was measured wearing two separate hoods. The mean(s.d.) fit factor was 1851(277) (Fig. 1c), comparing favourably with a fit factor of 100 required for the FFP3 standard. The fit factor was not decreased by speech and exaggerated movements (Fig. 1d). During real-time testing, the fit factor fell rapidly within 10 s of powering down the unit (Fig. 1e). The particle count within the hood reached ambient levels within 20–30 s. This was overcome by a bespoke doffing procedure that mandates the power to be switched off only after the doffing team has helped in removal and disposal of the hood. Loss of power can be disruptive, or even dangerous, within the operating theatre environment. It is therefore critical that PAPR units are incorporated within a system that ensures availability and safe storage of fully charged PAPR units to meet the demands of a busy operating department. A powered rack was therefore developed that can store and charge up to 14 PAPR units, providing a display of the charge status of each unit (Fig. 1f). This novel adaptation of a PAPR system provides safe, inexpensive, effective, and comfortable personal protective equipment (PPE) that is readily available and suitable for the entire surgical team. There is no requirement for prior fit-testing, and a supply chain could be created rapidly to ensure local availability. Other institutions are encouraged to develop the use of PAPR further as a pragmatic solution to PPE in the COVID-19 pandemic. Disclosure. The authors declares no conflict of interest. References 1 Søreide K Hallet J Matthews J Schnitzbauer A Line P Lai P et al. Immediate and long‐term impact of the COVID‐19 pandemic on delivery of surgical services . Br J Surg 2020 ; 107 : 1250 – 1261 Google Scholar Crossref Search ADS PubMed WorldCat 2 Jones RM Bleasdale SC Maita D Brosseau LM Program CPE. A systematic risk-based strategy to select personal protective equipment for infectious diseases . Am J Infect Control 2020 ; 48 : 46 – 51 Google Scholar Crossref Search ADS PubMed WorldCat 3 Johnson AT. Respirator masks protect health but impact performance: a review . J Biol Eng 2016 ; 10 : 1 – 12 Google Scholar Crossref Search ADS PubMed WorldCat 4 Howard RA Lathrop GW Powell N. Sterile field contamination from powered air-purifying respirators (PAPRs) versus contamination from surgical masks . Am J Infect Control 2020 ; 48 : 153 – 156 Google Scholar Crossref Search ADS PubMed WorldCat 5 Dalli J O'Keeffe D Khan F Traynor O Cahill R. Powered air purifying respirators (PAPR) for the protection of surgeons during operative tasks: a user perspective assessment . Br J Surg 2020 ; 107 : e328 – e330 Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Changing the nature of benign entities during the pandemic. A riddle asking for solution?Vailas, Michail; Mulita, Francesk; Sotiropoulou, Maria; Germanos, Stylianos; Benetatos, Nikolaos; Maroulis, Ioannis
doi: 10.1093/bjs/znab041pmid: 33734330
Dear editor, We have read with interest the article published by Palisi et al.1 about decreased hospital admissions, as far as emergency operations are concerned. Herein, we report our experience from a tertiary university hospital in Greece, covering a population of approximately 1.5 million people. Undoubtedly, the causes of sharp reduction of emergency surgical cases during COVID-19 are possibly multifactorial, reflecting a highly concerning and alarming situation with serious implications for public health. In our correspondence, we report the number of operations we have performed for non-complicated and complicated cases of appendicitis and cholecystitis, comparing periods before and after the initiation of the pandemic. We have chosen to include mainly these surgical pathologies, because they are among the most common surgical cases encountered, along with a compelling observation as far as their severity is concerned. In contrast with other studies, we have not observed a statistically significant difference between the total numbers of patients admitted for acute conditions between the two examined periods(494 vs 471). Interestingly enough, we report that the severity of phenomenally benign entities like appendicitis and cholecystitis shows trends of changing. More specifically, people admitted to our department during the pandemic presented with more complicated cases(i.e. perforation, gangrenous presentation), when compared with people admitted before this era (P < 0.05). Moreover, hospital stay and duration of operations have both increased, a fact that also justifies our conclusion that patients come to the hospital with delayed presentation. Undoubtedly, these results must be interpreted by health administrators worldwide with caution and solutions to improve healthcare access must be implemented, while simultaneously maintaining the integrity of the COVID-19 control measures. Ultimately, there are serious concerns that are raised, whether benign entities like appendicitis and cholecystitis will change their morbidity and mortality rates, a fact that may be associated with delayed presentation. Acknowledgements None. Financial Disclosure None. Conflicts of interest The authors have no other conflicts of interest to declare. References 1 Palisi M , Massucco P, Mineccia M, Celano C, Giovanardi F, Ferrero A. The disappearing of emergency surgery during the COVID 19 pandemic. Fact or fiction? Br J Surg 2020 ; 107 ( 11 ): e508 – e509 . Google Scholar PubMed OpenURL Placeholder Text WorldCat © The Author(s) 2021. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: [email protected] This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)