key: cord-028285-n4dommet
authors: Weilongorska, Natasha L.; Ekwobi, Chidi C.
title: COVID-19: What are the challenges for NHS surgery?
date: 2020-07-02
journal: Curr Probl Surg
DOI: 10.1016/j.cpsurg.2020.100856
sha: 
doc_id: 28285
cord_uid: n4dommet

nan

In December, 2019 while COVID-19 was unfolding in China, surgeons in the UK were enjoying some of their last few months of normality. By April, 2020 all National Health Service (NHS) trusts in the UK had halted their non-urgent elective operating, 1 and much of the surgical community had been redistributed to roles far from their specialized career trajectories.

The first UK identified case of COVID-19 was recorded in February, 2020. 2 By the March 11, 2020, the World Health Organisation (WHO) had declared a global pandemic. 3 It became rapidly apparent that despite the NHS being a highly revered healthcare system, it was sorely underprepared. With some of the lowest ratios in Europe of beds per population (2.5 per 1000) and doctors per population (2.8 per 1000), combined with the lack of experience of recent epidemics (Severe Acute Respiratory Syndrome-1, Middle Eastern Respiratory Syndrome, Ebola), which were successfully contained by other continents, COVID-19 presented an emergent humanitarian crisis for the UK.

The risk of nosocomial infection to the surgical workforce through both direct contact with surfaces, droplet or aerosol spray, or through intraoperative generation of fomites have led to abrupt changes in surgical practice during this unprecedented period. In the face of COVID-19, the risk profile of surgery to both patients and the operative team has dramatically increased. Routine procedural activities such as open suctioning, smoke generation (monopolar, bipolar diathermy, LASER), and the opening of pressurised cavities or orifices, are now considered high-risk. 4 To mitigate these risks, surgical services (across all surgical specialities) have made pandemic-response changes to their practice as guided by their specialist organizations, the Department of Health, Public Health England and input from the Royal Surgical Colleges.

As part of the immediate NHS response to the pandemic, surgical services were restructured to enable redistribution of resources. Surgical patients were grouped (obligatory inpatients, nonoperative, inpatient management, day case surgery, and outpatients), with guidance offered on the management of each category. 5 Key recommendations included consultant led decisionmaking, daily review of inpatient status, and extension of imaging (whenever required) to include chest screening.

All operative scheduling should be consultant sanctioned, when an emphasis on conservative management where feasible.

Decisionmaking for acute surgical presentations, namely between operative and non-operative management, or modifications to routine surgical strategies (such as open techniques versus laparoscopy, or other adjustments to surgical approach), have been informed by speciality guidance, but, ultimately, are the responsibility of the on-call or lead consultant. Most departments have initiated multiple consultant decisionmaking for acute admissions, in response to the pandemic.

With there being a short interval from the time of the first COVID-19 case presentation, to the development of a global pandemic, validated management algorithms to support changes in operative strategies are lacking. 6 The Royal Surgical Colleges stipulated that maintaining emergency surgical capacity, including major trauma provision, was the primary aim during the COVID-19 pandemic. 7 NHS surgical organizations have worked in collaboration with the international community to pool knowledge and adopt recommended practices from countries earlier exposed to the pandemic.

Internationally, grading systems have been adopted to denote the services available at each stage, depending on a hospital's pandemic burden. In some examples, these are quantified by number of cases, 8 whereas the NHS guidance is based on low, medium, high, or very high prevalence due to nationwide variation in hospital capacity. 9 Some specialities have adopted a 2-tier consultant-on-call arrangement to aid emergency work load, as well as providing contingency cover for unpredictable changes in professional fitness to practice, or isolation requirements. 10 Similarly, a prioritization system for cancer surgery has been implemented throughout the NHS (Levels 1a -3), to provide uniform understanding of oncological urgency (Table 2) . 11, 12 Operations proceed based on their assigned prioritization level, often in conjunction with daily prioritization meetings that enable multiple speciality discussions to ensure an agreed case order. Ultimately, the reduction in capacity has, for some patients, led to delays in cancer treatment and rescheduling of cases.

The NHS 2-week wait standards (for review of new or suspected cancer diagnoses) has been maintained, with an acceptance that first contact may be via telephone clinic. 13 Oncological management (whether medical or surgical) requires careful consideration between (1) safety and availability of treatment in the current climate, versus (2) the risk of metastasis. Surgeons have been required to liaise closely with oncologists, their MDT, and adopt a service-limited, less invasive approach.

The key components of NHS preoperative patient screening for COVID-19 are: structured questionnaires with temperature monitoring, viral real-time polymerase chain reaction (RT PCR) for SARS-CoV-2, and chest imaging. The aim of screening is to prevent pandemic spread and minimize the risk to patients and staff. On the other hand, COVID-19 screening investigations are performed only in response to risks identified through questionnaires, patient temperature, or clinical presentation. Not all surgical patients are screened by all possible modalities.

Patients can be categorized as confirmed COVID-19 positive, suspected COVID-19 (includes any patient with or without symptoms who has not been screened), and COVID-19 negative (following robust screening). As hospitals are high-risk environments, a patient's status may change during an inpatient admission. Attention should be paid to possible symptoms, accepting that multiple viral screening swabs may become necessary.

Increasingly, surgical patients are tracked down 1 of 2 pathways: COVID-19 positive (includes confirmed and suspected patients) or likely COVID-19 negative, recognizing that absolute certainty about status is not possible. Segregation of patients based on viral status occurs throughout NHS surgical pathways; however, complete separation of patients to different hospital sites has generally not been possible. Accordingly, hospital sites are deemed high-risk areas for potential transmission of COVID-19. As part of the exit strategy, independent hospitals have been recruited in the effort to return to elective operating. As these institutions have not housed acute COVID-19 positive patients, they are viewed as "COVID-free", "COVID-light", or "COVID-cold" zones. The use of a traffic light system has been adopted in many NHS trusts for clinical areas, including oprating rooms. Using this system, red denotes areas with confirmed COVID-19 cases, amber for suspected cases when results

are not yet available, and green for patients where COVID-19 is not suspected. Strategies employed to increase safety within the operating suite are discussed in more detail in the section on surgical process.

All NHS patients are questionnaire screened to identify risk of COVID-19 prior to surgery. Questions determine the presence of symptoms, history of exposure, isolation status, temperature status, presence of high-risk factors (eg, key workers) and vulnerable patient features.

In the case of acute or unplanned surgical admissions, preoperative screening questions are completed on admission. Patients may have symptoms, as part of their surgical pathology, that could be associated with COVID-19. Low-grade pyrexia is particularly troublesome and should be monitored carefully for signs of progression. In true emergency operating, screening may be impractical and therefore cases have had to be managed as suspected COVID-19.

For scheduled cases (planned trauma or elective operating), where delays to operating may be possible, screening occurs prior to admission. The aim is to determine COVID-19 status prior to surgery and, if possible, to delay operating until the patient can be managed through a COVID-19 negative pathway. Screening questionnaires are performed by phone and, if the patient is deemed low risk, a provisional date for surgery is given with enough time for viral swabs to be performed and reported. Any case in which there is a suspicion of COVID-19 infection or the presence of risk factors, will be referred to the lead consultant for discussion. All patients are re-screened by questionnaire and temperature check on the day of surgery as part of the admission and pre-operative assessment. Patient screening tools are essential for minimizing pandemic spread; however, they are not uniform across all NHS hospitals, rely on patient reporting, and are not formally validated.

The gold standard for testing for COVID-19 is pharyngeal swab RT-PCR for SARS-CoV-2 which detects viral RNA in situ. Routine testing involves nasopharyngeal and oropharyngeal swab, with sampling of the tonsillar region. Performing swabs is therefore difficult in some groups, which may affect the sensitivity of the test, making screening less reliable and unsuitable for patient directed hometesting. Location of viral expression appears to change with disease progression, impacting site detectability, and further complicating screening. 14 COVID-19 has been detected in blood, urine, peritoneal fluid, and stool; however, transmission from these modalities is thought to be low. [15] [16] [17] Faecal viral RT-PCR for SARS-CoV-2 may remain positive for a longer duration than other modalities, 18 particularly in children, which has implications for endoscopic, general surgery, urology, and paediatric procedures.

In the advent of COVID-19, the UK government's pandemic strategy differed from the strict measures of testing, tracing, and isolation recommended by the WHO. 19 The decision not to perform widespread testing and contact tracing was highly scrutinized and led to significant implications for the healthcare workforce. 20 Compared to many countries, the UK's facility for COVID-19 RT-PCR testing has been very limited. In response to public outrage, the government pledged to prioritize increasing the capacity of viral testing. Unlike most countries, routine patient testing for all hospital admissions is not yet conceivable. Revisions to the UK testing and tracing strategies seem to have missed the metaphorical "boat". 21 Limitations in screening capacity, unsatisfactory delays to result reporting (initially up to 72 hours), 22 and a high false negative rate (up to 20%) 23, 24 have complicated preoperative screening. The prolonged incubation period of COVID-19 (up to 14 days) has also been problematic. 25 The triad of asymptomatic carriers, non-specific symptoms, and absence of routine viral screening, reaped havoc to surgical workflow in the early weeks of the pandemic. Subsequently, all aerosol generating procedures (AGP) required full personal protective equipment (PPE), regardless of the RT-PCR result.

In response to these challenges, the Royal College of Surgeons released a consensus statement in April, 2020 detailing the screening pathway prior to elective surgery. 26 Patients require isolation (with shielding) for 14 days prior to surgery, to be asymptomatic for the preceding 7 days, and have a negative RT-PCR pharyngeal swab within 48 hours of surgery. International guidance recommends dual testing for preoperative surgical patients who have no history of exposure or symptoms. 27 Accordingly, patients with 2 consecutive negative results may be managed as COVID-19 negative in the operative setting. 28 Many NHS trusts do not yet have this system in place; however, with the UK government warning of a prolonged emergence from the pandemic, effective pathways will need to be followed to combat the backlog of surgical cases safely.

Chest imaging has been shown to have a key diagnostic role in COVID-19 and is the final modality of screening employed for some surgical patients. 29 The British Society for Thoracic Imaging released guidance supporting the use of computerised Tomography (CT) and chest radiographs (CXR) to identify features of COVID-19 infection. 30 Screening of the chest is not routine for all surgical patients; however, CT chest is indicated in patients requiring intensive care postoperatively. 26 Extending imaging to include the chest (either CT or CXR) is recommended in acute abdominal presentations, 26 and may be considered in other surgical presentations. Again, radiological signs vary with the course of disease and, therefore, imaging findings can be open to interpretation. A COVID-19 diagnostic algorithm has been developed to aid decisionmaking. 31 The increased imaging demand has been matched by an expanded capacity for hot reporting. Acute staffing changes, required to maintain these requirements, may be problematic as normal NHS workflow returns.

Ultimately, there are many complexities regarding screening for COVID-19. The unique risks of upper airway viral titers, in relation to anaesthesia and AGP, require careful consideration of all surgical cases. Variable carriage of viral load, progression of disease signs and symptoms, and problematic investigation sensitivities all complicate the picture.

Accordingly, surgeons are required to review the whole patient panel of results, which includes screening questionnaires, swabs, supporting blood tests, and any imaging performed, with a low threshold for repeat investigations. Developments in RT-PCR for SARS-CoV-2 testing within the NHS include decentralization of processing (enabling quicker turnover locally) and use of quicker detection systems. 32 Ideally, rapid and reliable point of care testing for COVID-19 would be available with a low false negative rate; however, due to the characteristics of the virus, it is unlikely that this will be realized.

Focus should instead be on how to improve investigation effectiveness, processing time, and reliability of reporting.

The protection and preservation of the surgical workforce was listed as the second priority in the "Guidance for surgeons working during the COVID-19 pandemic". 33 The widespread impact on staffing numbers has been dramatic due to isolation requirements, sickness, and redeployment.

Surgical services have required adequate staffing, with the potential to adjust to changing disease prevalence, despite a depleted workforce. Accordingly, staff flexibility and resilience have been crucial. Most scheduls include the provision of standby staff; residing at home, these personnel are readied for work and can be called in to cover shortfalls in staffing levels and/or sickness. The main aims are to minimize the exposure of the surgical workforce, enable adequate rest, and have escalation plans in place, if required. Redeployment strategies implemented at the local level vary hugely between NHS trusts. Professionals across the board have faced redeployment, often to unfamiliar roles. Some of the 10,000 NHS returners who responded to the national 'Bring Staff Back' initiative will have returned to the surgical workforce. 34 These individuals require additional training and support as part of their re-introduction to practice.

Since the advent of COVID-19, the operating rooms environment is a very different workplace. The general dynamic in operating rooms is less relaxed due to a multitude of challenges. Staff numbers are minimized for safety and their roles are more clearly defined. Operative cases are required to be consultant led. PPE is uncomfortable, impairs staff recognition, renders spoken communication difficult, and largely eliminates non-verbal communication from facial expressions. Unfamiliarity of staff with safety protocols can lead to inefficiencies and staff anxiety. As staff are assigned to a specific section of the operative suite, in keeping with their designated roles (operating room, anesthetic room, or corridor), there is increased segregation of staff and less interaction. With experience, there is an improvement in staff confidence and efficiency with COVID-19 safety protocols. Over time, individuals adapt to the cultural change involved in daily operating rooms turnover. 35 Post-procedural debriefs are crucial to staff development, as well as providing a platform to acknowledge any physical or psychological difficulties associated with current processes.

Staff requiring quarantine on account of their personal health requirements have been assigned low risk or contact-free activities. Changes to the on-call arrangements of the surgical specialities vary throughout the NHS, depending on staffing, services demand, and local policy. Some departments have maintained their pre-COVID-19 shift system, whereas others have required restructuring. Cross cover, doubling of staff cover, and contingency scheduls are strategies employed in NHS trusts. 36 On account of occupational changes to working hours and roles, remuneration may be required in some incidences.

During the COVID-19 pandemic, there have been many changes to practice. For some individuals, this has been overwhelming and frequent guideline updates have been difficult to interpret.

Dissemination of information to all members of the surgical team has been implemented largely by senior clinical staff. Using a communication task-force has been suggested as a strategy to reduce duplication of work and to keep team members informed. 37 Gaps in knowledge lead to increased staff anxiety. The use of daily trust-wide email updates has been employed by most NHS organizations to inform staff of updates within their own workplace.

In the surgical setting, COVID-19 transmission can occur through droplet, aerosol, and contact spread. PPE is required to mitigate against each of these routes. UK guidelines on PPE requirements have been subject to multiple changes and have been the source of controversy. In the early phase of the NHS COVID-19 experience, discussions about PPE dominated workforce concerns and the national media. Conflicting information, variance in local PPE recommendations, and restricted availability of required equipment led to significant workforce anxiety. Extensive workforce training has been required to ensure NHS staff are safely and appropriately using PPE. FFP3 mask or respirator fit-testing, as well as simulation training in donning and doffing PPE are now part of mandatory training for all patient facing personnel in the NHS.

Full PPE (fluid resistant gown, double gloving, visor or goggles, fit-tested FFP3 mask or respirator, disposable hat, shoe covers) should be worn in the operating rooms for any suspected or positive COVID-19 case, for AGP 38 (Table 3) , and for procedures for which the risk is unknown. Despite initial discrepancies in the recommended PPE requirements, guidance released by the Royal Surgical

Colleges and affiliated speciality organisations on March 27, 2020 reclassified laparotomy, laparoscopy, and endoscopy as high-risk procedures 39 .

Updates detailing PPE requirements for surgery and re-classifying AGP were released by Public Health England [40] [41] [42] but did not answer the supply chain concerns. Later guidance, in response to acknowledged PPE shortages, suggested a reduction in intraoperative protection, 43 Surgical ward staff also require access to PPE. Routine procedural tasks such as replacing feeding tubes, as well as general care of tracheostomies and general stomas, are all associated with higher risk of transmission. COVID-19 safety protocols suggest that these skilled aspects of patient care should be performed by experienced staff. 45 The use of heat and moisture filters for tracheostomies has also increased safety. Nasogastric and nasojejunal tube insertion frequently induces aerosol generation by local irritation-induced cough or sneeze response. 46,47 Likewise, chest physiotherapy can be considered from a similar stance. Routine care for COVID-19 positive patients with an active cough, also requires full PPE. Accordingly, the PPE requirement of the wider surgical team of healthcare professionals has been underestimated.

Supply of appropriate PPE has been a problem throughout the NHS, with severe shortages 48 compounded by a high case burden over a short period. 49 In April, a survey of UK surgeons and surgical trainees demonstrated that more than one half had experienced shortages of PPE over the preceding month, and approximately one third felt PPE was still inadequate and unsafe. 50 A survey of otorhinolaryngology surgeons revealed that 20% of trusts did not have the required PPE available and 95% of respondents felt the supply would run out during the crisis. 51 Furthermore, concerns about trust rationing, self-funded PPE, and reports of emotional blackmail or gagging surfaced. 52,53

Reuse protocols and cleaning of visors is now commonplace in the NHS. Across the surgical community, there are also concerns that UK guidance does not meet internationally reported standards. 54, 55 Inconsistencies in guidance, combined with difficulties in patient screening, have undoubtedly resulted in higher expenditure of PPE than necessary.

In most NHS trusts, a range of FFP3 masks were initially available to staff. With depletion of stocks, many healthcare workers have had to repeat fit-testing with alternative masks or respirators as certain models have become unavailable. A worrying gender imbalance in the suitability of PPE has surfaced. 56 The majority of PPE has been designed to fit an average man. 57 Masks and respirators are of particular concern, often being unsuitable, and resulting in high proportions of failed fit-tests in the female workforce. Given that 77% of the NHS workforce are women, many have been unable to work in high-risk areas, putting further strain on the system. 58 The wearing of full PPE is generally not a pleasant experience for most healthcare workers and can have a significant impact on morale. 59 Goggles, FFP3 masks, and respirators all have a significant impact on skin. Constant use can lead to abrasions, dermatitis, and pressure areas 60 which may necessitate the alternating of roles or days off work. 61 Wearing full PPE during operations is hot and restrictive. In certain specialist operating rooms, additional requirements, such as high ambient temperatures for burns surgery or radiation protection in orthopaedic procedures, exacerbate the unpleasantness. Operative discomfort may increase the risk of technical error. PPE can also interfere with important operative aids such as operating microscope, loupes, or headlights . 62 The impact of PPE on surgical efficiency is dramatic. Case duration is prolonged due to donning, doffing, down-time (to allow for air changes following intubation and extubation), surgical factors, and cleaning. 4 With process familiarity there is upskilling, leading to improvements in procedural duration, but this does not match standard operating times. 63 As elective operating recommences, adjustment of scheduling times will be necessary. Regardless of the backlog of cases, surgical centers will need to accept reduced efficiency as a trade-off for increased safety.

On account of the unavailability of COVID-19 testing in the UK, personnel testing for COVID-19 has been exceptionally limited. It is recognised that healthcare workers are at higher risk of exposure, could be asymptomatic carriers, and may unknowingly be the source of hospital-acquired infection in patients. NHS trusts have had to adopt a rough risk analysis of patients on admission (instead of routine testing), despite the fact that approximately 80% of people who test positive for COVID 19 are either asymptomatic, or experience only non-specific symptoms. 64 Consequently, unscreened staff are frequently exposed to untested members of the public, providing potential for viral transmission to either party.

Without adequate testing solutions available, the NHS has faced a dramatic rise in absenteeism. In line with the UK government's isolation recommendations, individuals have been instructed to completely self-isolate for 14 days in the presence of symptoms, and 7 days following close contact with a symptomatic person. A high proportion of NHS staff have had to self-isolate either due to personal or close-contact symptoms. In practice, without access to testing, an enormous number of households have had to self-impose cautionary isolation due to the presence of a symptomatic individual. In families with young children this has been particularly problematic. Many staff had to take multiple absences without clarity on whether they had suffered from COVID-19. Not only has this been incredibly frustrating for those involved but has also put pressure on the rest of the workforce. A survey by the Royal College of Physicians in April, 2020, found that more than 20% of respondents were isolating either with symptoms, or due to contact with a member of the household with symptoms. Only 31% had access to testing. 65 The NHS employee absence rates for 2020 have not yet been released, but these are expected to be the highest in recorded history, 66 with a huge impact on the total cost of COVID-19.

Later, testing was offered for symptomatic staff (following sanction by the trust microbiology or infectious diseases teams), in an attempt to return a proportion of the isolating workforce. As the emphasis on viral testing has increased nationally, and availability of tests has expanded, staff displaying symptoms now warrant screening. Against the backdrop of a national data vacuum, small data samples arising from isolated NHS trusts, which have adopted routine testing for all symptomatic staff, 67,68 unsurprisingly demonstrate the highest proportion of NHS workers testing positive for COVID-19 were those working in patient facing roles. In the absence of a proficient immunity test, multiple RT-PCR SARS-CoV2 viral swabs may be necessary per individual healthcare worker.

The lack of routine screening for asymptomatic staff has important social implications for healthcare workers and their families. With COVID-19 status unknown, as we move out of lockdown, NHS staff will be unable to be in contact with vulnerable individuals. The government has now pledged that with increased testing capacity, screening will be available regularly to asymptomatic staff 34 but a program for this has not yet been rolled out. Compulsory weekly viral screening for everyone may be the most robust strategy moving forward. 69, 70 

The COVID-19 pandemic has seen lower levels of training. From March 16, 2020, all courses, conferences, examinations, and other surgical education-based activities requiring physical attendance were cancelled. 71 Planned rotations in April, 2020 were suspended by Health Education England to minimise disruption. Across all surgical specialities, the training curriculums are competency based. It is recognised that the COVID-19 pandemic has been hugely disruptive to training and individualized placement objectives may not have been met. Although the Annual Review of Competency Progression (ARCP) process will allow some concessions, based on the COVID-19 pandemic, surgical trainees will still be required to meet the same standards in order to complete their training. Accordingly, senior trainees may be more adversely affected and in some circumstances additional time may be required to meet these competencies. Postponement of the final speciality examinations will, for some unfortunate candidates, result in extended training.

For those trainees redeployed on account of COVID-19, alternative duties may provide unique experiences, but in most cases, will lack direct surgical experience. The Joint Committee on Surgical Training (JCST) has emphasised that redeployed trainees will not be disadvantaged; however, it is recognized that the curriculum requirements will need to be achieved in future placements. 

The role of the WHO Surgical Safety Checklist (developed in June, 2008 and mandated into routine NHS practice in January, 2009), 75 has been largely omitted from recommended COVID-19 guidelines, but has nevertheless played an intrinsic role during the pandemic. As is standard in surgical practice, meetings are held at the beginning of operative lists to disseminate case based information, using the WHO checklist as a guide. These meetings are compulsory and are attended by all members of the team. During the pandemic, routine checklists have been expanded to include vital case-specific COVID-19 information.

All surgical cases require a discussion about the patient's COVID-19 status, the degree of aerosol risk for each part of the procedure (induction of anaesthesia, extubation, and for all operative phases), with PPE requirement stated for each stage. Important logistical considerations should also form part of the preoperative checklist, such as: wait-time for air changes following induction and termination of anesthesia, location of operating rooms donning and doffing areas, designated staff roles, and a detailed itinerary of the required (and potentially required) surgical instrumentation. 76 Frequent, structured communications are key to safe practice and particularly important during the COVID-19 pandemic. 77 Workplace risk remains high; predictions expect heightened risk level to remain for months to years. Accordingly, changes made to systems, staff handover, and general communications may become incorporated into routine NHS practice for the longer term, despite originally introduced as COVID-19 related cultural changes.

It should be assumed that the operating rooms environment and its contents are contaminated , 54 providing exposure for development of nosocomial COVID-19 infection. Furthermore, AGP are highrisk for viral transmission to healthcare workers, and must be managed in concordance with stringent safety protocols. Necessary adjustments to operating suite layout, staff working, and operating rooms flow have been implemented throughout the NHS surgical services to mitigate these risks. To ensure safety throughout the phases of a surgical procedure, modifications have been made to each component of the operative pathway. Viewed as separate parts, these include preprocedure team meeting (WHO checklist), transfer, induction of anesthesia, operative steps, extubation, and transfer to recovery. Wait times following instrumentation of the pharynx should be considered part of the anesthetic procedure.

Ventilation systems have been the subject of dispute. In the majority of NHS hospitals, operating rooms ventilation runs on positive pressure systems, with or without laminar flow. Literature from other countries recommending negative pressure ventilation in the management of COVID-19 cases, 78,79 initially generated concern. A consensus statement between the Royal Surgical Colleges, affiliated organizations and Public Health England have approved that positive flow ventilation systems are considered safe for the management of COVID-19 cases, 39 and that laminar flow is recommended. Acute restructuring of NHS operating rooms ventilations systems has not been feasible during the pandemic, but safe ventilation management has been crucial. Doors between the operating rooms and adjacent spaces should be kept closed to maintain effective airflow. 80 Most NHS operating operating rooms have a degree of open plan design. The heightened requirement for ventilation and reduced contamination has changed the demands of the operating suite. 81 Anesthetic rooms do not routinely have high frequency ventilation, and scrubbing up areas are usually confluent with the operating rooms space. Transforming operating suites into COVID-19 safe work spaces overnight, has been challenging. Example operating rooms layouts are provided for our institution, prior to COVID-19 (Fig. 1) , and demonstrating the repurposing of workspace areas during the COVID-19 pandemic (Fig. 2) .

Under current circumstances, all parts of the patient's pathway (induction of anesthesia, the operating procedure and recovery), now occur in the main operating suite. In our institution, the absence of doors between the scrubbing up area and the main operating rooms has required scrubbing and donning to be performed in the repurposed, anesthetic room. Access to operating rooms for the delivery of additional equipment should occur through the newly assigned "Staff entrance and donning area". The lack of a designated storage space for equipment which is separate from the main operating rooms space has required "external runners" to deliver kit into operating rooms, through the clean donning area (which would have previously been the anesthetic room). Equipment is passed from the "external runners" in the operating rooms corridor, to staff in full PPE stationed within the clean area. Knocking on the operating rooms door signifies to the internal theatre team that the equipment is available. The "internal runner", when ready, opens the door for a minimal period, accepting the required equipment. Pauses in operating, while this process is actioned, can prolong the procedural time.

Operations on children should be avoided due to the unique risks of asymptomatic carriers and difficulty of performing pediatric screening, examinations, and procedures. In exceptional circumstances, essential procedures can be performed. All children are managed as high-risk for COVID-19 transmission. The surgical pathway for children has been modified for safety accordingly.

Generally, children are cannulated on the ward and accompanied by a parent or guardian to the operating rooms entrance, where staff in full PPE meet them. The patient is then anaesthetized without the parent present. In some parts of the UK, child services have been reduced in peripheral hospitals, favoring centralization of cases to designated pediatric hospitals, thereby maximizing expertise.

The need to segregate suspected or confirmed COVID-19 patients into designated operating rooms has spurred the use of traffic light systems to denote case status. Ideally, completely separate operating suites, with isolated ventilation systems, should be used for suspected or positive COVID-19 patients. All non-essential equipment should be removed from the operating rooms environment and essential apparatus should be covered with plastic wrapping. 82 A detail run through of all required equipment should be detailed in the team briefing and kept sterile in a clean area within theatres enabling swift access. Unused items should be returned to stores without being contaminated.

Whenever possible, staff perform a dedicated role for the duration of an operation, thereby minimizing the number of people in the operating rooms, and reducing handovers. Due to additional steps and segregation of areas within the operating suite, the staffing requirement overall is greater. 63 Social distancing should be maintained, when practical, within the operating rooms environment. Based on national guidance, local NHS trusts individualize their COVID-19 response based on the existing infrastructure of individual hospital sites. Structural layout, PPE availability, and disease prevalence are taken into consideration.

All NHS trusts, but not all hospitals, have a critical care capacity. The total number of NHS critical care beds for combined adults and pediatric occupancy (under usual circumstances), totals 5,900 beds, 83 or 7.5 beds per 100,000 population. 84 This figure is lower than many European countries and posed an immediate concern in the advent of COVID-19. Halting elective operating and reassigning operating spaces has been the main contributor to NHS England's plan for an additional 30,000 critical care beds. 85 Difficulties in the procurement of essential equipment, including ventilators (due to supply flow problems and a global shortage) has, in some cases, resulted in redistribution of operating equipment. In other locations, due to an expanded critical care bed requirement, areas with capacity for ventilation were identified, recruited, and converted. Most commonly in NHS hospitals, these have been operating rooms, anesthetic rooms, and recovery areas, which has had an immediate effect on operative capacity. The consolidation of surgical cases (across all specialities) into the remaining operating rooms lists, has required daily multidisciplinary meetings to discuss prioritizations.

Operational adjustments to redirect elective surgeries to "COVID-19-free" zones, has seen the reopening of some surgical areas and utilization of private sector establishments. Block-buying of independent sector capacity has occurred on a national scale and is being managed by local NHS trusts. 85

During the COVID-19 pandemic, across all specialities, modifications to the technical aspects of surgical practice have been implemented. Within NHS practice, certain pandemic principles have emerged to reduce the risk profile of surgery (Table 4 ).

It is accepted that many surgical conditions may be managed conservatively. As a result, some patients who would have been transferred to specialist centers will have been managed locally. 86, 87 In the current climate, a trend is observed towards increased imaging to inform surgical decisionmaking. Patients with acute general surgical conditions such as suspected appendicitis and cholecystitis, should either have open procedures (due to the unknown risk of laparoscopic surgery) or be managed conservatively. Similarly, management of acute mastoiditis should now be medical with imaging support. 88 A detailed, collaborative, COVID-19 response has redefined the trauma management standards during the pandemic. 89 Increasingly, trauma cases that can be managed with local anesthetic procedures are performed whenever possible in the emergency department or trauma clinic setting to reduce the operating room burden. 9

The COVIDHAREM study has been announced to capture the impact on morbidity and mortality of differing approaches to the management of acute appendicitis during COVID-19. 90 Emergency surgery during this period has been complicated by later surgical presentations, most likely due to patient compliance with isolation or anxiety around entering a high-risk clinical area. Reports demonstrating a relative increase in the number of bowel obstructions during the COVID-19 pandemic are not surprising, making surgery more challenging and having a negative impact on patient outcomes. 91 Given that conservative management is being considered for a larger cohort of patients, the use of surgical scoring systems may help stratify patients. 80 The avoidance of general anaesthesia (GA) is primarily due to the associated aerosol risk;

however, there are also secondary advantages such as potential reduction in postoperative bed requirement and anesthesia related complications. The move away from GA has seen a reciprocal increase in use of regional anaesthesia. Newer techniques such as "wide awake local anaesthetic no tourniquet" (WALANT) technique 92 have gained an overnight increase in popularity. WALANT has been recommended by the British Society for Surgery of the Hand for routine practice during COVID-19 and is increasingly being used for other anatomical regions.

Many standard operative devices such as laser, bone saws, high-speed drills, skin dermatome, harmonic scalpel, and other tissue-sealing devices have been evaluated as high aerosol risk and have been temporarily replaced with alternative techniques. In real terms this has meant a temporary return to more traditional surgical techniques. 72 Settings of cautery devices should be as low as possible to reduce the generation of smoke and used with suction or intrinsic vacuum. 93, 94 There is an ongoing debate about the risks of open surgery versus laparoscopic surgery. The

Intercollegiate general surgery guidance advised against laparoscopic surgery due to the unquantified risk. 93, 95 Insufflation of body cavities may be associated with aerosol generation due to escape of fluid with high pressure gas. More detailed guidance later suggested that laparoscopic techniques for cases with clear benefit, could be used over alternative techniques, with use of full PPE to mitigate against potential transmission. 96 Prior to use, all equipment must be checked meticulously and operating room ventilation should be appropriate. Adjustments to technique to maximize safety include careful introduction of trocars to minimize leak, aspiration of abdominal cavity insufflation prior to removal of trocars, and the use of air filters. A consensus on safety of laparoscopic surgery has not been reached. The Association of Laparoscopic Surgeons of Great Britain and Ireland has provided a series of safety recommendations for laparoscopic practice in cases where there is a clear benefit. 97 Certain procedures involving the head and neck cannot eliminate exposure to AGP. For these highrisk operations, procedural planning is key. An emphasis on clear stepwise processes increases safety. 98 Tracheostomy placement and changes, whenever possible, should be delayed until patient is proven COVID-19 negative. When necessary, strict protocols should be followed incorporating modifications to standard practice, such as advancement of the endotracheal tube below the incision level to mitigate aerosol generation. 63 In keeping with the "essential surgery only" approach, many complex surgeries are simply not being performed. Surgical choices focusing on reduced operative time, low complication rates and minimizing the inpatient stay are favored. In the current climate, breast cancer patients are not being offered primary reconstructions. Similarly, in the severely injured limb, early amputation should be considered over limb salvage and reconstruction, requiring multiple procedures. In gastrointestinal surgery, patients are more likely to be offered a temporary stoma formation to reduce the risk of anastomotic leak and longer inpatient stays. 4,99 Surgical management of fragility fractures (the incidence of which remains high) are a priority, with acceptance that hemi-arthroplasty and sliding hip screw fixation in the current climate offer a beneficial reduction in operative time. 100 Surgical techniques to reduce complexity and follow-up contact are preferential. Examples include the use of absorbable sutures and percutaneous K-wires for fracture fixation.

Minimizing staffing numbers in the operating room also extends to the number of surgeons.

Operator requirements are dependent on the technical challenges of the procedure. In some operations, such as pediatric otolaryngology cases, a minimum of 2 surgeons are still recommended during the pandemic for safety reasons. 63 

The UK's daily figures for COVID-19 proven infections, hospital admissions, and deaths, appear to suggest that we are emerging from the peak. Lockdown measures have been, to some extent loosened, without a detectible effect on these trends. With the most vulnerable groups of people still under strict isolation, and with no clear strategy for their safe emergence, we may be falsely reassured. Recorded figures are valuable, but should be interpreted cautiously, taking into consideration the UK's screening challenges and the international variation in testing and recording practices.

Some of the surgical specialty organizations have released literature detailing the next phase of the pandemic response, encouraging a move towards resuming elective services. 104 The priority must be for safe return to surgical pathways and the readiness to do this will vary across NHS trusts. Gradual resolution of elective surgery will be limited by a multitude of factors, many of which have been discussed in this manograph. Prolonged procedure time will continue to have a dramatic effect, and it is unlikely that services will return to the pre-COVID-19 level of turnover. Should subsequent surges in COVID-19 prevalence occur, there may be a similar regression in availability of surgical services.

All surgical staff will continue to play a role in reducing the risk of transmission, thereby continuing to mitigate against the impact on patients and staff. Surgical trainees, who have been flexible during the pandemic period, will need their training requirements planned into the next phase response.

Changes to working patterns and surgical schedules have been extremely disruptive and decisions will need to be made about how these will be readjusted. Since January, 2020, the UK is no longer part of the European Union, which could lead to major changes in workplace standards. It is unclear if the EWTD rules for safe working will be abolished. Proposals to target the disruption to services, may encourage a move towards 7-day working. At the same time, COVID-19 delivered rapid delivery of flexible working, previously unimagined in the NHS. It is likely that the NHS will be challenged to maintain more adaptable ways of working for some individuals.

The effect of COVID-19 on patients has been dramatic and very difficult to quantify. The COVID-19 pandemic has brought a novel sense of risk around healthcare, with particular caution surrounding surgery. The psychological effects of social isolation, and the impact of media should not be underestimated. As we emerge from the peak, an emphasis on high quality research is now needed to generate data on critical deficiencies in knowledge, and to help inform decisionmaking in surgical care.

Early data suggest that COVID-19 has a detrimental effect on surgical outcomes. The overall mortality rate, in the presence of COVID-19 infection prior to, or following surgery, is higher than would be expected. 105, 106 This is highly concerning for patients, surgeons, and healthcare providers.

Robust research is required into the impact of COVID-19 on surgical outcomes.

One quarter of the UK population are deemed high-risk. 107 Patients' vulnerability factors will influence their level of anxiety around attendance to healthcare institutions and treatment decisions. Delays to cancer operartions, on account of service availability, oncological prioritization, or patient choice will have magnified the stress and uncertainty experienced by cancer patients and their families.

Increasingly, data are emerging suggesting there may be patterns in susceptibility to COVID-19.

Broadly, these could be grouped into potentially-modifiable and non-modifiable factors [107] [108] [109] [110] [111] (Table   5 ). Although some of the literature is speculative, these potential links are the cause of significant anxiety and require expedient scientific investigation. The increased risk of COVID-19-relatedmortality is particularly problematic for cancer patients requiring treatment. Ultimately, in some cases, the presence of risk factors will complicate treatment discussions and decisions.

Clearly, trends in susceptibility affect patients and staff alike. Looking forward, possible implications include the need for differential management of patients or staff based on the presence of risk factors, increased preoperative or occupational screening, and potentially, public health initiatives to address modifiable risks. This raises the question: as the largest employer in the UK, should be the NHS be more responsible for addressing the health of its workforce? If so, COVID-19 could result in an infrastructural shift towards greater emphasis on occupational health and well-being.

Interestingly, in the UK healthcare workers have not been shown to have higher death rates when compared to the general population. 112 Healthcare workers from Black, Asian and Minority Ethnic (BAME) groups, have been shown to have a significantly increased risk of mortality when compared to white healthcare workers. 113 Furthermore, national data suggests that Black, Pakistani and Bangladeshi individuals are at increased risk of mortality from COVID-19. 108 Although the data are striking, they are unlikely to represent ethnicity factors alone. Essential research investigating the link between ethnicity and risk of mortality, as well as other contributory factors, should be a national priority. As the UK moves into the next phase of COVID-19, a focus on understanding and managing vulnerability factors will be key.

Globally, an estimated 37.6% of cancer surgeries and 81% of benign operations will be delayed on account of the pandemic. 114 Many patients will have accepted alternative treatment pathways on account of COVID-19, with unknown effect on outcomes. Pathways designed to aid decisionmaking between surgeon and patient do have a role, but are not validated. 105 The NHS safeguards patient care by delivering treatment pathways within a series of strict timelines.

Cancer waiting times include standards for the time to diagnosis (31 days) and time to treatment (31 days from treatment decision, 62 days from initial referral). Clearly, in the current climate these may be more difficult to maintain; however, cancer care will be most protected. The management of benign conditions will inevitably suffer delays. The maximum duration for treatment of non-urgent conditions should be 18 weeks. Any breach of these standard waits results in a fine for the NHS trust.

Currently, most patient pathways have been frozen (on account of the exceptional circumstances), therefore not incurring these penalties. How suspensions to pathways, prolonged wait times for operations and, patients' expectations will be managed, has not yet been publicized. An emphasis on cancer management and other time-dependant operations will be the primary focus as services resume. The cancellation of some operations may have already led to harm, or may require adjustment to planned surgical interventions due to disease progression.

Rapid resolution of transplant, cardiothoracic, and vascular surgery services will be necessary to reduce the secondary morbidity and mortality associated with COVID-19. Transplant services in the UK have been dramatically affected by COVID-19. Live donations were held due to the relative risks to both patients. The complex infrastructure required for rapid organ retrieval, matching, and transplantation could not be maintained uniformly over the peak pandemic. Pancreas, liver and kidney services have been particularly affected, with the majority of centers still closed. 115 The national reduction in transplantation and donor availability will have contributed to the number of potentially preventable deaths. 116, 117 Non-urgent benign operations are likely to be suspended indefinitely until a strategy has been agreed for the urgent procedures. These patients are likely to be disappointed by prolonged waiting times. Delays to surgery will in many cases result in progression of disease and an associated impact on the technical complexity of surgery.

Pediatric surgery is a particularly difficult area. In general, surgeries are only performed in children when they are clinically urgent. Due to the challenges of performing adequate pharyngeal swabs in children and the frequent requirement for GA, all pediatric operations will need to be managed as high-risk cases. Age dependent operations such as cleft lip and palate are generally performed within a narrow window, based on a delicate balance of risks. With ongoing uncertainty about the risks of surgery in the presence of COVID-19 infection, pediatric surgeons will need to carefully consider the safe return to elective operating.

Outpatient cancer surveillance and imaging has largely been held. Telemedicine clinics, which are reliant on patient reported signs and symptoms, are unlikely to have been a substitute for professional assessments. 118 As a consequence, we are likely to see a rise in cancer recurrence, presenting later. High-risk imaging for oncological surveillance will resume, but managing the backlog will be challenging. The longer imaging gap in some patients will mean later detection of oncological metastasis or recurrence.

The government's decision to halt elective operating over the COVID-19 pandemic peak was necessary, but has led to an accumulation of cases. It has been estimated that clearing the backlog of these operations will take an estimated 45 weeks, working at a 20% increase in productivity. 114 Trusts invested in targeting these delayed procedures will however, be confronted with limited surgical capacity and reduced efficiency. An expansion of staff provision, operating room availability, and associated support services will be necessary. In practice, this translates into a systems approach to increased capacity, with as much emphasis on dressings clinics, physiotherapists, and radiographers as it has on surgeons and operating room staff. How this will be funded is not yet clear, but the UK is facing estimated costs of £2 billion. 114 The use of independent sector hospital services will play a key role in the expansion of NHS surgical capacity. Many patients will prefer to have procedures in COVID-19 "light" or "cold" sites, which may be safer. The logistics of managing patients through additional sites, is problematic. Information technology systems are different and are often not compatible with the parent NHS trust systems, leading to challenges with access to patient records and data protection. Many hospitals have not yet confirmed their position on trainee access to alternative sites, which, if denied, could have an ongoing detrimental effect on training.

On account of the many delays and unplanned changes to patient management decisions, the NHS will experience a unique wave of healthcare litigation. Cases of clinical negligence may target NHS trusts or the individual. Organizations such as the British Medical Association and the General Medical Council have provided guidance for members on practicing during the COVID-19 pandemic; however, there is ongoing professional concern about the personal level of risk. Returning NHS professionals may be particularly vulnerable. Undoubtedly there will have been preventable harm and deaths suffered as a consequence of the COVID-19 pandemic. Surgical specialty organizations have adopted a key role in the dissemination of available evidence to aid safe practice and should be used as a guide for professionals. Individuals should carefully discuss and document all patient management decisions influenced by the COVID-19 pandemic.

Current indemnity arrangements will cover events incurred over the COVID-19 period; however, the UK government has launched an additional COVID-19 clinical negligence scheme for additional scope. 119 The Coronavirus Act 2020 covers the services outsourced to independent hospitals on account of COVID-19. 120 Other high-risk areas of potential litigation include the manufacture of equipment and pharmaceuticals. 121 Use of telemedicine clinics has bridged an important gap in the availability of services, but the rapid development of virtual services, with temporary slackening on data protection standards, will have implications for patient confidentiality, with legal implications. 122 The rapid introduction of new systems are often associated with greater potential for error and breach of information standards.

The development of increasingly data-safe systems will be paramount.

COVID-19 has resulted in a significant number of challenges for surgery in the UK. By detailing the unique NHS experience, as well as the evolving responses to the COVID-19 pandemic, we offer a view into the current impact on surgical services. At the time of writing, the UK is thought to be emerging from peak prevalence. Navigating a safe return to surgical pathways, as the pressure on the health system changes, will be a slow process and will generate further challenges. With many countries entering their pandemic experience later, a map of the NHS surgical challenges will likely inform expectations and practice.

The consolidation of the challenges into the subgroups of surgical workforce, surgical patients, and surgical process has aimed to address the concerns of different NHS stakeholders, within a constantly evolving landscape. Many uncertainties remain, and the effects of COVID-19 on surgical practice are likely to be longstanding. The first weeks of the pandemic were an unsettling time for the nations as new ground was being navigated. The dynamic nature of the COVID-19 pandemic has made the generation of this monograph both interesting and challenging.

Despite the devastating loss of life, healthcare disruption, and international anxiety, we must identify the wealth of lessons gleaned from the COVID-19 pandemic and cultivate from them positive changes for our healthcare systems. The sharing of international experiences has been invaluable in tackling the COVID-19 response. Consensus statements have been crucial in guiding care decisions, but as we move forward an increased emphasis will be on evidence based medicine.

The response of both the public and the international healthcare community in tackling COVID-19 has been impressive. We will need continued vigor to manage the ongoing challenges facing surgery. Table 2 . NHS prioritisation system in COVID-19 pandemic 12 .

Emergency -operation needed within 24 hours

Urgent -operation needed with 72 hours

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