key: cord-0725673-j4o7m9ck authors: Ng, Jun Jie; Gan, Tiffany R.X.; Niam, Jen Yong; Menon, Raj K.; Ho, Pei; Dharmaraj, Rajesh B.; Wong, Julian C.L.; Choong, Andrew M.T.L. title: Experience from a Singapore tertiary hospital with restructuring a vascular surgery practice in response to national and institutional policies during the COVID-19 pandemic date: 2020-05-23 journal: J Vasc Surg DOI: 10.1016/j.jvs.2020.05.026 sha: 5531462d164d012a1d1cd9238c62553507320152 doc_id: 725673 cord_uid: j4o7m9ck Singapore was one of the first countries to be affected by COVID-19, with the index patient diagnosed on 23 January 2020. For two weeks in February, we had the highest number of COVID-19 cases behind China. In this article, we summarize the key national and institutional policies that were implemented in response to COVID-19. We also describe in detail, with relevant data, how our vascular surgery practice has changed due to these policies and COVID-19. We show that with a segregated team model, the vascular surgery unit can still function whilst reducing risk of cross-contamination. We explain the various strategies adopted to reduce outpatient and inpatient volume. We provide a detailed breakdown of the type of vascular surgical cases that were performed during the COVID-19 pandemic and compared it to preceding months. We discuss our operating room and personal protective equipment protocols when managing a COVID-19 patient and share how we continue surgical training amidst the pandemic. We also discuss the challenges we might face in the future as COVID-19 regresses. The statistics speak for themselves. As of 13 April 2020, an astounding 1.9 million people 18 around the world have been diagnosed with Coronavirus disease 2019 , resulting in 19 nearly 120,000 deaths 1 . Singapore was one of the first countries to have been affected by 20 COVID-19, having diagnosed the first case on 23 January 2020. The index patient was a Chinese 21 national from Wuhan, China, who arrived in Singapore with his family on 20 January 2020 2 . 22 Since then, as of 13 April 2020, a total of 2918 cases of COVID-19 have been diagnosed. Of 1 these cases, 1158 (39.7%) of patients remain hospitalized, with 29 (1.0%) patients requiring 2 intensive care. Nine patients (0.3%) have, unfortunately died from complications arising from 3 COVID-19 3 . 4 The sustained rise of COVID-19 cases in Singapore can be described by three distinct 5 waves of disease influx and propagation 4 . The initial surge in COVID-19 cases in late January 6 and February can be attributed to travellers from China visiting Singapore and causing limited 7 local transmission. This resulted in Singapore having the highest number of COVID-19 cases 8 outside mainland China for approximately two weeks in mid-February 5 . From March onwards, 9 the number of COVID-19 cases rose steeply again as Singapore citizens based abroad returned 10 home. Currently, in April, COVID-19 case numbers are surging again due to widespread local 11 transmission 3 . Preparation for COVID-19 in our unit begun in late January after Singapore announced 13 its index case of COVID-19 infection. In this narrative, we aim to describe the various 14 governmental and hospital policies that were implemented as a response to COVID-19. We also 15 aim to describe and discuss the aftereffect these policies had on vascular surgery services in our 16 unit. National policies 19 Equipped with lessons learnt from the severe acute respiratory syndrome (SARS) 20 outbreak in 2003, the government was quick to respond to the evolving COVID-19 situation 21 weeks before COVID-19 reached our shores 6, 7 . In January 2020, the government expeditiously 22 instituted measures such as mandatory temperature screening for all travellers, advising citizens 23 4 to defer all non-essential travel to China, and implemented compulsory quarantine measures for 1 all returning residents with recent travel history to China. New visitors with recent travel history 2 to China were also barred from entry or transit into Singapore 8 . 3 On 7 February 2020, as cases of COVID-19 continued to rise, and cases of with no prior travel history or traceable link to prior cases were discovered, the "Disease 5 Outbreak Response System Condition" (DORSCON) alert level was raised from yellow to 6 orange, signifying more severe disease and easier community transmission 9 . The DORSCON 7 alert level system is a systematic outbreak response system with a colour-coded framework 8 (green, yellow, orange and red) that reflects the severity of the outbreak (Figure 1) 10 . 9 On 11 March 2020, the World Health Organization declared COVID-19 as a pandemic 11 . The travel entry ban into Singapore was extended to include new visitors from Italy, France, Spain and Germany on 13 March 2020 12 . By 18 March 2020, Singapore citizens or residents that 12 returned home had to serve a 14-day stay-at-home requirement 13 With the surge of COVID-19 cases in early April 2020, more stringent measures such as the 17 closure of all non-essential businesses and schools were enforced by the government in an 18 attempt to curb local transmission. Public gatherings were prohibited by law. All Singapore 19 residents were strongly advised to stay and work from home whenever possible, unless for 20 specific reasons such as seeking medical attention or buying groceries 17 . The National University Hospital is an academic tertiary hospital located in the 1 Southwest of Singapore with a total of 1239 beds. Before COVID-19, bed occupancy rates were 2 commonly in excess of 90%. Crucial institutional policies had to be implemented to increase 3 resources for the potential influx of COVID-19 patients. From late January onwards, the listing of non-urgent elective surgeries was prohibited, 5 except for "time-sensitive cases" such as oncological cases or limb salvage procedures. 6 Departments were also urged to plan for a segregated team model for both clinical and non- The clear and concise flow of information to ground staff was paramount to ensure 17 compliance with implemented policies. This was achieved by daily emails and text messages 18 from the hospital's leadership. These messages also served to boost the morale of healthcare 19 workers and augment organizational loyalty. As the number of COVID-19 cases continued to 20 rise, arrangements were made for administrative staff to work from home from April 2020 21 onwards. Segregated team model 23 After the DORSCON alert level system was raised to orange on 7 February 2020, our 1 vascular surgery unit immediately adopted a segregated team model as part of its business 2 continuity plan. Our unit comprised primarily of four attending surgeons and four senior 3 residents or fellows. Each attending surgeon was paired to a senior resident or fellow to form a 4 pair. The roster was planned in a cyclical fashion such that each pair would move through four 5 sequential 7-day phases (inpatient, outpatient, back-up and rest). The inpatient team covered 6 ward patients and performed surgery, while the outpatient team ran the outpatient clinics. If 7 additional manpower was required, the team in the back-up phase could be mobilized to help. The segregated team model would prevent cross-contamination and ensure that the entire 9 vascular surgery unit would not be infected or quarantined in the event of COVID-19 exposure. It also allowed each team to have a 7 to 14 day wash-out period from their last patient contact 11 before embarking on patient contact again. The wash-out period allowed sufficient time for 12 symptom manifestation if a team member had contracted COVID-19 before returning to patient 13 care. A 7 to 14 day wash-out period was more than adequate after taking into consideration the 14 mean incubation time of COVID-19 18 . Besides segregating within the unit, inter-departmental segregation was practised. All 16 face-to-face multidisciplinary team meetings were suspended and replaced by virtual meetings. 17 As our unit provided consultative services to a rehabilitation-focused subsidiary hospital, these 18 consultations were also conducted in a virtual fashion. Outpatient clinics 20 Vascular surgery outpatient clinics were immediately scaled down when the DORSCON 21 alert level was escalated to orange on 7 February 2020 ( Figure 1) . We reduced the number of 22 scheduled outpatient clinic sessions from 10 half-day to 5 half-day sessions per week. Although 1 we kept our outpatient clinic open from 9 a.m. to 6 p.m. to accommodate any possible patient 2 that might require an urgent ad-hoc review, scheduled patients were only reviewed in the 3 morning session from 9 a.m. to 12 noon. We aggressively reduced the number of patients that 4 required scheduled on-site visits by conducting teleconsultations and reviewing electronic 5 medical records. As per the segregated team model, an attending surgeon paired to a senior 6 resident or fellow would run the outpatient services for 7-days before another pair takes over. The other segregated pairs that were on non-clinical duties would remotely review new clinic 8 referrals and conduct telephone interviews with patients that were scheduled for upcoming clinic 9 visits. Non-urgent new clinic referrals such as varicose veins without ulceration, asymptomatic 10 peripheral arterial disease or pre-emptive dialysis access creation were postponed. Patients that were on active follow-up were screened carefully via a combination of 14 Several measures have also been instituted to facilitate the discharge of patients that are 15 currently admitted. Expedited pathways were set up to accelerate the administrative processes 16 required to discharge stable patients to subacute facilities for continued wound care and 17 rehabilitation. Virtual meetings were held regularly between medical social workers, therapists 18 and the medical team to discuss and formulate discharge plans for patients with complex social 19 issues. The reduction in our bed occupancy rate meant that more bed space could be used to treat 20 incoming COVID-19 patients. As part of our inpatient services, we provide an emergency vascular surgical consult 1 service to medical teams that are managing COVID-19 patients. Thus far, we have not However, due to the various institutional policies implemented for COVID-19, the 21 amount of elective vascular surgery cases such as pre-emptive dialysis access creation, and 22 venous surgery have fallen. The amount of aortic-related cases have also decreased as we now 23 tend to postpone patients with abdominal aortic aneurysms who are asymptomatic. Interestingly, 1 the number of major amputations have risen considerably compared to 2019. This is primarily 2 due to a lower threshold in offering either primary major amputation for patients with a low 3 chance of successful limb salvage, such as those who present with severe infection or extensive 4 tissue loss, or early major amputation for patients who have not improved despite maximal 5 revascularization. As such, these patients can be discharged earlier to a subacute facility or 6 directly home to free vital bed space in the hospital. 7 We have also created and implemented an in-house scoring system to triage patients who 8 require arteriovenous dialysis access creation. This scoring system consists of variables such as 9 prior catheter-related blood stream infection, extended tunnelled catheter time of 6 months or 10 more, access concerns such as limited catheter options, or history of catheter malfunction. Currently, we still selectively perform arteriovenous dialysis access creation only for patients 12 who have two or more of the abovementioned variables. When COVID-19 subsides, this scoring 13 system can also be used as a tool to prioritize patients who require dialysis access creation earlier. In response to this inevitable paradigm shift in surgical training, we implemented several 21 measures to ensure continued training for our trainees. We curated surgical or procedural videos 22 from the various online sources for our trainees to view. For example, we found that the 23 "Houston Methodist DeBakey CV Education" channel on YouTube contained multiple highly 1 educational surgical videos and didactic lectures that were immensely useful to our trainees. We 2 also encouraged our trainees to listen to the "Audible Bleeding" podcast and participate in the 3 interactive online symposiums organized by Vascupedia. We found that a large myriad of tools 4 for vascular surgery education had already existed prior to COVID-19 and we aim to continue 5 using these tools to facilitate and augment surgical training in the foreseeable future. 6 Educational activities that were previously conducted in a face-to-face manner such as 7 journal clubs or case discussions have now been transitioned to a virtual platform. Virtual 14 Preparing for the future 15 We need to start preparing for the future. Technologies that have flourished during 16 COVID-19 such as telemedicine or remote monitoring technologies should be harnessed for our 17 future practice 26, 27 . We will face a large backlog of cases once COVID-19 dwindles. Sensible 18 triaging still applies, such that more essential cases are operated on first. As we gradually 19 increase our outpatient and inpatient services to pre-COVID-19 levels, we must continue to 20 screen for patients with potential COVID-19 and be vigilant in maintaining a high level of 21 hygiene. Once COVID-19 subsides, we plan to transition from the current four-phase segregated 22 model back to the pre-COVID-19 state by reducing the number of phases and simultaneously 23 13 increasing the number of medical staff in each phase gradually. This cautious approach is 1 adopted in anticipation of a second COVID-19 wave. 2 Conclusion 3 COVID-19 has affected our vascular surgery unit in multiple ways. Most of these 4 changes are invariably due to national and institutional policies made to preserve hospital 5 resources. These policies are essential and crucial, especially in a resource-constrained country 6 like Singapore. However, we are not alone as multiple vascular surgery units around the world 7 are experiencing the same changes 28 . As the number of COVID-19 cases in Singapore continues 8 to rise due to local transmission within several foreign labour communities, we must continue to 9 prepare for a sudden influx of patients. As vascular surgeons, we will have to remain dynamic 10 and tailor our vascular surgery services accordingly based on available resources. In the extreme 11 situation, challenging decisions like declining surgery for an elderly patient with a ruptured 12 abdominal aortic aneurysm to preserve intensive care unit capacity might have to be made. COVID-19) Situation Report -84 Organisation (WHO) web site Confirmed imported case of novel coronavirus infection in Singapore Ministry of Health Singapore's strategy in fighting Covid-19. The Straits Times, Singapore. 5 5. Coronavirus disease 2019 (COVID-19) Situation Report -30 Organisation (WHO) web site Commentary: Why Singapore is better prepared to handle COVID-19 than SARS Channel News Asia, Singapore. 13 8. Extension of precautionary measures to minimize risk of community spread in Singapore. 14 [Ministry of Health Risk assessment raised to DORSCON orange What do the different DORSCON levels mean Additional border control measures to reduce further importation of COVID-19 cases. 13 [Ministry of Health COVID-19: MCCY advisory on religious activities Circuit breaker to minimise further spread of COVID-19 Early Transmission Dynamics in Wuhan, China Characteristics of and Important Lessons From the Coronavirus 8 Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the 9 Chinese Center for Disease Control and Prevention Clinical course and risk factors for mortality of adult 11 inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Lower risk of venous thromboembolism in multiple Asian ethnic 18 groups COVID-19 Guidelines for Triage of Vascular Surgery Patients What we do when a COVID-19 patient needs an 4 operation: operating room preparation and guidance Robots may become heroes in war against COVID-19 The Global Impact of COVID-19 on Vascular Surgical 12