key: cord-0773869-rtvjlkg6 authors: Boyce, Louis; Nicolaides, Marios; Hanrahan, John Gerrard; Sideris, Michail; Pafitanis, Georgios title: The early response of plastic and reconstructive surgery services to the COVID-19 pandemic: a systematic review date: 2020-09-07 journal: J Plast Reconstr Aesthet Surg DOI: 10.1016/j.bjps.2020.08.088 sha: 0db6d2bdd1f894f9f8bbbb9ac5e5a4fa81a31a1f doc_id: 773869 cord_uid: rtvjlkg6 The World Health Organisation characterised the spread of coronavirus disease-19 (COVID-19) as a pandemic in March 2020, signalling medical governance and professional organisations worldwide to make urgent changes in their service. We have performed a systematic review of the literature to identify all published literature on plastic surgery and COVID-19, in an effort to summarise the evidence for future reference. Our search identified 1207 articles from electronic databases and 17 from manual search, out of which 20 were included in the final data synthesis. Out of the included studies, most originated from the United States (n=12), 5 from Europe, 2 from China and 1 from Australia. Strategies described to limit the spread and impact of the virus could be divided into 9 distinct categories, including the suspension of non-essential services, use of telemedicine, use of personal protective equipment, screening patients for COVID-19, restructuring the healthcare team, adapting standard management practices, using distance-learning for trainees, promoting public education and initiatives, and minimising intra-hospital viral transmission. The ever-changing nature of the COVID-19 may prompt plastic surgeons to adapt special strategies as pandemic progresses and subsequently declines. The findings of this review can prove beneficial to other plastic surgery departments in informing their response strategies to the pandemic and in a second wave of the disease. The World Health Organisation (WHO) characterised the spread of coronavirus disease-19 (COVID- 19 ) as a pandemic on 11 th March 2020 1 . This novel -coronavirus strain is phylogenetically related to the severe acute respiratory syndrome-like (SARS-like) bat viruses and was first identified in a cluster of cases in Wuhan, China 2, 3 . As of 10th June 2020, 7,145,539 confirmed cases and 408,025 deaths were reported globally, across more than 220 countries and territories 4 . A total of 289,144 confirmed cases and 40,883 deaths have been reported in the UK 4 . Inevitably, COVID-19 has impacted healthcare service, including surgical specialties such as plastic surgery. Clinical manifestations of COVID-19 can vary from an asymptomatic carrier state to severe pneumonia 5 . Fever, cough and fatigue, the commonest COVID-19 triad of symptoms, appear in 95%, 60.3% and 38.0% of cases, respectively 6 . Illness severity and case-fatality ratios increases substantially with age; elderly patients with multiple underlying co-morbidities are at considerable risk of morbidity and mortality, whilst younger people may experience mild to no symptoms at all 7 . People with subclinical manifestations of COVID-19 may never be tested, posing an enormous challenge for prevention and control of the disease 8, 9 . Following WHO recommendations, many nations have adopted public health measures including quarantine, social distancing and travel restrictions to slow the spread of COVID-19 10 . Despite these efforts, the rapidly evolving pandemic has placed an unprecedented burden on healthcare services worldwide, depleting hospital resources and leading to shortages in personal protective equipment (PPE) 11 . In the UK, the National Health Service (NHS) England has opened temporary critical care hospitals (Nightingale) to anticipate the need for additional bed capacity 12, 13 . The four Royal Surgical Colleges of the UK have released common policy statements and guidance in response to this changing landscape, including cancelling all non-essential travel for surgeons, suspending all educational activities, adapting the service and releasing online material for training [14] [15] [16] [17] [18] [19] . Similarly, the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) and British Association of Aesthetic Plastic Surgeons (BAAPS) have released policy statements and advice for members 20, 21 . Plastic surgeons have a responsibility to follow current guidance and recommendations to protect both the public and staff and support the frontline in minimise the virus" burden on healthcare services. We have performed a systematic review of the literature to identify all published literature on plastic surgery and COVID-19, in an effort to summarise the evidence for future reference. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search strategy aimed to identify all published literature addressing "surgery" during the COVID-19 pandemic. We avoided focusing the search to "plastic" surgery only, to capture all special topic publications that might have not included plastic surgery in their title or abstract. An electronic database search of MEDLINE (via Ovid), EMBASE, PubMed, SCOPUS, Cochrane Central and Web of Science Core Collection was conducted, using the keyword strategy detailed in Appendix 1. The search results were limited to records published in 2019 and 2020, up until 1 st May 2020. To supplement our results, a further manual search was performed by two independent reviewers on Google Scholar and through the bibliographies of all included articles. The inclusion criteria selected for studies addressing "plastic surgery" during the COVID-19 pandemic. The modified PICO framework for qualitative systematic reviews, outlined by Butler et al., was used to define the inclusion criteria:  Population: Plastic, dermatologic or facial plastic surgeons or staff working in plastic, dermatologic skin cancer surgery or facial plastic departments or clinics. The results of the electronic database searches were exported into a reference manager (EndNote X9.3) to remove duplicates. A biphasic study selection process was undertaken: three independent reviewers (L.B., M.N., R.S.) screened title and abstracts based on the inclusion criteria. Articles were included by default if any discrepancies arose between the reviewers during title and abstract screening. Full-text screening was performed by two independent reviewers (L.B., M.N.). Any discrepancies were resolved by senior author input. The author, year and country of publication and type of study was extracted from the full-text articles by two independent reviewers (L.B., M.N.). Each study was critically appraised to identify common themes amongst the included articles. Recommendations and interventions made and enacted in response to the COVID-19 pandemic were extracted from each article and grouped into distinct categories. Each category representing a homogenous set of strategies that were recommended and/or implemented by the plastic, dermatologic or facial plastic surgeons and/or departments or clinics from which the article originated. Our search identified 1207 articles from electronic databases and 17 from manual search ( Figure 1 ). The majority of articles excluded during title/abstract screening concerned other surgical specialties. No articles were excluded during the full-text screening phase. Following duplicate removal and article screening, 20 studies were included in the final data synthesis [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] . The main characteristics of the included studies are outlined in Table 1 . We identified 5 letters to the editor, 12 expert opinions, 1 review, 1 survey and 1 case report. All articles were published in 2020. Out of the 20 included articles, most originated from the United States (US) (n=12), 5 from Europe, 2 from China and 1 from Australia. Following critical appraisal and evaluation of the included articles, strategies described in the included studies to limit the spread and impact of the virus could be divided into 9 distinct categories (Table 2 ). Most studies reported on prioritising urgent care, including the suspension of non-essential services, (n= 16), while 12 studies reported on the use of telemedicine, 11 reported on appropriately using PPE, 9 reported on screening patients for COVID-19, 8 reported on restructuring the healthcare team, 6 reported on adapting standard management practices during the pandemic, 4 reported on the use of distance-learning for residents, trainees and medical students, 4 other studies reported on public education and initiatives, and 3 reported on controlling the hospital environment and logistics to minimise intra-hospital viral transmission. Sixteen out of 20 studies included in this systematic review reported that non-urgent or elective procedures have been cancelled or postponed in the respective plastic and reconstructive surgery departments 23, 25-37, 39, 41 . Nine studies additionally highlighted that non-urgent clinic visits and consultations have been rescheduled or restricted 23, 25-27, 29, 33, 35, 36, 39 . Six studies explicitly reported primarily refocussing care on urgent cancer and trauma cases, wherein morbidity is significant unless surgical intervention is urgently provided 22, 23, 25, 28, 32, 39 . Six studies recommend triaging care on a case-by-case basis, by assessing clinical priority 22, 25, 26, 31, 32, 34 . Telemedicine, or telehealth, involves the use of communication technology to facilitate the provision of clinical services 35 . Telemedicine technologies range from simple phone calls to store-and-forward imaging or video and the use of audio-visual telecommunications software, i.e. videoconferencing, to allow real-time correspondence 25, 35 . Twelve out of the 20 included studies report utilising telemedicine during the pandemic 22, 23, 25-27, 31-33, 35, 36, 38, 39 . All 12 studies advocate the use of videoconferencing for online consultations and post-operative assessments 22, 23, 25-27, 31-33, 35, 36, 38, 39 . Two studies report the use of telemedicine to communication between healthcare professionals 22, 27 . Fourteen studies recognised the importance of personal protective equipment (PPE) for healthcare staff when in contact with patients 22, 23, 25-31, 33-36, 39 . Two studies highlight the need for special attention and enhanced PPE when performing aerosol-generating procedures that involve nasopharyngeal or craniofacial spaces 29, 30 . Eleven studies recognise that shortages in hospital resources during the pandemic, has prompted the need to ration PPE 22-26, 29, 31, 33-36 . Three studies suggest donating unused resources to support hospitals and community healthcare efforts 25, 31, 33 . Nine studies identified the need to screen patients for COVID-19 prior to undergoing a procedure or attending hospital visits [25] [26] [27] [28] [29] [30] 39 . Five studies stress the importance of identifying suspected cases, by being alert to signs and symptoms of COVID-19 and recent travel or contact history 25, 27, 28, 31, 39 . Three studies outline screening protocols used in their department to deliver patient care efficiency, while protecting healthcare staff 28, 29, 39 . Two studies mentioned isolating infected patients and operating on confirmed COVID-19 cases in different rooms to uninfected patients 27, 39 . Eight studies make recommendations regarding the reorganisation of the healthcare team to protect staff and maximise effective teamwork 22, 23, 25, 27, 29, 31, 33, 37, 39 . Four studies express the importance of working collaboratively with the emergency department to manage the surge in patients 22, 23, 25, 31 . Three studies support rotating staff shifts to promote recuperation and reduce the risk of exposure 22, 33, 39 . Three studies advise limiting the number of healthcare staff in operating rooms 27, 29, 39 . Four studies report redeploying residents and/or medical students, who are interested in volunteering 22, 23, 25, 27 . Six studies have suggested various alterations to standard management practices with the aim of reducing hospital footfall or minimising the risk of viral transmission 22, 25, 27, 29, 30, 32 . To minimise hospital visits, 2 studies reported treating patients conservatively where possible 22, 27 . Two other studies suggest using absorbable sutures 22, 32 and finally 2 studies encourage plastic surgeons to educating patient to enable patient-led wound care and k-wire removal. For craniofacial procedures, 2 studies recommend using a scalpel over electrocautery (and bipolar over monopolar) for mucosal surfaces, minimising suction and irrigation and favouring closed reductions using self-drilling screws for facial fractures 29, 30 . Four studies discuss methods of distance-learning to permit the continuation of trainee education during the COVID-19 pandemic 25, 33, 40, 41 . These studies recommend using HIPPA-compliant videoconferencing application to conduct online webinars, didactic teaching, grand rounds, virtual conferences or even wards rounds, clinic visits or live streaming operations with the patient"s consent 25 . Additionally, 3 studies highlight that some examinations and interviews have been conducted online during the pandemic 22, 33, 41 . Three articles reported disseminate information to the public, including announcements, educational material and marketing 22, 38, 39 . Barry et al. argues that electric scooters should be prohibited during the pandemic 24 . Four studies made recommendations to alter hospital logistics and/or control the hospital environment to reduce the risk of nosocomial COVID-19 infection 22, 27, 39 29 . These studies opted to limit the number of visitors per patient, patient movement in the hospital and non-essential operating room personnel 22, 27, 29, 39 . Two studies described additional changes to the waiting room environment 22, 39 . This systematic review compiles the early published literature illustrating the response of plastic and reconstructive surgery departments to the COVID-19 pandemic. A variety of strategies with the overarching aim of preventing viral transmission were identified in this review. The included articles in this systematic review primarily included expert opinions and editorials, indicating an overall low quality of evidence. In addition, the majority of included studies originated from the US, likely due to the nation"s high case load and research output. Despite these limitations, this review may prove beneficial in informing the response to a potential "second-wave" of COVID-19 or future pandemics. The suspension of non-emergency services was the most widely reported strategy. This intervention would limit hospital footfall, reduce the healthcare team"s exposure risk and allow the reallocation of hospital resources, including beds and PPE, to support frontline staff 25, 33 . Equally, prioritisation of urgent cases was required to maintain adequate patient care in spite of the pandemic"s burden on healthcare services. The triaging protocol or system varied between institutions. Reissis et al. Telecommunication technology also provided a solution to the suspension of medical training and education 22, 33, 41 . Professional conferences and examinations worldwide were cancelled in accordance with social distancing measures 22, 33, 41 . The evidence base behind distance-learning is well established, and the benefits of accessibility and cost-effectiveness indicates the likely postpandemic persistence of online education in medical training 25 . To directly limit intra-hospital transmission of the virus, judicious screening for COVID-19 before undergoing an operation or attending hospital visits was highly recommended. At Shanghai Ninth People"s Hospital, patients underwent thorough epidemic history surveys, temperature detection, a coronavirus blood test, and chest CT scan within 24 hours; subsequently a two-week quarantine was enforced for suspected cases 39 Adequate PPE is essential to protect healthcare staff; however, shortages of this important resources was noted internationally. Decisive guidelines are critical in order to strike the balance between conserving resources and effectively protecting healthcare workers 34 . Donation unused resources and personnel was highly appreciated 25, 31, 33 29 . The study advocates a fluid-resistant gown, surgical gloves and a powered air-purifying respiratory (PAPR) to replace standard eye protection and an N95 respirator 29 . Surgical technique should also be adapted to minimise exposure of mucosal surfaces and generation of aerosols 29, 30 . Through effective leadership and teamwork, healthcare teams were reorganised during the pandemic. Armstrong et al. argued that a distributive leadership built on collaboration and consensus would keep staff engaged and empowered to maximise clinical effectiveness 22 . Rolling rotas were implemented whereby one cohort of staff worked in-hospital, while another cohort worked from home 22, 25 . Any member of the healthcare team who fell ill, were encouraged to stay home and self-isolate 22, 25, 37 . Operating rooms team were limited to essential personnel, while ward staff were assigned to a single ward or hospital zone to restrict movement around the hospital 27, 29, 39 . Additional measures to optimise patient and staff safety intraoperatively include using negative pressure ventilation, disposable gowns, ultraviolet light to disinfect operating rooms for at least 30 minutes between operations, and collecting drapes and equipment in special bags post-operatively 39 . Wang Z et al. also advocates centralising treatment for confirmed COVID-19 cases in designated institutions 39 . Keen trainees and medical students were often redeployed to bolster the frontline by performing basic clinical tasks and supporting community initiatives 22, 25 . The risk of intra-hospital COVID-19 infection could be further minimised with certain logistical considerations. In waiting rooms, making disposable alcohol-based handkerchiefs or hand sanitiser available, ensuring adequate air ventilation, removing potential infection sources (e.g. magazines) and spacing chairs 1.5 m apart reduces opportunities for viral transmission 22, 39 . Staggering appointments and limiting the number of accompanying persons or visitors per patient also reduces the number of patients in waiting rooms or wards at any given time 22, 27, 39 . Overall, the role of the plastic surgeon appears to have shifted towards supporting "frontline" healthcare staff 22 To reduce return hospital visits, various adaptations to typical management practices have been described, including giving ambulatory IV antibiotics for soft tissue infections, using removable splints and absorbable sutures, and empowering patients or carers to lead post-operative wound care independently. Opting for conservative treatment in patient who would normally have undergone surgical management was favoured by 27 out 47 hand surgeons surveyed by Ducournau et al. 27 . Reissis et al. set up a "one-stop" minor operations room, where procedures using local anaesthesia or the WALANT technique can be undertaken 32 . The ever-changing nature of the COVID-19 may prompt plastic surgeons to adapt the strategies discussed in this review as pandemic progresses and subsequently declines. Furthermore, conditions which were managed conservatively during the pandemic (i.e. without surgical intervention) can be followed up to assess surgical and patient outcomes to investigate whether conservative treatment is equally beneficial in several procedures. The findings of this review can prove beneficial to other plastic surgery departments in informing their response strategies to the pandemic and in a second wave of the disease. 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Plastic and Reconstructive Surgery -Global Open COVID-19 video conferencing: Preserving resident education with online meeting platforms Addressing the surgical training gaps caused by the COVID-19 pandemic: An opportunity for implementing standards for remote surgical training Rickesh Shah, Queen Mary University of Londonfor his contribution in article screening. All authors have made substantial contributions to all of the following:(1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data (2) drafting the article or revising it critically for important intellectual content (3) final approval of the version to be submitted. None Figure 1 : PRISMA Flowchart showing the study selection process.