key: cord-0863918-vmq1njfj authors: Yeung, Trevor; Merchant, Julia; Chen, Patrick; Smart, Corinne; Ghafoor, Hamira; Woodhouse, Fran; James, David; Symons, Nicholas; Boyce, Stephen; Jones, Oliver; George, Bruce; Lindsey, Ian title: The Impact and Restoration of Colorectal Services during the COVID‐19 Pandemic: A view from Oxford date: 2021-09-02 journal: Surg Pract DOI: 10.1111/1744-1633.12531 sha: 8eb184f66ff4e1001fe43ee4eac89e32856f1f9f doc_id: 863918 cord_uid: vmq1njfj OBJECTIVE: The coronavirus pandemic has significantly disrupted the way we deliver healthcare worldwide. We have been flexible and creative in order to continue providing elective colorectal cancer operations and to restart services for benign cases during the recovery period of the pandemic. In this paper, we describe the impact of coronavirus on our elective services and how we have implemented new patient pathways to allow us to continue providing patient care. METHODOLOGY: Data on major colorectal elective resections was prospectively collected in an Enhanced Recovery After Surgery (ERAS) database. Data on the number of proctology cases and telemed appointments were collected from the hospital theatre information management system and electronic patient record system respectively. RESULTS: During the pandemic, there was a complete shift towards cancer cases, with benign services and proctology cases being placed on hold. Hospital length of stay was reduced. We implemented earlier hospital discharge and more intense telephone follow up after elective major surgery. This has not resulted in an increase in post‐operative complications, nor any increase in readmission into hospital. During the recovery phase, we have introduced a higher proportion of telemed consultations, including one‐stop telemed proctology clinics, resulting in straight to tests or investigations. CONCLUSIONS: We have created a streamlined multi‐disciplinary pathway to reinstate our elective colorectal services as soon as possible and to minimise potential harm caused to patients whose treatment have been delayed. We anticipate many of these changes will be permanently incorporated into our clinical practice once the pandemic is over. COVID-19 has had a significant global impact on the delivery of elective colorectal surgery. (1) (2) (3) (4) (5) There has been a huge challenge in delivering safe care in the treatment of patients with colorectal cancer, and even modest delays can lead to significant impact on survival (6, 7) . During the peak of the pandemic, hospitals have been prioritising elective surgery for patients with cancer and delaying all non-essential surgery for benign conditions. Much of the literature has focussed on guidelines and strategies to maintain services for colorectal cancer throughout the pandemic. (8) (9) (10) (11) In the UK, we are now entering the recovery phase of the pandemic, and we are gradually opening up our elective services to meet the clinical needs of all our patients. In this paper, we describe our strategy and the implementation of new patient pathways to help streamline our service. We are fortunate that our Trust has split sites and therefore we have been able to segregate patients into COVID-positive and negative cohorts allowing for safer and more streamlined patient care. (12, 13) The John Radcliffe hospital is for emergencies and for COVID-positive patients, where our Surgical Emergency Unit (SEU) is based. The Churchill hospital is for COVID-negative patients who are screened prior to elective surgery. We are performing day case proctology procedures in COVIDnegative screened patients in an independent hospital in Banbury (Foscote hospital). This has allowed us to safely continue our elective cancer surgery during the pandemic peak and gradually increase our benign colorectal service during the recovery phase of the pandemic. The data on major colorectal elective resections was prospectively collected in an Enhanced Recovery After Surgery (ERAS) database. The data on the number of proctology cases was collected from the hospital theatre information management system (TIMS). The data on the number of telemed appointments was collected from the electronic patient record system (EPR, Cerner Millennium). All data points were anonymised prior to analysis. Data was analysed using GraphPad Prism 8. Mann Whitney test was performed on non-parametric data. Overall, from 1 st March to 31 st June 2019, in our centre there were 192 elective patients undergoing major surgery, of which 117 were for cancer, 50 for IBD and 25 for benign disease. For the same 5-month period in 2020, there were 133 elective patients, of which 107 were for cancer, 17 for IBD and 9 for benign disease (Figure 1) . Although overall numbers of elective patients were reduced during the pandemic, we were able to maintain a similar number of cancer operations. After UK national lockdown on 23 rd March 2020, we prioritised cancer operations and this was reflected in an increased number of cancer operations in March 2020 and all elective operations in April 2020 were for cancer ( Figure 2) . In May 2020, there was a reduced number of cancer operations as there were fewer referrals being made through clinic, and fewer cancers being diagnosed due to a reduction in endoscopy services. During the recovery phase of the pandemic, from May to June 2020, we have managed to restart our services for IBD and benign colorectal conditions. During the peak period, we focussed on cancer patients and dual consultant operating was implemented to increase the throughput of cancer operations. The patient casemix changed and the proportion of patients undergoing operations for IBD and other benign disease reduced, in accordance with ACPGBI guidelines (14) . In view of the significantly raised mortality and pulmonary complications in patients undergoing surgery with coronavirus (15), when this was discussed with patients with benign disease, many opted to defer their operation to a later date. From a management perspective, the patients who were offered a date for surgery but who declined due to risks associated with COVID still counted towards some of the main NHS targets, including the 52-week target. The reduction of hospital length of stay was achieved by discharging patients earlier and following them up carefully in a daily virtual ward round by telephone. These patients also underwent more frequent telephone follow up by our ERAS nurse specialists upon discharge. Patients were discharged from telephone follow up when both the patients and clinicians were happy with their recovery progress. If there were any concerns, the patients could contact the surgical team for advice, or they could attend SEU for an urgent face to face assessment. For the same cohort of patients, the readmission rate to SEU was 23/192 (12.0%) in 2019 and 10/133 (7.5%) in 2020, (Chi-square test p=0.19) (Figure 4) . Our patients underwent more frequent telephone follow up by our clinicians and by our ERAS nurse specialists with the aim to offer earlier support, advice and enable escalation of any complications or concerns. Overall, we found that our readmission rate during the COVID peak and recovery phase was not statistically different compared to the corresponding period in 2019. The reattendance rate (i.e. patients that were seen in SEU but were either discharged or kept on an ambulatory pathway) was 31/192 (16.1%) in 2019 and 9/133 (6.8%) in 2020 (Chi-square test p=0.01). The reduction in reattendance rate may be due to patient anxiety about attending hospital during the peak period. It may also be due to improved ERAS telephone support following discharge from hospital, where patients were signposted to GP for assessment and antibiotic prescriptions for surgical site infections and urinary tract infections, and for wound reviews remotely by the ERAS team. Examining the readmissions and reattendances data on a monthly basis, we observed Telemed appointments are increasingly used to triage patients and to minimise foot fall in hospital. We are also able to provide ongoing virtual colorectal services to selected patients. The outcomes of telemed appointments include bringing patients to clinic face to face, straight to test (CT/ MRI / FIT/ endoscopy), listing patients for surgery, further telemed appointment, and discharge, for patients that have previously been seen in clinic. We have also introduced one stop triaging and telemed clinics for proctology patients. example, a patient who has had multiple unsuccessful bands previously may benefit from a HALO procedure and therefore would be booked for a day case procedure rather than another flexible sigmoidoscopy and banding. Once patients are listed for surgery, they are stratified according to their clinical need and they are also assigned a COVID vulnerability score (i.e. the likelihood of a patient having excess mortality due to COVID-19) (Figure 10) . A fail-safe date for each patient is also documented, ensuring that patients are reviewed by a certain time frame if they have not been operated on or seen again in clinic. These actions enable our department to ensure patients are managed in an appropriate timeframe in order to limit the risk of harm. Prior to surgery, a patient health screening questionnaire is performed via telephone. In accordance to the latest NICE guidelines, the patient undergoes comprehensive social-distancing for 14 days prior to their scheduled procedure (16). They will also undergo a coronavirus swab test within three days prior to admission at a drive-in facility to minimise hospital contact, and they are advised to self-isolate from the day of the test until the day of admission. Virtually all face to face clinic appointments were cancelled immediately after UK national lockdown on 23 rd March 2020. During the peak of the pandemic, there was a complete shift towards telemed consultation, unless a patient needed to be reviewed or seen face to face. (Figure 11 ) During the recovery phase of the pandemic, we have seen a gradual restoration of face to face appointments, but telemed appointments still play an important role for patients who are unable to come to hospital for shielding or personal reasons. There were also significant changes in the provision of stoma specialist nursing. Prior to lockdown, the majority of stoma patients (82/98, 83%) were seen face to face with the remainder followed up by telemed appointments. Since lockdown in March 2020, virtually all appointments have been telemed. In lieu of formal face to face clinic appointments, most patients have been happy to use digital photography to email their stoma pictures for opinion. We are also in the process of starting video consultation with our patients (17) . During the recovery phase of the pandemic, stoma nurses have been arranging ad hoc face to face meetings with patients to tie in with any other hospital appointments they have, for example in the radiology department or oncology outpatients, thereby streamlining the patient's hospital journey There has also been an increased use of telemed and virtual consultation in our patients on the ERAS programme. Prior to the onset of COVID-19, there was an emphasis on patient optimisation prior to surgery. Plans to launch phase 1 of the ERAS Prehabilitation programme have now been put on hold, and resources have been directed towards supporting more intense ERAS nurse led follow up. Wound reviews are now done by email with patients sending in photos which are later uploaded onto their electronic patient record. Patients are now more engaged with their own care, management and recovery, and are eager to be discharged quickly. They feel more empowered and many are doing their own wound management rather than relying on district/practice nurses. One potential drawback of the increased use of telemedicine is that it does carry a risk of wrong or delayed diagnosis. However, if we were not to offer telemedicine at all, it runs the risk of delaying seeing patients who are otherwise shielding and would not be able to come for a face to face clinic appointment. On balance of probabilities, we believe that telemedicine can be a useful tool to help restart services during the recovery period. The coronavirus pandemic has significantly disrupted the way we deliver health care. We have created a streamlined multi-disciplinary pathway in an attempt to reinstate our elective colorectal services as soon as possible and to minimise potential harm caused to patients whose treatment have been delayed. We have been flexible and creative in order to continue providing elective colorectal cancer operations and to restart services for benign cases during the recovery period of the pandemic. Earlier hospital discharge and more intense telephone follow up after elective major surgery have not resulted in an increase in post-operative complications, nor any increase in readmission into hospital. We have also introduced a higher proportion of telemed consultations, including onestop telemed proctology clinics, resulting in straight to tests or investigations. We anticipate many of these changes will be permanently incorporated into our clinical practice once the pandemic is over. The challenges in colorectal cancer management during COVID-19 epidemic. 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Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland Considerations for Multidisciplinary Management of Patients with Colorectal Cancer during the COVID-19 Pandemic The need of COVID19 free hospitals to maintain cancer care Updated ACPGBI Guidance on Resuming Elective Surgery Prioritisation of Colorectal Surgery during COVID-19 Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study NICE COVID-19 rapid guideline: arranging planned care in hospitals and diagnostic services Declarations Ethics approval and consent to participate: Not applicable Competing interests: The authors declare that they have no competing interests