key: cord-0908250-bop86jmt
authors: Rana, Roshan-e-Shahid; Ather, Muhammad Hammad
title: Change in surgical practice amidst COVID 19; example from a tertiary care centre in Pakistan
date: 2020-05-01
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2020.04.035
sha: ec62e4985f3a759a50af5bdc6ffdbaf91174bbc5
doc_id: 908250
cord_uid: bop86jmt

nan

Surgical Practice amidst COVID 19

Surgical care is an integral component of any healthcare system and its continuous provision is essential for both elective and emergent cases. However, operating rooms (OR) are a high-risk zone for infection transmission. The surgical specialties and anesthetist are equally exposed.

They often have to perform emergency surgeries in uncertain circumstances with patients COVID status undefined. This calls for immediate actions to maintain a balance between adequate provision of surgical services and preventing transmission along with judicious use of resources.

As of 22 ND procedures was prepared by surgical subspecialty heads and shared with operating room management to facilitate the process. A stringent criterion was followed, where in such cases were screened through a process. This include identification of patients at high risk of COVID-19 infections, approval by section head/ service line chief followed by anesthetist approval (Fig. 1 ). Before finalizing, each list was discussed in a meeting between operating room (OR) leads including surgeon, anesthesiologists and nursing manager a day prior. Each specialty was assigned specific operating days and operating rooms for semi-elective cases. The number of OR functioning at any particular day were also reduced to 7 from normal 17 operating rooms; 5 for semi-elective cases and 2 for emergencies. A separate OR suite (normally used for orthopedic surgeries) which is located adjacent but away from the main operating area was dedicated for suspected or confirmed cases of COVID 19. This suite was designed recently in 2015 as a state of the art facility with laminar flow ceilings, individual temperature and humidity control, and

High-efficiency particulate air (HEPA) filters.

All OR cases were screened by a three-item questionnaire at the time of booking and again 24 hours prior to procedure.

It included following questions: 1) Any symptoms of cough, runny nose, shortness of 4 breath, sore throat in last 14 day, 2) history of travel (patient or family members) within last 14 days, 3) Contact with any COVID positive or suspected COVID patient. For semielective cases in case of any of these items being positive the case was re-assessed and necessary actions were taken after discussing with Infectious disease experts (Fig. 1) .

For emergency/urgent cases that were screened positive, the provision was to perform it in COVID designated OR following strict PPE.

Though the number of clinics in each specialty was cut down but at no time the clinics were on a complete shut down. Tele-clinics were also introduced from beginning of April; which before this pandemic were non-existent in our hospital.

To decrease exposure of team members, the residents, interns and other medical officers were exempted from these clinics.

In view of a sudden loss of work force, due to exposure quite a few of the residents and interns were quarantined, some drastic changes were made in the resident/interns duty roster. Each specialty was split into two teams with each team working on alternate weeks. Even on working week the duties were assigned in a way that only minimum number of required residents were on the floor. As an example if 5 Team A and B has four residents each, two residents did alternate 24 hours shift for a

week. This was done to minimize the exposure and to keep sufficient manpower reserves for coverage in case of patient surge.

University stopped all classes and clinical activities for the medical/nursing students. Gathering of more than 5 was prohibited, which impacted administrative meetings and academic activities. However, within the first week of lockdown department decided to reconvene all academic sessions including grand round, Journal clubs, Tumor boards etc, albeit all online via Zoom™. It provided a portal for learning and also kept the team members connected.

The significance of psychological well-being was recognized early on and steps were taken to address issues emanating from lockdown, all of a sudden very low clinical activity for some and extremely high and stressful activity for other health care providers. Frequent informal meetings were conducted by chair with faculty and residents to have their input, to know their feelings and also to provide them moral support. Department in collaboration with Psychiatry also offered short wellness sessions for residents.

It's been almost four weeks now that these strategies have been implemented one after the other and so far in department of surgery no major corona crisis has happened. Those who were positive and those who were exposed have now joined back work. Department right now aims to continue this scheme at least for this month. which is almost one fourth of GPs with basic degree only. 6 In this vulnerable mile lieu of health care system, any unusual burden bears the potential of massive health system crises. So strategies that cut down exposure are of paramount importance.

It is not possible to curtail the surgical care for a long time hence, a plan that could gain a balance between services and exposure was essential. Our department planned and implemented these strategies in a span of few days with continuous review for any shortcomings and with a constant reminder to team members, "every case increases the risk of infecting our co-workers."

None to declare

None.

Not commissioned, Editor reviewed.

See the real time Pakistan and Worldwide COVID-19 situation

American College of Surgeons

COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures

World Health Organisation

Pakistan Key Indicators

Ministry Of Finance, Government of Pakistan

Budget in Brief

Physicians (per 1,000 people) -Pakistan

Fig 1: Process flow for surgical procedures

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