key: cord-0910114-i2g65y53
authors: Nguyen, Dao M.; Kodia, Karishma; Szewczyk, Joanne; Alnajar, Ahmed; Stephens-McDonnough, Joy A.; Villamizar, Nestor R.
title: Impact of COVID-19 on the Delivery of Care for Thoracic Surgical Patients
date: 2022-02-17
journal: JTCVS Open
DOI: 10.1016/j.xjon.2021.11.015
sha: 1cf4c88af2045b335b6dd76de0da007c6a6b8e2f
doc_id: 910114
cord_uid: i2g65y53

Objective This study aims to determine the impact of the COVID-19 pandemic on the delivery of care for thoracic surgical patients at an urban medical center. Methods A retrospective analysis of all thoracic surgical cases from 5/1/2019 to 12/31/2020 was conducted. Demographics, pre-operative surgical indications, procedures, final pathologic diagnoses, and perioperative outcomes were recorded. A census of operative cases, relevant ancillary services, and outpatient thoracic clinics were obtained from our institutional database. Results 619 cases were included in this study (329 pre-COVID-19 and 290 COVID-19, representing an 11.8% reduction). There were no differences in type of thoracic procedures or peri-operative outcomes between the two cohorts. Prolonged reduction of thoracic surgical cases (50% of baseline) during the first half of the COVID-19 period was followed by a resurgence of surgical volumes to 110% of baseline in the second half. Similar incidence of cases were performed for oncologic indications during the first half while more benign cases were performed in the second half coinciding with the launch of our robotic foregut surgery program. After undergoing surgery during the pandemic, none of our patients reported COVID-19 symptoms within 14 days of discharge. Conclusion During the initial surge of COVID-19, while there was temporary closure of operative services, our healthcare system continued to provide safe care for thoracic surgery patients, particularly those with oncologic indications. Since phased reopening, we have experienced a rebound of surgical volume and case mix, ultimately mitigating the initial negative impact of the pandemic on delivery of thoracic surgical care.

supply, and rapid, accurate diagnostic tests were being developed with sparse testing center 79 capabilities 5 . Given the many unknowns and the profound, devastating impact of SARS-CoV-2 80 to the Northeast United States, drastic actions were rapidly implemented nationwide to reallocate 81 medical resources to prepare for the inevitable future waves of COVID-19. 82 Hospital systems developed plans and new polices to limit admissions and elective 83 surgical procedures to maintain inpatient bed availability for COVID-19 patients, to ensure a safe 84 work environment for staff, and to preserve precious, limited PPE 6-7 . Leading professional 85 surgical organizations provided guidelines to assist medical centers and surgeons in triaging 86 resections impart an additional risk for health care providers, particularly for anesthesiologists 93 and the surgical team [16] [17] [18] . 94 The University of Miami Health System (UHealth) is an academic tertiary care center 95 serving large counties of South Florida, including Miami-Dade, Broward, and the Florida Keys. 96 In conjunction with the state health department, we implemented a systematic closure of elective, 104 We sought to determine the impact of the COVID-19 pandemic, including the closure of 105 surgical services to ration resources, on the delivery of thoracic surgical care. We aim to survey 106 the effect of the pandemic on our surgical volume and case composition, and ultimately 107 determine if such restrictions of care affected surgical outcomes. pulmonary function testing (PFT) were derived from the healthcare system central database.

Data collected from 3/1/2020 to 12/31/2020 formed the COVID-19 group, which was further 129 subdivided into two five-month periods (3/1/2020 to 7/31/2020 and 8/1/2020 to 12/31/2020) 130 representing the first wave and the subsequent 2 nd and 3 rd waves, respectively. Clinical data questionnaire on post-discharge COVID-19 symptoms, which included fever, cough, shortness 138 of breath, and loss of taste / smell, or confirmed COVID-19 infection at subsequent clinical 139 encounters, including for telehealth visits, for up to one month post-procedure 23 . Any post-140 procedure COVID-19 testing result in our health system was obtained. 

A total of 619 thoracic surgical cases (610 patients) were performed over the 20-month 149 study period; 329 procedures in the pre-COVID-19 control group (5/1/2019 to 2/28/2020), and 150 290 procedures in the COVID-19 group (3/1/2020 to 12/31/2020) representing a cumulative 151 11.8% reduction in case volume (Table 1) . To date, of the patients admitted for thoracic surgical 152 operations, none reported SARS-CoV-2 symptoms or infection within 14 days of discharge from 153 the hospital. Figure 2A demonstrates the impact of the pandemic and hospital closure on 154 thoracic surgical cases, inpatient cases, and all surgical procedures over the 10-month period 155 with the preceding 10-months serving as a historical control. There was a dramatic but rapid 156 recovery of total and inpatient cases performed, with the nadir in April 2020 of about 22% of which reflects inpatient-only cases, was decreased to 50-60% of baseline during the first wave 160 (3/2020 to 7/2020) but rebounded to be consistently 110-120% of baseline volume during the 161 second and third waves (8/2020-12/2020). The overall reduction in thoracic cases for the entire 162 ten months period during the pandemic was 11.8%. Figure (Table 3) .

The consequences of the COVID-19 pandemic worldwide have been immense, with 223 uncertain long-term implications, especially for oncology patients, and a varying degree of 224 ramifications for years to come 24-26 . While our thoracic service did experience a decrease in the 225 number of procedures performed during the pandemic, the overall reduction in case volume was 226 only 11% , with no real effect on the delivery of care for patients with thoracic malignancies.

The initial surge of COVID-19 transiently affected our surgical services in general and with a 228 J o u r n a l P r e -p r o o f slightly longer delay for thoracic surgery. We were able to rapidly recover, and even to 229 overperform during the subsequent waves of the pandemic. This trend, however, was not observed for thoracic cases. Possible causes for the prolonged 295 reduction in thoracic case volume during the first wave of the pandemic (3/2020 to 7/2020) 296 include: reduction of ancillary services (e.g. our pulmonary function laboratory), diagnostic tests (interventional radiology transthoracic biopsy or interventional bronchoscopy), patient reluctance 298 to be admitted, postponed non-urgent cases, and a temporary pause of thoracic case referrals.

During the second and third waves (8/2020 to 12/2020), our thoracic surgical service 300 functioned at, and even above, pre-COVID-19 volumes, with a larger proportion of benign 301 pathologies in the case composition. This reflects improved resource management and allocation 302 of care and a potential backlog of those patients with benign thoracic conditions who were 303 deemed non-emergent in the first wave. Furthermore, the increased surgical performance of the 304 thoracic service also coincided with the launch of our robotic benign foregut surgery program in 305 Fall 2020. Not only was our thoracic surgery service able to recover to levels above our pre- There are several limitations to consider. We are reporting the results of our 325 retrospective, observational study from a single institutional experience which may prevent the 326 generalizability of our findings. Analysis was performed using a historical control (the preceding 327 ten months prior to the COVID-19 pandemic) which may not be directly comparable, and the 328 observed difference may be due to unmeasurable or unknown variables not related to the 329 pandemic. We report in-hospital and 30-day morbidity and mortality. Long-term follow-up was 330 not the main objective of this observational study intended to document the immediate impact of 331 hospital and operative service closure on surgical volume and short-term postoperative 332 outcomes. Finally, patients may have presented to outside facilities, not reported to our service 333 care providers during in-person or virtual clinic visits, which is not included in the data analysis.

In summary, one can safely operate upon thoracic surgical patients during a pandemic by 335 following appropriate protocols incorporating public health measures and applying predictive 336 models to estimate COVID-19 admission and resource availability, leading to phased-reopening 337 of surgical services (Figure 3) . We discuss the relevance of our study in the broader societal 338 context (Video 1). While the negative consequences of the COVID-19 pandemic are immense 339 and the future has yet to reveal its entire impact and long-term outcomes, the lessons we learned 340 at the University of Miami, as a society, and as a health care system are extremely valuable. In There was a 5-month reduction of thoracic surgical volume at the beginning of the J o u r n a l P r e -p r o o f 

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