key: cord-0911438-rsdyiygo authors: Pignatti, Marco; Pinto, Valentina; Miralles, Maria Elisa Lozano; Giorgini, Federico A.; Cipriani, Riccardo title: How the COVID-19 pandemic changed the Plastic Surgery activity in a regional referral center in Northen Italy date: 2020-05-15 journal: J Plast Reconstr Aesthet Surg DOI: 10.1016/j.bjps.2020.05.002 sha: f956e7b02c1d2c3342adbe956cb9da8f67e19b6a doc_id: 911438 cord_uid: rsdyiygo The Covid 19 epidemic has modified the way that plastic surgeons can treat their patients. At our hospital all elective surgery was canceled and only the more severe cases were admitted. The outpatient department activity has been reduced also. We present the number and diagnoses of patients, treated as in- and out-patients, during seven weeks from the onset of the epidemic, comparing our activity from the lockdown of elective surgery with the numbers and diagnoses observed during the same weeks of last year. Finally we underline the importance of using telemedicine and web-based tools to transmit images of lesions that need the surgeon's evaluation, and can be used by the patient to keep in touch with a doctor during the distressing time of delay of the expected procedure. On February, 21st 2020, the first case of Coronavirus Disease 2019 (COVID- 19) was reported in Italy. Since then the disease rapidly expanded and on March 11, 2020 , the World Health Organization (WHO) declared it to be a pandemic 1 . As of April 6, 2020, Italy, with a number of deaths exceeding 16.500 2 We established that patients with melanoma, Merkel carcinoma, infiltrative large squamous cell, and basal cell carcinoma, mainly of the face, had to be considered as surgical emergencies and their treatment was guaranteed. In addition, our team of plastic surgeons continued to be involved in multidisciplinary groups to provide reconstruction in other urgent cases, such as head & neck cancers, breast cancer, pelvic-perineal cancers, sarcomas or soft tissue infections such as necrotizing fasciitis. All the patients already booked on an outpatient clinic at the time the switch from elective to urgent activity was implemented were contacted, on a daily basis, to evaluate the urgency of their case and to decide whether to cancel, postpone or maintain their appointment. In most cases this was done by a doctor, specific expertise being needed to judge the urgency and to assume the responsibility for the postponement. The appointments for large, bleeding, rapidly growing, or dangerously located squamous and basal cell carcinomas were kept as booked. In all other cases, prescriptions or suggestions for conservative treatment were given and the appointment postponed to 3 to 6 months. For the patients of this "uncertain group" the use of telemedicine and webbased tools was particularly useful to decide whether a visit was necessary, and also to follow the evolution of the problem. FIGURE 2 All the patients booked at the outpatient clinic for the following day, for whom the need to be seen at the hospital was uncertain, were contacted by telephone. To gain more visual information of the clinical condition, after clarifying the privacy matters and obtaining consent, the patients were invited to send pictures of the lesion that should be evaluated. The patients chose the web -based tool, email or messaging apps (e.g. Whatsapp, Telegram, Messenger), they were more familiar with. On the basis of the image, further decisions were taken. few days before the first COVID-19 case diagnosed in Italy) to Friday, April 3 2020, for a total of 7 weeks. The "pre-COVID-19" period used as a control went from Monday, February 18 to Friday, April 5 2019, for the same number of weeks. Consulting the Hospital database, we collected the number of all surgical procedures performed by plastic surgeons on patients admitted to the University Hospital or in the satellite hospitals during the two periods. Also, we collected the number of patients accessing the Plastic Surgery outpatient clinic and the reason for access. Data analysis and data manipulation have been developed using Python's library Pandas while all the images have been produced using Matplotlib library. In the entire "COVID-19" period (7 weeks 2020) 98 surgical procedures were performed (78 at the University hospital, 20 at the satellite hospitals). The activity had a gradual reduction in the first 5 weeks and reached a nadir at week 5, after closure of the elective activity (Friday, March 13, week 4). In the "pre-COVID-19" 7 weeks period (2019) 152 surgical procedures were performed (109 at the University hospital, 43 at the satellite hospitals). As expected, the reduction of surgical activities was evident when comparing the two 4 weeks periods. In the "COVID-19" period (7 weeks 2020), patients accessed 908 times the Plastic Surgery outpatient clinic compared to 1678 times on the "pre-COVID-19" period. In the "COVID-19" period (7 weeks 2020), 108 surgical procedures were performed at the Plastic Surgery outpatient Minor Surgeries under local anaesthetic compared to 200 procedures on the "pre-COVID-19" period. The decisional flow chart that we applied for the screening of outpatients and follow-up of operated patients is shown in detail in FIGURE 1. As expected, a significant reduction of the total number of surgical procedures was seen in the "COVID-19" period compared to the usual activity. The reasons for surgery also changed significantly. As required by the reorganisation of the hospital activity, only patients with a diagnosis of malignancy were operated on during the COVID-19 period. No urgent surgery for infection, haematomas, necrosis, delayed wound healing or other complications was performed in the study period. If, on one hand, this might be justified by the reduced number of technically demanding procedures, such as elective free flaps, or extensive surgeries like abdominoplasty or breast reduction, this may also be due to a general reduction in access to the emergency room. Overall, the non-COVID-19 use of the emergency room was greatly reduced, both because of the limitations in movement imposed to the population (with consequent less accidents and crime) and by the fear of getting infected inside the hospital's premises. In fact, the cardiology association has issued a warning on the increased numbers of heart-related deaths because of the reluctance of the patients to go to the hospital 7, 8, 9, 10 . The consequences of canceling elective surgery are difficult to foresee. As stated in a recent Editorial 11 , many elective non-urgent surgeries will become urgent at some point in time, and therefore we will probably face a consistent back-log of procedures that we'll need to perform when the COVID-19 epidemic will end (nobody still knows when) 12 . The delayed surgeries that we'll certainly need to perform in the future are the squamous and basal cell carcinomas that, at the moment, are only treated when severe and progressive. It is possible that these skin cancers will grow in the next months, requiring a more complex surgical approach 4 . How will the hospital organization change after Covid-19? As many opinion makers say, this epidemic will force all of us to reconsider, and possibly change, many aspects of our living style. This is true also for the health system. As an example, the consistent reduction in number of patients accessing the outpatient clinic demonstrates that a considerable amount of work could benefit from reorganization. The follow-up visits after minor surgeries performed under local anaesthesia could be avoided by using only subcutaneous reabsorbable sutures and providing adequate training for stitch removal and dressing to the personnel already working in the territorial ambulatory services. Another example concerns the pathology reports that, before COVID-19, were given to the patient in the outpatient clinic, in order to explain the diagnosis and the plan for subsequent surgical or medical interventions. During the epidemic, all the patients who had undergone a biopsy were contacted by telephone, the report was explained, sent by email and only a subset of the patients were invited to return to the hospital. In what may be the first pandemic of the social-media age, plastic surgeons are trying to manage patients remotely, in real time, by using online services. Telemedicine has been in use for a long time in some countries Including, among others, the United Kingdom, Scandinavia, North America, Bolivia, Brazil, and Australia, especially where big distances and a low population density made it necessary 13, 14, 15 . With the evolution of modern technology and of the internet web applications, the interest for telemedicine has expanded to more countries and medical specialities, including Plastic surgery 16 . Due to the "visual nature" of their field, plastic surgeons have pioneered the professional use of social networks. Often, the commercial nature of cosmetic surgery has played a role in the use of the internet 17, 18, 19, 20, 21 . However the use of internet tools for monitoring reconstructive surgery patients has been largely described 22, 23, 24 .Instant sharing of images or video calls allow plastic surgeons to make an easy consultation, filtering only clinical cases that really need to be evaluated in person for an adequate treatment. Copyrighted material is shared through personal messages according to each own social media copyright policy 30, 31, 32, 33 . To avoid legal action for malpractice in telemedicine, it is mandatory for the surgeons to establish appropriate boundaries in online communication with patients, keeping highest ethical and deontological standards in physicianpatient relationship 28, 29, 34 . The importance of these legal and privacy limitations was recognized The destructive effect of COVID 19 in our lives has changed also the working way of hospitals. In our Department of Plastic Surgery, in the second most affected Region in Italy, the number of patients admitted to hospital for elective procedures greatly decreased, surgery being limited to malignancies. In the outpatient department, where also the number of patients have been reduced to 26% of the previous load, a great help to surgeons was given by the internet. In fact it was possible for the surgeons to make an approximate diagnosis on the basis of the images provided by the patients and for the patients to feel connected with the surgeons, despite the lockdown. These web based tools, allow patients to communicate with their treating surgeons, not only to discuss medical problems but also to express psychological frailties due to the delaying of treatment. The internet resources, however, cannot completely replace the direct diagnostic opinion nor the human relationship. The authors declare no potential conflicts of interest with respect to the research, authorship, and publication of this article. The authors received no financial support for the research, authorship, and publication of this article. 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BULLETIN: HIPAA Privacy and Novel Coronavirus Telemedicine in the Time of Coronavirus FIGURE 1. The flowchart explains wich patients can be managed by telemedicine: Patients already booked in outpatients clinic; patients needing follow up for previous surgeries (either complicated or complex to manage at home); patients looking for a surgeon The Plastic Surgery outpatient clinic activity during the overall "COVID-19" period (7 weeks 2020) and during the corresponding period of 2019 are shown STOP of elective surgery FIGURE 6. Comparison of the reasons for access to the Outpatient clinic during the 4 last weeks 2020 The chart shows the outpatient Minor Surgery (local anaesthetic) activity during the overall "COVID-19" period (7 weeks 2020) and during the corresponding period of STOP of elective surgery FIGURE 8. Comparison of the diagnosis for Minor Surgery in the 4 last weeks 2020, after stop of elective activity Table 1. The numbers of outpatient clinic access , outpatient minor surgery