key: cord-0934597-dgyvbarm authors: Benedetto, U.; Goodwin, A.; Kendall, S.; Uppal, R.; Akowuah, E. title: A Nationwide Survey of UK cardiac surgeons view on clinical decision making during the COVID-19 pandemic date: 2020-04-29 journal: nan DOI: 10.1101/2020.04.24.20078105 sha: b5f862b139c6592e2c75fbae0f206798836e3a09 doc_id: 934597 cord_uid: dgyvbarm Background: No firm recommendations are currently available to guide decision making for patients requiring cardiac surgery during the COVID-19 pandemic. Systematic appraisal of national expert consensus can be used to generate interim recommendations until data from clinical observations will become available. Hence, we aimed to collect and quantitatively appraise nationwide UK senior surgeons opinion on clinical decision making for patients requiring cardiac surgery during the COVID-19 pandemic. Methods: We mailed a web-based questionnaire to all consultant cardiac surgeons through the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) mailing list on the 17th April 2020 and we pre-determined to close the survey on the 21st April 2020. This survey was primarily designed to gather information on UK surgeons opinion using 12 items. Strong consensus was predefined as an opinion shared by at least 60% of responding consultants. Results: A total of 86 consultant surgeons undertook the survey. All UK cardiac units were represented by at least one consultant. Strong consensus was achieved for the following key questions:1) before hospital admission every patient should receive nasopharyngeal swab, PCR and chest CT; 2) the use of full PPE should to be adopted in every case by the theatre team regardless patients COVID-19 status; 3) the risk of COVID-19 exposure for patients undergoing heart surgery should be considered moderate to high and likely to increase mortality if it occurs; 4) cardiac procedure should be decided based on ad-hoc multidisciplinary team discussion for every patient. The majority believed that both aortic and mitral surgery should be considered in selected cases. The role of CABG surgery during the pandemic was more controversial. Conclusions: In the current unprecedented scenario, the present survey provides information for generating interim recommendations until data from clinical observations will become available. U O B C o n f i d e n t i a l Systematic appraisal of national expert consensus can be used to generate interim recommendations for patients undergoing cardiac surgery during COVID-19 pandemic until data from clinical observations will become available. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. No firm recommendations are currently available to guide decision making for patients requiring cardiac surgery during the pandemic. This can translate into significant variability in clinical practice and patients' outcomes across cardiac units. Systematic appraisal of national expert consensus can represent a rapid and efficient instrument to provide support to heath policy makers and other stakeholders in generating interim recommendations until data from clinical observations will become available. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted April 29, 2020. . Conclusions: In the current unprecedented scenario, the present survey provides information for generating interim recommendations until data from clinical observations will become available. The Coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on healthcare globally, including on the delivery of cardiac surgical care [1] [2] . Cardiac surgery is the single largest user of intensive care unit beds [1] [2] and resource re-allocation to treat practice and for patients [3] . We aimed to collect and quantitatively appraise nationwide UK senior surgeons' opinion on clinical decision making for patients requiring cardiac surgery during the COVID-19 pandemic. We mailed a web-based questionnaire to all consultant cardiac surgeons through the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) mailing list on the 17 th April . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . 2020. In view of the rapidly evolving circumstances and the need for timely outcome presentation, we pre-determined to close the survey on the 21 st April 2020. This survey was primarily designed to gather information on UK surgeons' opinion on which patients should be considered for cardiac surgery under the current COVID-19 pandemic using 12 items. As at the time of the survey, there was significant variability on clinical activities across centres, the first part of the questionnaire gathered information on local factors (local resource relocation to treat COVID-19) that may have influenced surgeons' view. Strong consensus was predefined as an opinion shared by at least 60% of responding consultants [3] . A total of 86 consultant surgeons undertook the survey. All UK cardiac units were represented by at least one consultant. Figure Table 1 shows the results of the survey in the overall sample and in groups stratified by working in units with resource relocation. In the overall sample, strong consensus (≥60%) was achieved for the following key questions:1) before hospital admission every patient should receive nasopharyngeal swab, polymerase chain reaction (PCR) and chest computerised tomography (CT); 2) the use of full Personal Protective Equipment (PPE) should to be adopted in every case by the theatre team regardless patient's COVID-19 status; 3) the risk of COVID-19 exposure for patients . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . was a strong consensus that this pandemic will not have an impact on surgical activities when normal operating conditions will be re-established. We are realising that non COVID-19 infection related deaths may be extremely important component of the health impact of the COVID-19 pandemic worldwide due to healthcare resources relocation to acutely respond to the pandemic. However, there is little direct evidence to inform the management of patients requiring cardiac surgery under the current rapidly evolving circumstances. Initial reports have suggested that non COVID-19 related cardiovascular mortality and morbidity are likely to be significantly affected [4] . In particular, the number of cardiac surgeries has dramatically decreased as intensive care facilities and staff have been urgently required to treat COVID-19 patients. Even . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . needs to include nasopharyngeal swab, PCR, and chest CT for every patient during the pandemic. Screening is essential to contain the infections and avoid post-operative complications. However, testing before admission can delay treatment which may affect clinical outcomes in some cases and this approach will need to be appraised in the following months. A tailored approach may become necessary if the pandemic continues for several months as suggested by several epidemiologists. Surgeons were also in agreement that the theatre team should adopt full PPE for all the procedures performed during the pandemic. It is possible that the pandemic will last for several months and it will need to be determined the impact of full PPE on team performance (i.e. communication, surgical vision and dexterity and fatigue) and its potential consequences on clinical outcomes. Most surgeons and particularly those working in units currently unaffected by the pandemic, believed that the risk of COVID exposure for patients undergoing cardiac surgery is moderate to high and can have serious consequences on patient's outcome. This information can represent an important element to support patient's counselling before compelling clinical evidence becomes available. Finally, there was a strong consensus that each surgical case requires ad-hoc multidisciplinary team decision and patient's selection at surgeon's discretion under the current circumstances was believed to be acceptable only by a very small number of responders. Clearly, multidisciplinary team discussion for each patient requires flexible approaches such as conference call discussions or emails exchanges, and consideration must be given to sensitive data protection and confidentiality and the need of maintaining clinical documentation standards. There was no strong consensus with regards to specific types of cardiac procedures. However, the majority believed that both aortic and mitral surgery should be considered in selected cases. The role of CABG surgery during the pandemic was more . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. . is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted April 29, 2020. Society of Thoracic Surgeons COVID-19 Taskforce and the Workforce for Adult Cardiac and Vascular Surgery Canadian Society of Cardiac Surgeons. Cardiac surgery in Canada during the COVID-19 Pandemic: A Guidance Statement from the Canadian Society of Cardiac Surgeons Consensus development for healthcare professionals Outbreak on ST-Segment-Elevation Myocardial Infarction Care in Hong Kong, China. Circ Cardiovasc Qual Outcomes The authors would like to thank Dr. Arnaldo Dimagli for his invaluable support during the preparation of the present work.