key: cord-0982108-634kydrg authors: Gammeri, Emanuele; Maria Cillo, Giulia; Sunthareswaran, Romeshan; Magro, Tania title: Is a ‘COVID-19 free’ hospital the answer to resuming elective surgery during the current pandemic? Results from the first available prospective study. date: 2020-07-15 journal: Surgery DOI: 10.1016/j.surg.2020.07.003 sha: cb73dcc667c408f93a6640b9c6fd5c5aaeb736ad doc_id: 982108 cord_uid: 634kydrg BACKGROUND: Resumption of elective surgery during the current Coronavirus disease 2019 (COVID-19) pandemic crisis has been debated widely and largely discouraged. The aim of this prospective cohort study was to assess the feasibility of resuming elective operations during the current and possible future peaks of this COVID-19 pandemic. METHODS: We collected data during the peak of the current pandemic in the United Kingdom on adult patients who underwent elective surgery in a ‘COVID-19 free’ hospital from 8(th) April to 29(th) May 2020. The study included patients from various surgical specialities. Non-elective and pediatric cases were excluded. The primary outcome was 30-day mortality post operatively. Secondary outcomes were the rate of COVID-19 infections, new onset of pulmonary symptoms after hospitalisation, and requirement for admission to the Intensive Care Unit (ICU). RESULTS: A total of 309 consecutive adult patients were included in this study. No patients died nor required ICU admission. Operations graded ‘Intermediate’ were the most commonly performed procedure representing 91% of the total number. One patient was diagnosed with COVID-19 infection after being transferred to the nearest local emergency hospital for management of post-operative pain secondary to common bile duct stone and was successfully treated conservatively on the ward. No patient developed pulmonary complications. Three patients were admitted for greater than 23 hours. 27 patients (8.7%) developed complications. Complications graded as 2 and 3 according to the Clavien-Dindo’ classification occurred in 14 and 2 patients, respectively. CONCLUSIONS: This prospective study shows that, despite the severity and high transmissibility of novel coronavirus 2 (SARS-CoV-2) disease, ‘COVID-19 free’ hospitals can represent a safe setting to resume many types of elective surgery during the peak of a pandemic. Hospital under the reference PCG014. It was deemed that ethical approval was not 88 required for this study. This study was registered in the Research Registry #5780. 89 90 91 Evidence before this study 92 We searched MEDLINE (PubMed) regularly while writing this manuscript to ascertain 93 that this was the first study to report on elective surgery performed in a 'COVID-19 free' 94 hospital. Key words included elective surgery, COVID-19, non-urgent surgery. Key words 95 were combined using Boolean Operators and MESH terms were exploded throughout. All 96 abstracts generated from the search were read and full-text publications of those 97 abstracts meeting the search criteria on initial screening were reviewed by all four 98 authors to confirm no studies reporting on elective surgery in COVID-19 free hospitals 99 were missed. 100 The definition of COVID-19 free Hospital we chose comprises a "COVID-19 free 103 building" where there are no inpatients with suspected or proven SARS-CoV-2 infection. 104 However, if necessary, it was possible to allow patients to remain overnight. Sufficient No accompanying persons were allowed into the hospital with the patients. Furthermore, 108 all non-medical health care professionals working at our 'COVID-19-free' hospital were 109 employees at the BMI CH and did not work in any other NHS facilities, theoretically with 110 minor work-related exposure risk to the coronavirus compared to frontline staff who 111 have been working at COVID-19 hot sites. The only staff members who could be 112 potentially exposed in their workplace to the novel coronavirus were operating surgeons 113 and anesthesiologist who were also working in other settings. 114 In order to limit the number of these health care professional into the BMI CH, only 115 senior trainees and consultants were permitted to deliver services at the COVID-19 free 116 site. In accordance with local government guidelines, all staff members wore dedicated 117 scrubs for sessional use while at the COVID-19 free hospital. 12 No uniforms were worn 118 outside of the clinical settings or when travelling. Utilisation of the increased shower 119 facilities was encouraged to further minimize infection risk. In addition, health care 120 professionals were screened for symptoms and temperature on entrance to the hospital. 121 Staff were excluded if they failed that screen and directed to NHS testing facilities and 122 isolation as per government protocols. Staff did not return to work at any site until they 123 were cleared from an occupational health viewpoint and had isolated for the required 124 Cases were chosen from a traffic-light based system derived from a risk stratification 135 tool developed by the surgical leads from each specialty ( Figure 1 ). All cases were vetted 136 by the most senior operating clinicians who had final approval on chosen cases based on 137 urgency, practicality, and those that could be carried out as day-cases or 23 hour stays. 138 All cases included were also deemed low risk for complications 139 A rigorous and well established patient selection pathway was designed. Patients being 140 considered to be operated on in this setting were contacted by telephone by their named 141 consultant to explain the procedure and to elicit their consent and ensure suitability. 142 Patients were asked if they experienced any recent of the most common clinical features 143 of COVID-19 infection, such as any fever, cough, dyspnea, myalgia, anosmia, or other 144 respiratory symptoms. 13 Moreover, we investigated if they were cohabiting with anyone 145 who suffered symptoms of COVID-19 or who was self-isolating as per governmental 146 guidelines. The telephone assessment was recorded on the hospital electronic medical 147 record. 148 As national guidance was introduced, the preoperative process was refined to include 149 detailed instructions to patients to self-isolate for at least 14 days before and 14 days 150 after the procedure. During the data collection, we followed the daily updates of the 151 guidance from the Royal College of Surgeons England. 2 Starting from April 29, 2020, all 152 patients undergoing elective surgery must have had a negative swab test within 72 hours 153 from the day of the scheduled procedure. 14 Comorbidities and body mass index (BMI) were assessed for all patients undergoing an 159 operative procedure, and an American Society of Anesthesiologists physical status 160 classification (ASA) score was assigned after anesthesiologist review (Table 1) . Basal 161 temperature was checked and recorded for each patient at the entrance of the BMI CH 162 and prior to be transferred to the theatre suite. Vitals signs, such as blood pressure, heart 163 rate, respiratory rate and saturation on room air were checked and recorded as per our 164 standard pre-operative check list. As stated by the European Society of Surgical Oncology, 165 and because of the junior doctor redeployment to critical areas such as the intensive care 166 unit, the majority of operations were performed by consultants, SAS (Specialty and 167 Associate Specialist), or Higher Surgery Trainees (also called Registrars). 15 168 Follow up was carried out for 30 days postoperatively; the electronic medical records 169 from hospitals and general practitioners (GPs) were searched on a daily basis to assess if 170 there were complications, hospital re-attendances, or GP visits. 171 Operating theatre facilities 175 No changes were made to theatre air flow conditions. Our local standard operating 176 procedure was used to decrease exposure and to affect as few staff members as possible: 177 intubation took place in theatre with a minimum time of 5 minutes passed thereafter 178 before other staff could enter, thus ensuring that sufficient air changes had occurred, 179 thereby designed to decrease the risk of aerosol contamination to less than 1%. 16 None 0 None 0 ( Pre-operatively 104 (33.7) Post-operatively 1 CBD, common bile duct; ARDS, Acute Respiratory Distress Syndrome; PCR polymerase chain reaction. Each patient is scored within each category such that they are first stratified in terms of consequence if not operated on (e.g. death) then time to harm if not operated on (e.g 2-6 months) and then to their COVID risk of breaking isolation in order to come into hospital. WHO Director-General's opening remarks at the media briefing on COVID Recovery of surgical services during and after COVID-19 COVID-19: Recommendations for Management of Elective Surgical Procedures. American College of Surgeons Surgical operations during the COVID-19 outbreak: Should elective surgeries be suspended? Deeply reconsidering elective surgery: worldwide concerns regarding colorectal surgery in a COVID-19 pandemic and a Singapore perspective Covid-19: all non-urgent elective surgery is suspended for at least three months in England SAGES and EAES Recommendations Regarding Surgical Response to COVID-19 Crisis Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans Partnership working with the Independent Sector Providers and the Independent Healthcare Providers Network (IHPN): Letter from Neil Permain Available from Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet.;0 . Epub ahead of print Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection infectionprevention-and-control/reducing-the-risk-of-transmission-of-covid-19-in-the-hospitalsetting Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the Updated Intercollegiate General Surgery Guidance on COVID-19 COVID-19 infection prevention and control guidance The Clavien-Dindo classification of surgical complications: five-year experience Number of coronavirus (COVID-19) cases in the UK. GOV.UK. Available from This is the first prospective data on resumed elective surgery performed in a 'COVID-19 free' hospital. The importance of this study is that, despite the severity and high transmissibility of SARS-CoV-2 disease, 'COVID-19 free' hospitals in the independent sector represent a safe setting to resume elective surgery during the peak of a pandemic.