key: cord-1015956-9033a5c6
authors: Ingram, Martha-Conley E; Raval, Mehul V; Newton, Christopher; Lopez, Monica E; Berman, Loren
title: Characterization of initial north American pediatric surgical response to the COVID-19 pandemic()
date: 2020-06-09
journal: J Pediatr Surg
DOI: 10.1016/j.jpedsurg.2020.06.001
sha: 51541fd2fe6726c33845b44414a3e843ebe2916e
doc_id: 1015956
cord_uid: 9033a5c6

INTRODUCTION: The impact of COVID-19 pandemic on pediatric surgical care systems is unknown. We present an initial evaluation of self-reported pediatric surgical policy changes from hospitals across North America. METHODS: On March 30, 2020, an online open access, data gathering spreadsheet was made available to pediatric surgeons through the American Pediatric Surgical Association (APSA) website, which captured information surrounding COVID-19 related policy changes. Responses from the first month of the pandemic were collected. Open-ended responses were evaluated and categorized into themes and descriptive statistics were performed to identify areas of consensus. RESULTS: Responses from 38 hospitals were evaluated. Policy changes relating to three domains of program structure and care processes were identified: internal structure, clinical workflow, and COVID-19 safety/prevention. Inter-hospital consensus was high for reducing in-hospital staffing, limiting clinical fellow exposure, implementing telehealth for conducting outpatient clinical visits, and using universal precautions for trauma. Heterogeneity in practices existed for scheduling procedures, implementing testing protocols, and regulating use of personal protective equipment. CONCLUSIONS: The COVID-19 pandemic has induced significant upheaval in the usual processes of pediatric surgical care. While policies evolve, additional research is needed to determine the effect of these changes on patient and healthcare delivery outcomes. Level of Evidence. III

Shortly after the arrival of SarsCov2 (also known as Corona Virus Disease-2019 ) to the United States, hospitals and care systems began preparing for the expected onslaught of patients progressing rapidly through mild respiratory symptoms to severe pulmonary illness [1] [2] [3] . Initial evidence demonstrated a higher prevalence of COVID-19 disease in the adult population, while data surrounding pediatric populations has been comparably sparse. [4] [5] [6] [7] Hospitals that provide healthcare for children have had to make major changes to day-to-day operations despite the fact that COVID-19 affects relatively few pediatric patients. An ideal response to the pandemic would incorporate changes to promote social distancing and minimize exposure without compromising delivery of time-sensitive healthcare for children. It is unclear how this balance can best be achieved. Furthermore, guidelines from the Center of Disease Control and Prevention (CDC) toward public, hospital, and government behaviors have been changing rapidly. 8, 9 As the COVID-19 response continues to evolve, the degree to which structural changes have translated to the frontline of pediatric surgical care is unknown. Pediatric_Surgeons?q=covid-19). 10 The document opened on March 31, 2020 with requests for information on hospital policies for staffing, patient care, and COVID-19 prevention and safety.

In this article, we present a summary of the first month of the pandemic response across hospitals offering children's surgical care in North America.

J o u r n a l P r e -p r o o f Information page. 10 The link to the document was made publicly available on this APSA   COVID-19 page, and, concurrently, responses were directly solicited from the APSA QSC, 

Most hospitals reported significant staffing changes to minimize exposure of healthcare workers. Ninety-five percent (36 hospitals) reported decreasing staff coverage, and 37 hospitals (97%) reported also reducing clinical fellow coverage. Twenty-one (55%) hospitals converted to a weekend schedule with skeleton crew and one rounding team, while 12 (30%) hospitals J o u r n a l P r e -p r o o f reported converting to a Team A/Team B structure. Nineteen (50%) hospitals restricted the work duties of surgeons older than 65 years, surgeons with underlying medical conditions, and/or surgeons who were pregnant.

One in five hospitals (22%) reported their hospital was sharing equipment with neighboring adult facilities. The most common equipment shared include ventilators from pediatric operating rooms and intensive care units (ICUs), followed by attending staff sharing duties with the adult facilities. A small minority (10%) of hospitals reported that their surgeons were covering adult services, including the Acute Care Surgical service and Surgical ICUs. Five hospitals (13%) reported they were actively accepting adult patients, and thirteen hospitals (34%) reported that plans were in place to do so in the case of decreased local adult capacity during a COVID-19 surge. Among these 18 sites, 4 (22%) reported willingness or active acceptance of COVID-19 positive adults, while the majority were planning to accept only non-COVID-19 adult patients.

Given the potential for redistribution of pediatric patients to free up space for adult patients, we asked respondents about pediatric patient transfers within their systems. Thirty (80%) pediatric surgical hospitals reported that they were not needing to transfer pediatric patients away from their centers for general or trauma care, in order to cohort and care for COVID-19 positive patients. Four (10%) hospitals specifically reported that they were receiving more pediatric patients from neighboring regional or community hospitals, as those centers were working to limit patient exposure to COVID-19 positive adult patients.

The approach to management of trauma patients poses a particular challenge during COVID-19, since there is often no time to screen for symptoms or determine likelihood of infection, and many of these patients might need to undergo aerosolizing procedures urgently, such as intubation. Most (87%) of hospitals reported using universal PPE when caring for J o u r n a l P r e -p r o o f trauma patients. Twenty-two hospitals (57%) reported they considered all trauma patients to be COVID-19 Persons Under Investigation (PUI), and required use of N95 and safety goggles or face shields during trauma assessments. Only 6% of hospitals reported selective use of N95 for symptomatic patients or those undergoing active COVID-19 positive screening, level 1 traumas, or patients needing airway management.

In the wake of the changes listed above, and following the mandate of the American College of Surgeons (ACS) 8 , 38 (100%) of hospitals reported cancelling elective operations.

The approach to operative case scheduling for non-elective cases was found to vary among reporting hospitals. Approximately 1/3 of hospitals exclusively used American College of Surgeons (ACS) guidelines 8 to determine whether cases should be rescheduled, 1/3 of hospitals used ACS guidelines and evaluated inclusion on a case-by-case basis, and 1/3 of hospitals were requiring hospital or division leadership to sign off approval for proceeding with a submitted case before it could be scheduled.

All hospitals reported that anesthesiology teams were required to wear full PPE with N95 and safety goggles for intubation of COVID-19 positive or PUI in the operating room. At the time of evaluation, one third of hospitals were routinely performing COVID-19 testing preoperatively. Of these, eleven hospitals (83%) were testing all semi-urgent patients before their operative procedure, while the rest only reported ability to test eligible PUIs before surgery.

Risk of COVID-19 transmission has also influenced hospitals to consider reducing use of laparoscopy for operations, and in some cases, to restructure management of pediatric appendicitis. Overall, twenty-seven (71%) hospitals reported changing their guidelines and practices around use of laparoscopy. Twenty-two (64%) hospitals reported using filtration during laparoscopy for all patients, and five (23%) of these hospitals reported minimizing use of laparoscopy to reduce potential healthcare worker exposure to COVID-19. An additional 15% of hospitals reported they had not yet made changes, but were considering limiting laparoscopy to J o u r n a l P r e -p r o o f reduce spread. Half of surgeons (47%) reported not changing usual pathways of care for managing appendicitis, but 10% (four hospitals) reported they were considering a change. Of the remaining nineteen respondents, three (13%) reported their hospitals were uniformly treating acute appendicitis non-operatively (a change from prior practice), and nine (25%) hospitals were (newly) making decisions for non-operative appendicitis on a case-by-case basis.

The COVID-19 pandemic has led to a marked increase in telehealth across nearly all hospitals. Thirty-six (95%) hospitals reported early conversion to telehealth for outpatient clinic visits. Of these participating in telehealth, 28 hospitals (78%) reported their providers were able to conduct clinic visits from home. Finally, 10 hospitals (26%) reported use of telehealth for inpatient consults and transfer evaluations, further limiting in-person physical exams and presurgical evaluations.

By far, the most common guidelines in this domain centered around universal masking policies, patient visitation, COVID-19 testing, and mechanisms of preserving N95 masks.

Twenty-five hospitals (67%) reported implementation of universal masking policies in their hospitals. Eight (33%) required staff and healthcare workers alone to wear masks, compared with fourteen (55%) extending this regulation to include staff and families. Thirty-two of the hospitals (84%) were restricting patient visitors to one or zero caregivers. Among hospitals allowing visitors, the most common policy indicated that the list of allowable visitors was established at the time of admission, and was not permitted to change over the course of the patient's stay. Additionally, twenty-two hospitals (57%) reported they were cohorting PUIs with true COVID-19 positive patients. Importantly, hospitals reported persistently long wait times for COVID-19 results, with 75% of hospitals reporting wait times of 12 hours or longer (IQR 4-72 hours).

Finally, 75% of hospitals reported sterilizing or reusing N95 masks. The most common policy reported among hospitals was reuse of masks until soiled or dirty, with most policies allowing re-use up to 10 days. Among the 6 hospitals who reported sterilizing N95 masks, 4 reported using UV light sterilization, and 2 reported using Hydrogen Peroxide sterilization techniques.

Within each of these domains, hospitals specifically reported on several changes impacting resident and fellow duties and training. Nearly every hospital associated with a clinical fellowship reported decreasing fellow presence on service and in the operating room.

The most common policies included separating clinical fellows from one another, alternating their weeks on-service (95% of hospitals) and limiting fellow presence in cases with PUI or COVID-19 positive patients (42% of hospitals). Clinical education and training for surgical residents was also described as restrictive in favor of social distancing practices. Thirteen percent of hospitals reported excluding surgical residents entirely from operations with COVID-19 positive patients. Hospitals also report having surgical residents stay outside of PUI or COVID-19 positive exam rooms for rounds, traumas, or consultations in order to limit the number of physicians exposed (30%). Additionally, 44% of hospitals reported that rotating surgical residents were being pulled away from their pediatric surgical rotation to help with coverage of COVID-19 patients in their home (adult) hospitals. Finally, 97% of hospitals reported they had transitioned didactics to remote or online sessions only, with only 1 hospital having to cancel didactics entirely in light of the pandemic.

Optimal guidance around appropriate or expected COVID-19 response for pediatric surgical hospitals has been limited and mostly extrapolated from adult practices. In this report, we demonstrate that the number and type of changes occurring among and within hospitals has been significant, and continually dynamic. We did not find that hospitals at dates closer to the J o u r n a l P r e -p r o o f state's predicted surge data implemented more changes than those hospitals who were further away from surge date at the time of evaluation. This is likely related to the fact that local policy change is likely to be driven by local response to the pandemic, which does not necessarily correlate with surge proximity. There are many factors affecting the number and types of changes occurring in institutions including local government restrictions such as shelter-in-place orders, governor mandates calling for cancellation of all elective surgery, and others.

Nonetheless, while there is tremendous variability in the challenges faced by pediatric institutions throughout the country, hospitals independently developed similar approaches to both care for patients and protect their teams. The most immediate and common changes included implementing protocols to reduce healthcare worker presence in the hospital (including residents and "vulnerable" surgeons), reducing inpatient volume to conserve resources, and modifying guidelines for operations (including laparoscopic operations and management of appendicitis) to minimize frequency of aerosol-generating procedures. We also observed that variability existed across hospitals in their abilities to provide essential prevention and safety measures during the initial response. For example, only 2/3 of hospitals reported universal masking procedures in place, and only 1/3 of hospitals were found to offer pre-operative COVID-19 testing for patients. In addition, rates of at-home telemedicine for physicians and capacity for rapid COVID-19 testing of inpatients were lower than expected. These findings suggest that increasing technical support across pediatric surgical hospitals may be necessary for improving response. 13 While this report provides a glimpse into the activity surrounding COVID-19 response for pediatric surgical hospitals, many unanswered questions remain. First and foremost, we do not yet know the effect of these clinical workflow and internal structural changes on patient outcomes. For example, the 26% of hospitals that are conducting inpatient consults and transfer evaluations remotely using telehealth have introduced a dramatic change in the dynamics of patient-provider communication. Even prior to the pandemic, clinicians have held J o u r n a l P r e -p r o o f significant apprehension using telemedicine to evaluate pediatric physical exams 14 , and applications of telehealth to surgical care have been ongoing areas of investigation. 15 Nonetheless, despite unknowns or apprehension around the service, introduction of a greater need to preserve workforce and maintain social distancing has pushed hospitals to adopt these systems rapidly. Further, we do not yet know the effect of delaying seemingly "elective" cases, including hernia repairs or enterostomy reversals 8 , may have for children's health. Concerns about unintended consequences have been raised for adult patients 13 and the risk/benefit ratio for pediatric patients may be even less favorable, since the risk of pediatric morbidity from COVID-19 appears to be comparably low 4, 7 . Tracking the short and long-term outcomes of the unique cohort of pediatric patients treated within surgical centers through the pandemic will be incredibly valuable and informative for future innovations and policies implemented in healthcare.

Second, hospital practices to increase healthcare worker social distancing, and limit exposure of trainees to clinical units, has held significant implications for trainee education. We observed that 95% of hospitals participating in the document support pediatric surgical fellowships. Though most hospitals reported continuing education virtually, the loss of clinical learning associated with limited in-person consultations and evaluations cannot be overstated.

Further, efforts to limit fellow coverage in the operating room may have a potentially deleterious effect on graduating fellow case volumes, which has not yet been quantified. The significance of this phenomenon is underscored by the fact that the American Board of Surgery has published hardship modifications to pediatric surgery training requirements including reductions in required time on service and minimum case volumes 16 . These concerns extend to resident trainees, as well, whose exposure to pediatric surgery is likely to be compromised if they are pulled back to their home programs or have schedules truncated in a team A/team B fashion.

The importance of increasing healthcare worker safety by implementation of social distancing J o u r n a l P r e -p r o o f measures is not disputed; however, the effects of these measures on training of future generations has yet to be determined.

An inherent limitation of the data presented in this report is the dynamic nature and rapidly evolving environment of COVID-19 response. Hospital policies and guidelines are changing daily. These data represent a self-reported snapshot in time and do not fully describe the fluctuation of change occurring at the hospital level. These data also represent a convenience sampling of voluntary reporting that may have inherent biases in terms of hospitals that elected to participate. Nonetheless, a sampling of 38 hospitals from geographically diverse locations and practice types provides a unique glimpse of contemporary practices that may be generalizable. The importance of this work lies in its ability to capture a sense of priority, importance, and relevance, among pediatric hospitals, for policies guiding the balance of maintaining high quality of care and also healthcare worker safety. Leveraging the technical prowess, skill, and readiness of pediatric surgeons to combat and serve in a national pandemic with the existing responsibility of providing care for children is not easy, nor previously prescribed.

Because of the variability across the country (both in demand and response capability), it is not possible or ethical to establish a universal standard on many of the issues presented here. Therefore, the demonstration of these practices is hoped to serve as guidance of community-established "best practice" examples, which can be utilized by other hospitals in the absence of a universal standard. Certainly, further study is needed to examine effects of these changes, develop evidence-based practices, and to guide future practice. Nonetheless, the information shared through this document reveals valuable themes for present and future investigation. We will continue to evaluate these changes iteratively in the weeks and months to come. Ultimately, we hope these summative reports will help inform future policies and guidelines around pandemic response and pediatric surgical best practices. J o u r n a l P r e -p r o o f 

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