key: cord-1032135-kacjdolq authors: Cano-Valderrama, Oscar; Morales, Xavier; Ferrigni, Carlos J.; Martín-Antona, Esteban; Turrado, Victor; García, Alejandro; Cuñarro-López, Yolanda; Zarain-Obrador, Leire; Duran-Poveda, Manuel; Balibrea, José M.; Torres, Antonio J. title: Acute Care Surgery during the COVID-19 pandemic in Spain: changes in volume, causes and complications. A multicentre retrospective cohort study date: 2020-07-15 journal: Int J Surg DOI: 10.1016/j.ijsu.2020.07.002 sha: b4966d31f86d888456dd2bdafb3ad86cc546ef43 doc_id: 1032135 cord_uid: kacjdolq BACKGROUND: during the COVID-19 pandemic, the number of Acute Care Surgery procedures performed in Spanish hospitals decreased significantly. The aim of this study was to compare Acute Care Surgery activity during the COVID-19 pandemic and during a control period. MATERIAL AND METHODS: a multicenter retrospective cohort study was performed including patients who underwent Acute Care Surgery in three tertiary care hospitals in Spain during a control (11(th) March 2019 to 21(st) April 2019) and a pandemic (16(th) March 2020 to 26(th) April 2020) period. Type of surgical procedures, patients´ features and postoperative complications were compared. RESULTS: two hundred and eighty-five and 117 patients were included in each group. Mean number of patients who underwent Acute Care Surgery during the control and pandemic periods was 2.3 and 0.9 patients per day and hospital (p<0.001), representing a 58.9% decrease in Acute Care Surgery activity. Time from symptoms onset to patient arrival at the Emergency Department was longer during the pandemic (44.6 vs. 71.0 hours, p<0.001). Surgeries due to acute cholecystitis and complications from previous elective procedures decreased (26.7% vs. 9.4%) during the pandemic, while bowel obstructions and abdominal wall hernia surgeries increased (12.3% vs. 22.2%) (p=0.001). Morbidity was higher during pandemic period (34.7% vs. 47.1%, p=0.022), although this difference was not statistically significant in the multivariate analysis. Reoperation rate (17.9% vs. 12.8%, p=0.212) and mortality (6.7% vs. 4.3%, p=0.358) were similar in both groups. CONCLUSION: during the COVID-19 pandemic, a significant reduction in the performance of Acute Care Surgery procedures was observed. Moreso, a longer time from symptoms onset to patient arrival at the Emergency Department was noted. Higher morbidity was observed in patients undergoing Acute Care Surgery during the pandemic period, although there was not any difference in mortality or reoperation rate. Declarations of interest: none. No financial support was needed to perform this study. -CONCLUSION: during the COVID-19 pandemic, a significant reduction in the performance of Acute Care Surgery procedures was observed. Moreso, a longer time 2 from symptoms onset to patient arrival at the Emergency Department was noted. Higher morbidity was observed in patients undergoing Acute Care Surgery during the pandemic period, although there was not any difference in mortality or reoperation rate. Acute Care Surgery; Emergency Surgery; COVID-19; SARS-CoV-2; pandemic. Acute Care Surgery Activity was decreased during COVID-19 pandemic. A higher delay of the patients presenting in the Emergency Department was observed during the pandemic period in patients who underwent Acute Care Surgery. During COVID-19 pandemic, a higher morbidity rate was found in patients undergoing Acute Care Surgery; although mortality and reoperation rate did not increase. In late December 2019, 7 patients presenting unusual pneumonia were detected in Wuhan (China) and reported to the Chinese Center for Disease Control and Prevention [1] . Since then, the disease, called COVID-19, has spread all around the world; and is considered a pandemic since 11 March 2020 according to the World During the pandemic, health care systems and hospitals had to adapt their structures to this new scenario. Intensive care capacity had to be increased, transforming recovery facilities and even waiting rooms into ICU beds. Medical and nursing staff were redistributed and outpatient clinic visits were cancelled or conducted online or by phone [3, 4] . Departments of Surgery were, for sure, affected by these changes; elective procedures were delayed, staff members were allocated to reinforce the ICU and surgeons were reorganized in closed working groups to avoid infections between them [5, 6] . Certainly, another one of these changes was a reduction in Acute Care Surgery Activity (ACSA). Reduction in ACSA was clearly observed in Spanish hospitals [7] , taking into account that Spain was one of the most affected countries by COVID-19. However, this has also been observed in other territories seriously hit by the pandemic, such as Italy [8] . The aim of this study was to analyze the reduction in ACSA. ACSA during COVID-19 pandemic was compared with a control period to quantify this reduction. Also, the main causes and consequences of this change in ACSA were studied. A multicenter, retrospective and analytic cohort study was performed. Patients were included if they underwent Acute Care Surgery (ACS) in the Department of Surgery of one of the hospitals included in the study (three tertiary care hospitals in Spain, two of them in Madrid and the third one in Barcelona) during the study periods. Patients who underwent minor surgical procedures were excluded. Differences with p<0.05 were considered statistically significant. Quantitative variables were expressed as mean (95% confidence interval (CI)) and categorical ones as number of patients (percentage). Univariate analysis was performed with Fisher, X 2 , and Student-T tests, as appropriate. The possible relationship between the study period and the morbidity was analyzed using a logistic regression model. Variables that were statistically or clinically Four hundred and two patients were included in the study. Two hundred and eighty-five (70.90%) underwent surgery during the control period; one hundred and seventeen (29.10%) during the pandemic. Mean age was 54.3 (95% CI 52. 3 Mean delay of the patient to present at the Emergency Department and mean delay of the surgical procedure were 52.7 (95% CI 45.5-59.8) and 12.4 (95% CI 10.9-13.9) hours respectively. Mean SOFA score was 1.2 (95% CI 0.9-1.5), with 129 (36.24%) patients with a SOFA score higher than 0. Three hundred and sixty-four (90.55%) patients were not suspected for COVID, 31 (7.71%) were COVID negative, 4 (1.00%) were suspected for COVID and 3 (0.75%) were COVID positive. Table 1 compares the patient's characteristics in both periods of time. A statistically significant increase was observed on the delay of the patient to present at the Emergency Department (44.6 vs. 71.0 hours, p<0.001). Also, a non-statistically significant increase in the SOFA score was observed during the pandemic period (SOFA score higher than 0 in 33.87% vs. 41.67% patients respectively, p=0.160). Laparoscopic approach was more frequently performed in the control period (63.64%, vs. 43.30%, p<0.001). This difference persisted even when the variable laparoscopic approach was adjusted with the variable diagnoses using a logistic regression (OR= 3.4, p=0.001). A change in the medical conditions that required surgery took during the pandemic (Figure 2) . Even though the percentage of patients who underwent ACS due to acute appendicitis or anorectal abscess were similar in both periods, acute cholecystitis and surgeries required for treating complications of previous elective procedures decreased (26.67% vs. 9.40%) and at the same time, surgical interventions due to intestinal obstruction and reparation of abdominal wall hernia increased (12.28% vs. 22.22%). Interestingly, in the group of patients diagnosed with acute appendicitis, a significant increase in the rate of complicated appendicitis was observed during the pandemic period (7.95% vs. 42.50%, p<0.001). After performing the multivariate analysis, which included both delay of the patient to present at the Emergency Department and laparoscopic approach as confounding variables, pandemic period was not statistically associated with morbidity (OR=1.2, 95% CI 0.7-2.2, p=0.501). With the development of the COVID-19 pandemic, some authors have published their surgical experience during the pandemic [6, 10, 11] or have reported their protocol to treat surgical patients with COVID-19 [12] [13] [14] [15] [16] [17] [18] . Nevertheless, as far as we know, the reduction of ACSA observed during this pandemic has never been properly reported. Only two letters to the editor have been published [7, 8] . The first one reports the initial experience of our group [7] ; the second one recalls the experience of italian colleagues [8] . Furthermore, we have not found reports that study ACSA at any other pandemic throughout time. Nevertheless, two studies reported a decrease in surgical activity during Ebola pandemic [19, 20] . During the pandemic the daily number of ACS procedures decreased from 2.3 to 0.9, cutting in half the activity that took place during the control period. This decline in the activity should be carefully taken into account in those regions where the pandemic is still developing, as well as if a new outbreak takes place. The resources usually assigned to ACS could then be reoriented to attend patients with COVID-19, increasing the potential resources of the health systems by for example shutting down operating rooms and using anaesthesia machinery as mechanical ventilators in the Intensive Care Units. Several factors could explain the reduction in ACS procedures. First of all, patients could be delaying attending the Emergency Departments to avoid being infected with the SARS-CoV-2 [8, 21] . In our series, a statistically significant increase in the time between symptoms onset and patient's arrival at the Emergency Department was observed. This delay has also been noted in other Emergency Departments; for example, Lazzerini et al. reported a case series of children that delayed their visit to the Emergency Department due to fear of infection or collapse of the health system. Clinical outcome of these paediatric patients was discouraging [22] . It has been seen that that this delay could result in more advanced diseases [23] . And in accordance with this finding, in our series a higher proportion of patients who underwent appendectomy presented complicated appendicitis (8.0% vs. 42.5%, p<0.001). The increase in severity was also observed with SOFA scale, although this difference was not statistically significant. The reduction in ACSA could also be explained by modifications in lifestyle habits. For instance, changes in dietary fat quantity and quality could decrease the incidence of biliary complications, such as acute cholecystitis. And this reduction was in fact observed in our series. However, treating these conditions medically, rather than surgically could be another plausible explanation and could even demonstrate a trend in choosing more conservative therapies in order to avoid hospitalization. This strategy has been proposed by some authors, for example, to treat acute appendicitis [24] . This hypothesis could then explain why certain procedures that do not count with alternative treatments, such as incarcerated abdominal wall hernia reparation or bowel obstruction, were increased during the pandemic period, while surgical procedures such as appendicectomy or anorectal abscess drainage remained stable, and cholecystectomy was less frequently performed. Finally, we also compared the postoperative course in both groups of patients. Mean length of hospital stay was shorter during the pandemic period. Probably, this finding is due to early discharge implemented during the COVID-19 pandemic to decrease the risk of nosocomial infection. Complications were more common during the pandemic period. Greater severity of the patients could be the most plausible explanation for the higher morbidity we experienced, as the complication rate was not statistically associated to the pandemic period when a multivariate analysis was performed. Moreover, although morbidity was higher in the pandemic period, reoperation rate and mortality were similar in both groups; at the same time the percentage of severe complications was higher in the control period group. These findings suggest that minor complications were more common during the pandemic because delayed and more severe patients underwent surgery, but severe complications were probably similar in both groups. The main limitation of this study was that patients undergoing non-operative treatment could not be studied. The retrospective design of the project could also be considered a weakness. To avoid this limitation, data from both periods were collected using the same methodology. The main strengths of our paper were that a significant number of patients were included and that it was performed in three tertiary care hospitals located in Spain, where the pandemic has been really severe. During the COVID-19 pandemic period a significant reduction was observed in the number of ACS procedures performed. ACSA during this period was reduced to half the activity in the control period. A significant delay of the patients' arrival at the Emergency Department was also observed. Diagnoses changed during the pandemic period; acute appendicitis and anorectal abscess were similar in both periods, acute cholecystitis and complications from previous elective procedures decreased and bowel obstruction and abdominal wall hernia reparation increased during the pandemic. A higher morbidity was observed in the patients undergoing ACS during the pandemic period, although mortality and reoperation rate did not change. Acute Care Surgery Activity was decreased during COVID-19 pandemic. A higher delay of the patients presenting in the Emergency Department was observed during the pandemic period in patients who underwent Acute Care Surgery. During COVID-19 pandemic, a higher morbidity rate was found in patients undergoing Acute Care Surgery; although mortality and reoperation rate did not increase. The following additional information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories, then this should be stated. This research was approved by the Institutional Review Board (Code: 20/282-E_COVID). Please enter the name of the registry, the hyperlink to the registration and the unique identifying number of the study. You can register your research at http://www.researchregistry.com to obtain your UIN if you have not already registered your study. This is mandatory for human studies only. COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention, JAMA (2020) Epub ahead of print Implementation Guide for Rapid Integration of an Outpatient Telemedicine Program during the COVID Epub ahead of print COVID-19 Epidemic in the Middle Province of Northern Italy: Impact, Logistics, and Strategy in the First Line Hospital Epub ahead of print Optimizing response in surgical systems during and after COVID-19 pandemic: Lessons from China and the UK -Perspective General and Digestive Surgery Service in a tertiary hospital Reduction in emergency surgery activity during COVID-19 pandemic in three Spanish hospitals. BJS (2020) Epub ahead of print What happened to surgical emergencies in the era of COVID-19 outbreak? Considerations of surgeons working in an Italian COVID-19 zone A segregated-team model to maintain cancer care during the COVID-19 outbreak at an academic center in Singapore Coronavirus pandemic and Colorectal surgery: practical advice based on the Italian experience European Society of Trauma and Emergency Surgery (ESTES) recommendations for trauma and emergency surgery preparation during times of COVID-19 infection Perioperative Considerations During Emergency General Surgery in the Era of COVID-19: A Epub ahead of print Emergency surgery during the COVID-19 pandemic: what you need to know for practice Epub ahead of print Surgical management of suspected or confirmed SARS-CoV-2 (COVID-19)-positive patients: a model stemming from the experience at Level III Hospital Epub ahead of print Surgery in the time of Ebola: how events impacted on a single surgical institution in Sierra Leone Urgent digestive surgery, a collateral victim of the COVID-19 crisis? Delayed access or provision of care in Italy resulting from fear of COVID-19 Diagnostic Delay During the COIVD-19: Liver Abscess Secondary to Acute Lithiasic Cholecystitis Antibiotics alone as an alternative to appendectomy for uncomplicated acute appendicitis in adults: Changes in treatment modalities related to the COVID-19 health crisis Hyperlink to your specific registration Oscar Cano-Valderrama: study design, data collection, data analysis, writing Xavier Morales: study design, data collection, data analysis, writing Carlos Ferrigni: study design, data collection, data analysis, writing Estaban Martín-Antona: study design, data analysis Yolanda Cuñarro-López : study design, data analysis, writing Leire Zarain-Obrador: study design, data collection Balibrea: study design, data analysis Torres: study design, data analysis Conflict of interest: none.No funding was needed to perform this study. Authors would like to Dr. Marinero for English grammar review. 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