key: cord-1053271-fl67myzq authors: Melander, Sixten; Almström, Jimmy; Enlund, Gunnar; Frykholm, Peter title: The COVID‐19 pandemic first wave in Sweden: A national registry study of the effects on pediatric anesthesia and surgery date: 2021-06-11 journal: Paediatr Anaesth DOI: 10.1111/pan.14203 sha: d52df1e9b320064fac593aa80db22b2a907efcc7 doc_id: 1053271 cord_uid: fl67myzq BACKGROUND: The COVID‐19 pandemic is pushing healthcare systems to their limits. Dramatic reductions in the adult elective surgery are ubiquitous, but corresponding changes in pediatric services are not well described. The Swedish Perioperative Registry contains data on all anesthetic procedures in Sweden, and therefore, provides a unique opportunity to analyze the effect of the pandemic on the pediatric anesthesia capacity on a national level. We hypothesized that there would be a significant reduction in pediatric elective procedures. The aim was to determine the effects on pediatric surgical and anesthetic services during the first wave of the COVID‐19 pandemic in Sweden. METHODS: For this retrospective registry cohort study, we extracted all procedures performed on patients <18 years of age in 2020 and 2019. Weeks 12 to 26 of 2020 were defined as the first wave, and data were analyzed according to level of care, type of surgery, procedure code, and emergency or elective surgery. RESULTS: We found 7015 fewer procedures during the first wave epoch. Elective cases were reduced by 53.7% while emergency surgery was not significantly affected. During the peak of the first wave in April, there was a 72.8% reduction in elective cases; ENT/maxillofacial surgery showed the greatest reduction (86.7%). The surgical and anesthesia capacity recovered to near‐normal levels by the end of June 2020. CONCLUSION: We conclude that the impact of COVID‐19 on pediatric surgical procedures in Sweden during the first wave of the pandemic was dramatic, but elective services were restored a few months after the peak. The COVID-19 pandemic has changed national healthcare systems dramatically with an increasing need to prioritize patients with urgent medical conditions. It is estimated that elective surgeries globally have been reduced by as much as 80% during the worst months of the virus outbreak. 1 Compared with most other countries, Sweden has adopted a different approach during the pandemic trying to flatten the curve using recommendations instead of lockdowns. 2 Despite this strategy, a recently published report by the Swedish National Board of Health and Welfare confirmed similar reductions in elective surgery within the adult population as seen in most other countries. There is now growing concern that this backlog of surgical procedures will lead to an increase in patient morbidity and mortality. 3 Children are generally considered less likely to develop severe COVID-19 disease and represent a low proportion of diagnosed cases. 4 Regardless, one can suspect that many pediatric hospitals have been forced to change their focus to emergency care because of uncertainty regarding total number of hospital beds and the relocation of personnel. Another consideration is the cancelation of elective procedures due to the fact that children are prone to common colds, which are difficult to differentiate from COVID-19 symptoms. The extent to which elective surgery within the pediatric population has been affected during this past year is uncertain, but an international survey has indicated similar reductions as within the adult population. 5 In order to mitigate the negative effects of postponed procedures and finding ways to restart national healthcare systems, we need to present robust data and analysis on a national level. The Swedish Perioperative Registry (SPOR) contains data on virtually all performed surgeries in Sweden. 6 An important purpose of the registry is to enable regional and national comparisons, and therefore, enhance the quality of anesthesia and surgical care in the Swedish healthcare system. In the context of our study, SPOR provides a unique opportunity to present actual outcomes in regard to pediatric anesthesia and surgery on a nationwide scale. The aim of this article was to present how pediatric surgery and procedures requiring anesthesia in Sweden have been affected during the first wave of the pandemic. Our hypothesis was that there would be a significant reduction in elective procedures during the first wave of the pandemic compared with the number of procedures during the corresponding period the previous year. After ethics approval (Swedish Ethical Review Authority 2020-01909), a report of all registered procedures in subjects <18 years of age during 2019 and 2020 was requested from SPOR. Written informed consent was waived. The STROBE checklist for observational studies was adhered to. After approval from the SPOR scientific committee, the report was acquired in October 2020. The report contained no personal identification numbers, but a wide range of data on every procedure such as age of the patient, date and time of procedure, diagnosis, anesthesia code, surgical code, and elective/emergency status. Centers that joined SPOR later than January 2019 were excluded. The primary endpoint was reduction in surgical procedures, diagnostic procedures, or other treatments requiring anesthesia. Secondary endpoints were differences between hospital type and main specialties, respectively. We started by analyzing weekly changes in the total number of procedures, comparing two corresponding epochs: week 3 to week 34 in 2020 and 2019, respectively. This interval was chosen to include a few weeks before the first Swedish COVID-19 cases were diagnosed, encompassing the whole first wave of the pandemic but also the aftermath during summer. The next step was to define the period for quantitative analysis. For the purposes of this study, we defined the first wave of the pandemic as the period including the first and last consecutive weeks with more than 5% decrease in number of procedures. We analyzed the weekly data categorized according to level of care (university hospital, county hospital, and district hospital), type of surgery (limited to general surgery, orthopedic surgery, urologic surgery, and ENT/maxillofacial surgery), procedure code (limited to the 10 most common procedures), and emergency or elective surgery. Finally, we identified the peak of the first wave as the single week with the most prominent reduction in total number of procedures. We extracted data on total (adult and pediatric) COVID-19 infection rate and death rate from the Swedish Public Health Agency No power analysis was performed since the measurement period was defined a priori. The mean and number of weekly procedures were reported, and the differences between the epochs were displayed as 95% confidence intervals (95% CI) and percentage changes. Repeated measures ANOVA or Student's t test (two-sided, paired samples) were used to detect weekly changes and differences between the two epochs. p < .05 signified statistical significance. In total, 68 Swedish hospitals reported 10 991 pediatric surgical or diagnostic procedures in the selected period of 2020 compared to 18 006 in the matched weeks of 2019. This amounts to 7015 fewer procedures during the pandemic and, therefore, a reduction in the total number of 39.0%. The reduction in elective cases was 53.7% (6819 fewer cases, p < .001). In many countries, the COVID-19 pandemic has had a profound and long-lasting impact on healthcare systems in general and elective surgery in particular. Using a new national database for anesthesia and surgery, we provide data on the reduction in the number of pediatric procedures requiring anesthesia during the first wave of the pandemic in the spring of 2020 in Sweden. Elective ENT surgery was most severely affected; all services returned to normal in less than four months. The peak of the first wave was week 15 (second week of April) during which a 57.0% reduction in total caseload was registered (750 less cases in 2020); the reduction in elective cases was 72.8%. The 10 most common procedures in 2019 and the corresponding numbers in 2020 are shown in Figure 1 . The effects on elective and emergency surgery in the four major surgical specialties are displayed in Table 1 and Figure 2 . During the peak week, elective surgery was severely affected in all four specialties, ranging from 68.3% in orthopedics to 86.7% in ENT/maxillofacial surgery, which also showed the greatest effects on total F I G U R E 1 Number of performed anesthetics for the ten most common procedures in 2019 (y-axis), comparing 2020 and 2019 during the first wave of the pandemic, in this paper encompassing 14 weeks from March 15 to June 27. Arm X-arm fracture. Diagnostic examination includes some nonoperating room procedures. *p < .05, **p < .001 Table 3 contains selected events and issued recommendations during the studied period. We performed a registry-based analysis of the impact of COVID-19 on procedures involving anesthesia in children in Sweden. We could demonstrate severe but transient reductions in the total number of weekly procedures during the first wave of the pandemic. Our data show a maximum reduction by 57% during the peak in April, but a more modest average reduction of 39% for the whole study period. The changes were almost entirely affected due to cancelations of elective procedures (54%), while emergency surgery was left largely unaffected. In general, the reduction in procedures was more prominent in smaller hospitals. This is probably related to the fact that more complex pediatric cases are centralized to the university hospitals and, therefore, less likely to be canceled, while county and district hospitals deal mainly with basic ENT surgery and the occasional pediatric trauma and other emergencies. As the infection rate abated at the beginning of summer, many hospitals could restart their elective services, most likely since there was a relative overcapacity of staff in anticipation of a continued pandemic. We conclude that the impact of COVID-19 on pediatric surgical procedures in Sweden during the first wave of the pandemic was dramatic, but elective services were restored a few months after the peak. Healthcare providers encouraged to increase testing but testing capacity very limited. The Public Health Agency issues advice to the public: avoid unnecessary visits to health care and elderly care. 11-Mar Gatherings of more than 500 people should be canceled. WHO declares COVID−19 a pandemic. 14-Mar The Ministry for Foreign Affairs advises against international travel until July 15. High schools, colleges and universities to initiate distance learning, but primary and secondary schools unchanged. The Public Health Agency advices the public to avoid unnecessary travel 20-Mar Government asks the SoS to coordinate the need for ICU beds. Swedish military deploys first field hospital. Public gatherings of more than 50 people forbidden. 30-Mar Public Health Agency recommendations: All visits to nursing homes are forbidden. Mission to increase testing. Advice on physical distancing and personal responsibility. Shortage of certain intensive care medications in some hospitals. Swedish ICU capacity doubled Government orders the SoS to coordinate health care needs for the summer. Travel restrictions within Sweden eased. In our study, data were collected from the SPOR database in the For the purposes of this study, we defined the first wave as all consecutive weeks with more than 5% reduction in the total number of procedures. Interestingly, travel restrictions were initiated by the European Union on 17 March but the first major restrictions from the government were implemented toward the end of March, which is three weeks later than when hospitals started canceling elective cases. Previous studies have indicated that pediatric elective surgery has been completely discontinued, at least in the early parts of the pandemic. 5, [9] [10] [11] In our material, all categories were affected, but notably, the category of ENT and maxillofacial surgery was significantly reduced during the whole period, and the reduction during the peak week of April reached 86.7%. This is not surprising for a number of reasons. Firstly, the bulk of ENT procedures in children are such as grommets and adenoidectomy may often (but not always) be postponed several months or even years without serious harm to the child. Secondly, respiratory infections are common in this patient group and many procedures are aerosol producing, therefore, disqualifying surgery when symptomatic. Unfortunately, there is a lack of comparative data concerning pediatric ENT surgery, but several reports from adult or mixed ENT departments are reporting similar reductions. [11] [12] [13] In an attempt to avoid unnecessary cancelations and thereby risking long term negative effects in patients, international guidelines have quickly been established to restart pediatric ENT surgery worldwide, but we are not aware of any such measures from professional organizations in Sweden. 14 The effects on pediatric orthopedic surgery were relatively mild during the study period, but this can probably be explained by the fact that the most common pediatric orthopedic procedures are emergency cases, such as arm fractures (Figure 3 ). In contrast, 75% of the responding pediatric orthopedic surgeons reported 75% reduction in activity in a survey from Turkey. 15 A study from Finland reported a 31% reduction in orthopedic trauma procedures, and the authors postulated that this was partly attributed to severe restrictions, such as school closure and restriction of social gatherings. 16 Despite the fact that hospitals will necessarily prioritize emergency care, several authors report that urgent medical conditions in children are also being delayed, potentially with severe consequences. 19 Table 3 , it is not within the scope of this paper to comprehensively describe or analyze the effects on the pandemic in the community as a whole. There is no doubt that the mortality due to COVID-19 has been much higher compared with the neighboring Nordic countries. In fact, overall COVID-19 mortality was among the highest in the world during the first wave. In spite of the muchcriticized short-comings of the elderly care resulting in high death rates, our data suggest that hospital-based health care seems to have coped comparably well, supported by a recent report of a decrease in overall 60-day mortality in hospitalized COVID-19 patients from 24.7% in March 2020 to 10.4% postwave. 28 As everyone is aware of (in March 2021), the pandemic is not over yet and the results in the present study may not be valid for the second or third wave of the pandemic. However, we think it is valuable to publish the effects so far, to facilitate comparisons of national outcome data in regard to pediatric surgical capacity. Although SPOR aims at complete coverage of all surgical and anesthetic procedures in Sweden, we discovered that one of the four major pediatric hospitals did not enter data into the registry. We double-checked for other missing data and found that three district hospitals and one county hospital joined SPOR too late to provide complete data for the study and have, therefore, been excluded. Fortunately, the annual number of procedures in the above five hospitals amounts to approximately 8000 (roughly 12% of the total number of annual procedures) and is, therefore, not likely to have had a major impact on the results. Concerted efforts have been initiated to convince the missing pediatric centers to join the registry to ensure complete national datasets in future studies. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans The first eight months of Sweden's COVID-19 strategy and the actions and actors that were involved Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services Systemic review of COVID-19 in children shows milder cases and a better prognosis than adults Pediatric Surgery during the COVID-19 Pandemic: An International Survey of Current Practice Surgery was successful -but how did it go for the patient? 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Lancet Reg Health The COVID-19 pandemic first wave in Sweden: A national registry study of the effects on pediatric anesthesia and surgery The authors wish to thank Statistician Nermin Hadziosmanovic at the Uppsala Clinical Research Centre for statistical guidance. The authors declare that they have no conflicts of interest. PF and GE involved in study conception and design. JA, SM, and PF wrote the paper. All authors involved in analysis, editing and approval of the paper. SM and JA shared the first author position. The data that support the findings of this study are available from the corresponding author, [PF], upon reasonable request. https://orcid.org/0000-0001-9438-3644Peter Frykholm https://orcid.org/0000-0001-6402-136X Peter Frykholm @FrykholmPeter