Invited commentary on “Optimizing response in surgical systems during and after COVID-19 pandemic: Lessons from China and the UK – Perspective. Int J Surg, 2020, May 4, Epub ahead of print”

Dear Editors,

Currently the world is experiencing an unrivalled crisis of modern times. Surgical care in general should be well thought of to prevent undue exposure of surgeons and other health care workers (HCWs) to the risk of infection transmission. Increasing load of surgery also usurps the hospital resources and facilities, which remain precious in a pandemic. Therefore, a strategy to help keep essential surgical systems working effectively and to provide the best surgical care for emergency conditions is the need of the hour.

Liu et al. propose triaging in a surgical system following a predicted choice of patients, who need emergent care, as a key measure to decrease exposure of HCWs to infection [1]. In furtherance to this concept, Andrea et al. recommend cancellation of all educational activities such as grand rounds and tumour boards to reduce gathering [2]. Easily accessible fever clinics with a dedicated task force increase the availability of more HCWs in other areas of the hospital [1]. Based on their experience in dealing with the outbreak in Wuhan, China, Zhang et al. [3] adopted the idea of adult fever clinics. Although they used home care and isolation as a strategy, they do not recommend it, as inappropriate home care may be life threatening.

Virtual consultation is another strategy that obviates the need of interaction with doctors in person, and thus reduces disease transmission risk. Virtual consultation is also an instrument of “forward triage”, which sorts patients before they reach hospital [4]. The use of televisit system for hospitalised patients and electronic ICU monitoring programs, where 60–100 patients in multiple hospitals can be monitored by physicians on a single platform, are significant advancement of the virtual platform [4]. Houston's Project ETHAN [5] (Emergency Telehealth and Navigation) uses telemedicine to add to the care offered by paramedics, which may reduce unnecessary patient transfer to the emergency department. Furthermore, quarantined physicians can use virtual consultations, thus sparing other physicians for in-hospital care.

The Local Resumption of Elective Surgery Guidance of the American College of Surgeons [6] states that before making guidelines for screening of asymptomatic patients, it is important to know, understand and update the local testing capabilities and turnaround time. It recommends RT-PCR testing for all patients undergoing planned surgeries or for selected patients after screening, with or without mandatory preoperative quarantine. Emergency surgery should be a priority and all hospitals should develop a policy for such procedures. Others recommend use of dedicated negative pressure OR, restricting entry of OR staff, full PPE for scrub team, limited use of electrocautery and ultrasonic scalpels, and to avoid laparoscopy [7]. Limited operating on cancer patients with consideration of alternative treatment strategies such as oral chemotherapeutic drugs should be considered [1].

It is imperative to have a robust PPE management system and the American College of Surgeons Local Resumption of Elective Surgery Guidance [5] recommends PPE for all airborne and droplet contacts to be made available for at least 30 days before releasing restrictions on surgeries. Recommendations for infected patients, persons under isolation, cancer patients and non-infected patients should be framed locally.

As of now the future course of the pandemic is not very clear. Once the epidemic ebbs, Andrea et al. suggest a selective increase of booked surgeries paying particular attention to minimise the exhaustion of workforce in order to avoid “a crisis after a crisis” [2]. To sum up, with frequent change in the nature of challenge, management recommendations should be flexible keeping in line with newer evidence as and when generated.

Funding

Nil.

Provenance and peer review

Invited Commentary, internally reviewed.

Declaration of competing interest

None.