Table 5.

Actions proposed by our panelists to effectively mitigate the impact of COVID-19 on children’s surgery in the context of the Global Initiative for Children’s Surgery (GICS) Optimal Resources for Children’s Surgery (OReCS) document

Action item (OReCS framework domain)	Panel's comments
Educational resources (human resources and training)
i. For all providers & trainees	“First of all, about education, it is very important to have material not only for senior surgeons but also for junior surgeons, general surgery residents, fellows, and pediatricians. We had this experience yesterday. We did a webinar about the basic pediatric surgery for pediatricians, and we had more than 400 participants who thought this experience was very good."
ii. For general public	“There is a dire need to provide public education via radio/TV shows to inform the public about the safety of visiting hospitals given all SOPs are followed.”
iii. Online Media	“Once elective surgeries resume, GICS can always assist with the training of pediatric surgeons as well as the exchange of knowledge and skills through online media.”
iv. Large versus small groups	“I think both large webinars and smaller focus groups are very helpful in their own ways. We recently conducted a webinar on hypospadias, which was attended by 500 people. This allowed a greater reach and answering a lot of questions from the chat option.”
	“In Pakistan, there seems to be a preference for interactive sessions and small group discussions over webinars among surgeons and trainees. These small group sessions encourage easier communication of the day-to-day challenges faced during the pandemic.”
v. Adapted to local needs and resources	“I also think that translation of fundamental material would be very important. Sometimes you think that everybody knows English, but I have some friends, colleagues, fellows who do not know how to speak English.”
Guidelines (Quality improvement)
Safety
i. Procedures	“One of the key topics requiring attention right now is the safety of conducting minimally invasive procedures, including laparoscopy and thoracoscopy in children.”
ii. Perioperative care	“GICS could help with the development of standard safety protocols for pre-op, intra and post-op surgical care in children. This is especially important in Indonesia, where the number of pediatric surgeons is very low.”
	“We can have appropriate guidelines on appropriate PPE for different COVID-19 status, so what do you use for negative patients? What do you use for a suspected patient who has to go to the OR without a test? And, what do you use for the positive patient?”
iii. Healthcare Professionals	“GICS could design and propose guidelines for patient preparation prior to surgery, role and importance of RT-PCR and other tests, prioritization of surgical cases and minimizing backlog, appropriate set up of operating rooms and anesthesia units, and safety of HCWs and other staff in the OR and Post-Anesthesia Care Unit (PACU).”
Adaptability
i. Local needs	“About the guidelines, I think it’s also important to have guidelines for institutions that don’t have a lot of resources. I think that’s not fair to have guidelines from only high-income countries. We also need something that is safe for low resource settings.”
ii. Low- and Middle-income country (LMIC) representation	“Because each country and region have their own guidelines for PPE, testing, quarantine, and treatment, not all of these resources will be available in LMIC settings. However, people can see them and choose which ones apply. There must also be sufficient LMIC representation to know what is available and practical.”
Prioritization
i. Essential and emergency surgery	“There is also a need for guidelines on what procedures are considered essential and which are not from all subspecialties.”
	“In Africa, we are getting to the place of community spread as some countries are trying to open up, some are still having restriction measures involved, so how do people conduct themselves during this time when they have to do emergency surgery with the fact that there is community spread, where you are having patients coming in and you may not know their status, but you have to go to the operating room immediately.”
ii. Elective surgery	“GICS could help with guidelines on the best practice of elective surgeries (e.g., hernia, circumcision, and specifically laparoscopic surgery), precautions for surgery of COVID-19 and non-COVID-19 patients.”
Accessibility	“Another way that GICS could help would be to ensure that all relevant resources and recommendations are available in one place on the website. For example, it took me a very long time to find out that D-dimer tests for hypercoagulability can actually indicate the need for early anti-coagulation in symptomatic patients.”
Backlog (human resources & training; service delivery)
i. Strengthening the surgical workforce capacity	“Once we open and people are working, GICS can help with putting together surgical teams, who can travel from region to region offering surgery at surgical camps. This is especially in areas where we have very few providers and children have a very high burden of surgical diseases.”
ii. Engaging local providers and telemedicine	“It will also be important to involve local providers, even if they are general surgeons or pediatricians, to actually elicit findings when you are doing telemedicine. I find this very useful and I actually liaise with them all the time.”
Research (Quality improvement)
i. Profile of pediatric surgical cases	“Research should be done on the profile of pediatric surgical cases done during the pandemic in both high-income countries (HICs) and LMICs.”
ii. Outcomes	“In addition to gathering evidence to guide clinical practice, we also need to start looking at the community-based assessment of unmet need and the impact of COVID-19 on surgical outcomes.”
	“Research efforts should focus on long-term effects (including mental health and inflammatory conditions) of the pandemic on children.”
iii. Safety of surgical procedures	“Research is needed on the safety of procedures and which alternatives can be used e.g., laparoscopy versus laparotomy, in order to keep meeting the demand of pediatric surgery.”
iv. Financial burden	“Additionally, financial stress can also be assessed by interviewing families, and I think this will be important when we approach donors to convey what financial stresses patients are suffering from.”
v. Delayed surgical management	“It would also be helpful to review patient records for the last 6–12 months to assess how many patients are missing essential visits that might affect them adversely.”
	“The information we can begin gathering now includes adverse outcomes, delay in starting essential treatments, such as casting clubfoot, delay in developmental dysplasia of the hip surgery, delay in removal or application of 8 plate.”