Keywords COVID-19 pandemic - guidelines - surgery
COVID-19 pandemic, apart from its direct effect on health due to the viral infection,
has affected the health status of many individuals by its impact on the health delivery
system. This impact has been mainly due to relocation of health resources for treating
the large number of existing or anticipated COVID-19 patients when extensive community
spread of the disease is present. The fear of spread of the disease to the health
care workers (HCWs) and other patients has made medical institutions to suspend most
of the medical and surgical services. One area of health care delivery system that
has been affected badly in most of the institutions is the provision of surgical services.
Elective surgery was suggested to be curtailed as per most of the government advisories
and guidelines issued by various national surgical societies. The effect of the delay
or denial of surgical care for cancer patients as well as other ailments will definitely
affect overall cure rate as well as quality of life of many patients. Resumption of
these services was essential. But factors such as the presence of asymptomatic carrier
stage, rapid infectivity, increased morbidity and mortality in surgical procedures
when performed in a COVID-19 patient, and transmission with increased viral load during
surgery to the HCWs if the patient is COVID-19 carrier make this resumption difficult
and worrisome to the entire workforce of the hospital. Hence, a guideline was formulated
in our institution, which is a tertiary care university teaching hospital with average
1,200 surgical major procedures every month. This was prepared based on the existing
published articles[1 ]
[2 ]
[3 ]
[4 ]
[5 ]
[6 ]
[7 ]
[8 ]
[9 ] and advisories from health agencies. They were developed by the senior surgical
and anesthetist's team with inputs from the medical administrators, the infection
control department, and the senior nursing staff manning the operation rooms. These
guidelines helped us resume the services soon after the national lockdown in India
which was declared on March 23, 2020. Feedbacks were essential to address lacunae
in the structure and implementation of the guidelines. With this aim, a questionnaire
was prepared and distributed among the HCWs from the surgical departments to assess
the effectiveness of the guidelines. This article reports the findings of the survey
and analyses the positive and adverse responses from medical and supportive staffs.
Brief Outline of the Guidelines Implemented
Brief Outline of the Guidelines Implemented
The guidelines assumed that when community spread is present or declared, each patient
should be considered to have the possibility of harboring the virus. The guidelines
were formulated on the information available from published literature, guidelines
issued by various professional bodies and the governmental agencies. The guideline
triaged the patient based on the urgency of the surgery and whether the patient belonged
to COVID-19 high- or low-risk groups. The precautionary measures included usage of
various types of personal protective equipment (PPE), quarantine, and preoperative
polymerase chain reaction (RT-PCR) testing. The guidelines prescribed three grades
of precautions based on the risk stratification and also the norms for preoperative
and postoperative ward care, and patient transfer protocols. The flow chart based
on these guidelines is depicted in [Figs. 1 ] and [2 ]. The guidelines got prepared at the start of the first lockdown (March 23, 2020)
in India. But full implementation started by the second lockdown period and is continuing
till this report is prepared, with timely modifications based on changing prevalence,
governmental regulations, and results of this survey.
Fig. 1 Patient pathway for scheduling the surgery. The risk stratification was based on
several factors which included the presence of COVID-19–type symptoms, history of
international or out of the state travel within 28 days, contact with a suspected
COVID-19 patient in quarantine, hailing from a hotspot or containment zone, health
care workers who handled a patient without appropriate personal protective equipment.
Fig. 2 Categorization of surgery: E1, priority elective; E2, semiemergency that can wait
for 7 to 14 days; and E3, emergency to be done at the earliest. Quarantine status
denoted by: Q0/no quarantine, Q1/7 days, Q2/14 days, Q3/28 days. RT-PCR testing status:
T1 if only one test done, it is 48 to 72 hours prior to admission and if two tests,
T1 at day 0 and T2 at 48 hours prior to admission. Precautions: Grade 1 nursing care
in normal ward, surgery with PPElevel 2 . Grade 2 nursing care in normal ward, surgery with PPElevel 3 , postoperative care in special zone with special zone ICU care with PPElevel 2 for patients with high aerosol generating conditions such as on tracheostomy or ventilator.
Grade 3 admission in COVID ward. Surgery to be done in negative pressure area with
PPElevel 3 for procedure. Postoperative care in COVID ward with PPElevel 3 till PCR test is negative. Personal protection equipment: level 1: disposable apron,
gloves, surgical face mask (visor if AGP is present). Level 2: disposable impermeable
gown, N95 mask, visor, shoe cover, and gloves. Level 3: full body coverall, shoe cover,
N95 mask, goggles/visor, and multiple layers of gloves. AGP, aerosol generating procedure;
ICU, intensive care unit; PCR, polymerase chain reaction; PPE, personal protective
equipment; RT, reverse transcription.
Methods
The questionnaire was prepared and the responses were collected, ∼2 weeks after the
full implementation of the final version of the guidelines. The questionnaire ([Fig. 3 ]) had four domains. The first was regarding the impact of the epidemic on the practices;
the second domain had questions related to the formulation of the guidelines followed
by set of questions to look at its implementation (third domain) and effects (fourth
domain). Finally, free hand column was left for suggestions for improvement. Both
English and Malayalam language versions were created. Even though linguistic validation
was not performed, the translation as well as back translation was done by experts.
This was circulated among the different categories of HCWs. These included surgical
consultants, surgical residents, anesthesia consultants and residents, nursing staff,
and paramedical staff including technicians and the administrative personnel. Personnel
working in all surgical specialties were included. The questions were sent via Google
Docs link and were to be answered online with anonymity being maintained. Signing
in with own e-mail ID was essential to make sure that duplications do not occur, but
software had the inbuilt ability to maintain the anonymity.
Fig. 3 Questionnaire.
Statistical Analysis
Analysis was done using IBM SPSS version 20 (SPSS Inc., Chicago, IL). The results
which are given as percentage with 95% confidence limit were used for all categorical
variables. To obtain the association of categorical variables, chi-square test was
applied. A p -value of < 0.05 was considered as statistically significant
Results
Out of the total 217 respondents, nursing staff constituted 43.3%, surgeons 19.4%,
surgical residents 13.8%, anesthetists 13.9%, technicians 4.1%, and administrative
staff 5.5% ([Fig. 4 ]).
Fig. 4 Frequency of responders.
Questions Related to the Practice
Large majority of respondents (83.4%) agreed that there was a significant drop in
the number of patients. Majority were of the opinion that it was not due to the shortage
of staff (67%) or due to undue fear of colleagues about the disease (81%). Forty-one
per cent attributed the drop in the number of patients, due to the logistic difficulties
they faced in accessing the health care facilities ([Fig. 5 ]).
Fig. 5 Effect of COVID-19 on practice.
Questions Related to the Formulation of Guidelines
The vast majority (90%) felt that the institution came up with the guidelines at the
right time and almost all (99%) agreed that the guidelines were helpful and 94% felt
it was essential. Regarding the variables selected in formulating the triage principles
for ensuring safety, the “quarantine” and the “COVID RT-PCR testing” were found to
be appropriate by 90 and 93% respondents, respectively ([Fig. 6 ]).
Fig. 6 Questions related to formulation of guidelines.
Questions Related to the Implementation
Majority (86%) felt that the guidelines implemented assured safety in the work practices
and 89% felt the presence of an infection control department overseeing these to be
helpful. On the question whether the guidelines were difficult to understand and carry
out, there was a mixed response with ∼60% disagreeing and 20% agreeing with others
being neutral; 45% of respondents felt that the guidelines caused delay in the procedures
due to the excessive coordination needed. Fifty-seven per cent felt that the guidelines
helped the appropriate usage of personal protection kits and overall cost reduction
([Fig. 7 ]).
Fig. 7 Questions related to implementation.
Questions Related to the Effects or Benefits
Forty per cent of the respondents felt that the guidelines increased the work burden.
To the specific question that whether the guidelines caused mental agony, only 20%
felt so. A very large majority (93%) felt that the guidelines ensured patient safety
and also that the guidelines would need modifications and streamlining as the situation
evolves. The presence of an infection control department to advise in COVID-19 precautions
was appreciated by 89% of the responders ([Fig. 8 ]).
Fig. 8 Questions related to effects of implementation.
In majority of the questions, there was a near unanimity among all the responders
in their response. But in few areas, the response was divided in nature. These were
analyzed to see whether there was any difference among the medical (doctor) versus
supportive (nurse, technician, and administrator) groups. Among the reasons for drop
in number of the patients during the COVID-19 time, difficulty felt by the patients
to have access to the hospital was thought to be a reason by medical group and not
by the supportive staff with a statistically significant difference ([Fig. 9 ]).
Fig. 9 Effect on practice as felt by medical and supportive staffs.
The medical group expressed the view that the guidelines were difficult to carry out
as compared with the view by the supportive group (p < 0.001). The medical group also felt that the guidelines delayed carrying out of
the procedures (p < 0.001). More number of medical staff felt that the guidelines increased the work
burden (p < 0.001). To the question whether the guidelines increased mental agony, there was
more agreement from the medical group than the supportive group (p < 0.052) ([Fig. 10 ]).
Fig. 10 Effect of guidelines differences between medical and supportive staffs.
Discussion
The COVID-19 pandemic has created great disruption in the delivery of health services
to the non-COVID-19 population all over the world. The disruption has been felt markedly
in the running of surgical services with the fear of increased mortality and increased
disease spread being the commonly cited reasons. The nature of the virus transmission
and rapid spread coupled with the health advisories created a sense of insecurity
among the HCWs, health administrators, as well as the patients and their families.
Steps had to be put in place to allow safe surgical practices at the earliest. Even
though the surgical societies across the world had put up their own guidelines, they
did not help the day-to-day running of the service. They were mostly concerned with
the type of procedure to be chosen and the modifications in the conduct of surgery
and anesthesia to be adopted. Hence, the present guidelines and surgical workflow
were created and implemented. These suggested a clear workflow for patients who were
categorized as per their urgency of treatment, the risk of COVID-19 positivity, as
well as the precautionary measures to be adopted at each level. We could continue
provision of the services to a great level implementing these guidelines. Being a
dynamic situation, the guidelines need to be adaptive to the changing situation. This
necessitated feedback from all those who were responsible in running the surgical
services. Hence, this questionnaire was prepared.
There was an obvious fall in the number of patients attending the clinics. The majority
of the respondents especially the doctor group thought that this was due to the logistic
difficulties the patients had in accessing the hospital facilities. The lockdown and
other restrictions in the transportation may be the reason for this. This will need
to be addressed by facilitating transportation and hospital care for non-COVID-19
patients by both governmental agencies and hospital administrators.
In general, the responses to the implementation-related questionnaire were positive.
The respondents were of the opinion that the guidelines ensured work safety, helped
in streamlining the patient care, and appropriate usage of PPE. Aziz et al's[10 ] study of rapid guidelines strongly recommended that each state/province/country
develops a triage protocol and system to support legal framework to permit triage
in clinical setting, which is based on local practices and legislation. The guidelines
detailed the way of proper donning and doffing of PPE by the staff, minimizing the
number of staff entering the patients' room, remote access to equipment controls and
bundle care, develop and implement response plans to endotracheal intubation, cardiac
arrest for patients with COVID-19.
Implementation of these guidelines was found to cause some delays in the delivery
of treatment. Among the responders, the medical group felt more concerned about the
delay. The difficulties in implementation of the guidelines were also felt more by
the medical group. This may be explained by the fact that they were really taking
more responsibility in getting the patients organized for the surgical treatment.
The respondent felt that the guidelines ensured patient safety. Majority of them did
not appreciate any increased work burden with some disparity between the medical and
supportive staffs. The proportion of those who felt having increased workload was
more among the medical staff, probably due to the need of triaging, ensuring the quarantine
and COVID-19 test status.
Xiao et al's[11 ] multicenter cross-sectional survey of psychological levels during COVID-19 pandemic
showed that 55.1% of participants had psychological stress higher than during severe
acute respiratory syndrome; 54.2 and 58% of HCWs had symptoms of anxiety and depression.
The authors concluded that independent risk factors for anxiety and depression were
gender, professional title, protective support, and contact history. Spoorthy et al[12 ] in a recent literature review showed that nurses had higher anxiety and depressive
symptoms as compared with doctors. A scoping review by Shaukat et al[13 ] showed that HCWs experienced high levels of depression, anxiety, insomnia, and distress
in this COVID-19 pandemic. Female HCWs and nurses were disproportionately affected.
The German study of Zerbini et al[14 ] showed that job strain due to increased workload, organizational changes in working
team and conflicts with colleagues, and uncertainty about the future due to health
care system and economic crisis were the most common causes for psychosocial burden.
In our questionnaire, the presence of mental agony was found to be not great, but
relatively, this was more among the medical staff contrary to the previous studies.
But in the present study, the psychological effects were not addressed in detail but
only with a single question, hence may not be fully representative of the real picture.
The analysis of the feedback suggested that the implementation of these guidelines
helped greatly to streamline the surgical activities. It improved the morale of the
staff and allowed them to undertake surgical procedures with confidence. A study from
our institution showed that with implementation of these guidelines, our surgical
workload equaled 60% of that during a similar period during last year.[15 ] Based on the findings of this survey, we incorporated steps to reduce the delay
in the work execution and provided more secretarial assistance to the medical staff
to reduce their increased workload created by implementing the guidelines.
Limitations of the Study
The questionnaire may reflect the attitude of staff from an academic hospital. Since
the working environment may be different in other types of medical providers, the
findings may not represent the entire spectrum of types of hospitals.
Conclusion and Future Directions
Conclusion and Future Directions
The present study showed that implementation of the guidelines for ensuring safe surgical
practice was welcomed by all the HCWs, which included both doctors and supportive
staff. Insisting on quarantine and preoperative RT-PCR testing were found to be appropriate
measures by the respondents. Compared with the supportive staff, the doctors felt
that patient accessibility was a reason for drop in the number and felt more concerned
about the delay and increased workload created by these guidelines. But all uniformly
felt that it ensured patient safety as well as streamlined the services. The findings
of the study will indicate that in future immediate steps should be taken to implement
similar guidelines at the earliest if such situations arise and that these should
be dynamic in nature taking into account the differing concerns of the medical and
supportive staffs.
