Safe elective surgery during COVID-19. The relevance of collaborative work

The pandemic caused by SARS-CoV-2 has been an enormous challenge for society and healthcare systems both in Spain and worldwide. Since the World Health Organization (WHO) formally declared the COVID-19 pandemic in March, the rate of infection has varied both geographically and over time, but one factor has remained constant: healthcare service have had to adapt to deal with a new, acute, hitherto unknown disease they did not know how to treat, which endangered the health not only of their patients but also of healthcare workers due to the initial shortage of personal protective equipment.

The severe impact of the first wave in some regions coupled with concerns about the spread in other regions compelled hospitals to rapidly reorganize their resources, dedicating their departments and all their staff to the care of COVID-19 patients, and considerably increasing their capacity to care for critical patients.¹ The immediate results of these contingency plans were the cancellation of practically all non-urgent surgical activity. Estimates suggest that during the first 12 weeks of peak disruption, over 28 million elective surgery were cancelled worldwide, and more than half a million in Spain.²

The impact this has had on patient safety transcends the mass cancellation and subsequent reduction in access to surgical treatments. Delays in diagnosis caused by organisational reshuffles, the public's reluctance to seek emergency care or to request a doctor's appointment, in addition to the diagnostic errors caused by a general focus on diagnosing patients with COVID-19, have had a direct, but indeterminate, impact on morbidity and mortality in people with non-COVID-19 pathology.³

The resumption of diagnostic procedures and, above all, elective surgery to meet public demand once the initial disruption had been resolved became a moral imperative and a priority for government, hospitals and healthcare workers. The Spanish Society of Anaesthesia and Resuscitation (SEDAR) and the Spanish Association of Surgeons (AEC) led a multidisciplinary working group made up of representatives from the Spanish Society of Infectious Diseases, the Spanish Society of Preventive Medicine, Public Health and Hygiene, and the Spanish Association of Surgical Nurses whose mission was to draw up a consensus document for both healthcare workers and patients on “Recommendations for safe surgery scheduling during the COVID-19 pandemic”.⁴

These recommendations were necessary for several reasons. On the one hand, with many hospitals in Spain still overwhelmed by the first wave, these recommendations were vitally important to maintain a COVID-19-free care pathway in which non-deferrable surgery can be performed. With over 50% of beds occupied by COVID-19 patients (following peak periods of more than 100% occupancy of acute care beds⁵) and surgery restricted to emergency cases, initial de-escalation efforts were hampered by a lack of evidence for the best time to restart elective surgery. In the absence of studies, the working group adopted the expert consensus developed by the AEC and the European Association for Endoscopic Surgery for a dynamic scale for surgery activity based on hospital occupancy by COVID-19 patients.⁶ On the other hand, various studies have showed a significant increase in morbidity and mortality among patients with SARS-CoV-2 who undergo surgery, even in the pre-symptomatic phase of the COVID-19 disease.^7–9 Therefore, the working group agreed on a clinical-epidemiological and microbiological screening algorithm in which patients underwent polymerase chain reaction (PCR) testing within 72 h prior to surgery in order to minimise the risk of operating on SARS-CoV-2-positive patients. This strategy was mainly developed to protect patients against respiratory complications due to viral co-infection. In the foregoing algorithm, the decision to operate is taken after considering the level of risk of SARS-CoV-2 in the community (epidemiology) and the risk of complications in the patient in the event of inadvertent surgery while infected with COVID-19. The preoperative screening algorithm is based on the following criteria: (1) the alert scenario according to the AEC scale; (2) the epidemiology of the hospital's catchment area. This algorithm is the first to recommend using the two-week cumulative incidence rate; (3) the patient's risk according to the risk factors described by the co-authors of the COVIDSurg Collaborative⁷; (4) the risk of the procedure based on the expected need for postoperative critical care, the need for open surgery above the upper abdomen, or airway management with orotracheal intubation.

Healthcare workers are a potential source of infection for hospital patients, and although this can be avoided by maintaining COVID-19-free care pathways, a paradigm shift in protective strategies was recommended involving the universal use of high-efficiency masks and goggles during aerosol-generating procedures, and the use of surgical masks, hand washing, and interpersonal distancing at all times.

The collaboration between various scientific societies that started after the first wave has been maintained and expanded with the incorporation of new societies. Together, these societies have published updates based on the knowledge acquired and emerging scientific evidence. During the second wave of the pandemic, the need to optimize recommendations in order to maximize the capacity of hospitals and allow them to continue their surgical activity became even more evident, despite the surge in COVID-19 patients.¹⁰ In the second wave, the pressure on hospitals was less intense compared to the first wave and admission management was improved. As a result, fewer hospitalised patients required critical care. This afforded a certain flexibility in the alert scenario and allowed a greater number of scheduled surgical activities to be maintained despite the high occupancy of critical beds by patients by COVD-19 patients, provided that “clean” circuits were ensured. In addition, in order to reduce the number of patients in COVID-19 wards and maintain surgical activity, non-infectious patients were released from isolation, as recommended in the literature.^11,12

Clinicians have always had to balance patient safety with healthcare demand, and now more than ever we need to work together to give all patients equal access to diagnostic and surgical procedures. We need to guarantee the safety of both patients and healthcare workers by either clearly separating COVID-19 and non-COVID-19 pathways, or by implementing a safe, feasible preoperative screening system.

It is the responsibility of hospitals and healthcare workers to manage their resources in order to minimise the impact that the high demand generated by COVID-19 patients can have on elective surgery.

Various scientific societies, led by SEDAR and the AEC, have shown their commitment to achieving this goal, and work tirelessly together with healthcare workers and the health authorities to offer patients the best and safest care.

Conflict of interests

The authors have no conflict of interest to declare.