The impact of COVID-19 on access and availability of radiological imaging and surgical intervention at the east Midlands major trauma centre: An icon trauma study

Introduction: During the COVID-19 pandemic, Major Trauma services were subject to significant challenges including reduced access to Computed Tomography (CT) scanning and restrictions on operative intervention due to limited intensive care beds. This study evaluated the pandemic's impact on access and timeliness of imaging and surgical intervention Method: This observational study compared 2 cohorts of patients admitted in a 10-week period during the COVID-19 pandemic and a similar time period in 2019. Variables included demographics, time to CT scan and to surgery and operative characteristics. Statistical comparisons were undertaken using Mann Whitney U, Fisher's exact and Chisquared tests Result: Of 642 patients, 405 were admitted in 2019 and 237 in 2020 representing a 41.5% absolute reduction in trauma admissions during the pandemic. There were no statistical differences (P=0.2585) between arrival to the Emergency Department and time to CT scan across both years (median 42 minutes) or between operative approach (P=0.728) and level of post-operative care (P=0.788). However, there were statistical differences in time to surgery (P=0.0193) and operative length (P=0.0141) with a 2-fold increase in overnight operating, 31.2% increase in patients operated on<24 hours from admission, and 42.9% reduction in surgery lasting >120 minutes during the COVID-19 pandemic Conclusion: Early robust restructuring of trauma services during the COVID-19 pandemic ensured timely access to appropriate imaging and surgery for major trauma injured patients. The higher rates of overnight surgery and shorter duration of procedure were likely explained by the increased onsite availability of suitably trained trauma surgical teams Take-home Message: COVID-19 had the potential to significantly impact Major Trauma services, however excellence in patient care was maintained by quick restructuring to staff, space and services Improvements to the Major Trauma pathway have become ingrained into daily practice and optimised for future outbreaks .

Antibiotics as first-line alternative to appendicectomy in adult appendicitis: 90-day follow-up from a prospective, multicentre cohort study.

BACKGROUND: Uncomplicated acute appendicitis can be managed with non-operative (antibiotic) treatment, but laparoscopic appendicectomy remains the first-line management in the UK. During the COVID-19 pandemic the practice altered, with more patients offered antibiotics as treatment. A large-scale observational study was designed comparing operative and non-operative management of appendicitis. The aim of this study was to evaluate 90-day follow-up. METHODS: A prospective, cohort study at 97 sites in the UK and Republic of Ireland included adult patients with a clinical or radiological diagnosis of appendicitis that either had surgery or non-operative management. Propensity score matching was conducted using age, sex, BMI, frailty, co-morbidity, Adult Appendicitis Score and C-reactive protein. Outcomes were 90-day treatment failure in the non-operative group, and in the matched groups 30-day complications, length of hospital stay (LOS) and total healthcare costs associated with each treatment. RESULTS: A total of 3420 patients were recorded: 1402 (41 per cent) had initial antibiotic management and 2018 (59 per cent) had appendicectomy. At 90-day follow-up, antibiotics were successful in 80 per cent (1116) of cases. After propensity score matching (2444 patients), fewer overall complications (OR 0.36 (95 per cent c.i. 0.26 to 0.50)) and a shorter median LOS (2.5 versus 3 days, P < 0.001) were noted in the antibiotic management group. Accounting for interval appendicectomy rates, the mean total cost was €1034 lower per patient managed without surgery. CONCLUSION: This study found that antibiotics is an alternative first-line treatment for adult acute appendicitis and can lead to cost reductions.

The icon trauma study: The impact of the COVID-19 lockdown on major trauma workload in the UK

Introduction: Anecdotal evidence suggest a direct impact of the SARSCOV- 2-pandemic on presentation and severity of major trauma. Method: This observational study from a UK Major Trauma Centre matched a cohort of patients admitted during a 10-week period of the SARS-CoV-2-pandemic (09/03/2020 to 18/05/2020) to a historical cohort admitted during a similar time period in 2019 (11/03/2019 to 20/05/ 2019). Demographic differences, injury method and severity were compared using Fisher's and Chi-squared tests. Multivariable logistic regression examined the associated factors predicting 30-day mortality. Results: Of 642 patients, 405 and 237 were in the 2019 and 2020 cohorts respectively. 1.69%(4/237) of the 2020 cohort tested SARS-CoV-2 positive. There was a 41.5% decrease in trauma admissions in 2020. The 2020 cohort was older (median 46 vs.40 years), more comorbid and frailer (p<0.0015). There was a significant difference in injury method with a decrease in vehicle related trauma, but an increase in falls. There was a 2-fold increased risk ofmortality in the 2020 cohort that in adjustedmodels, was explained by higher injury severity and frailty. Positive SARS-CoV-2 status was not associated with increasedmortality onmultivariable analysis. Conclusions: Patients admitted during the SARS-CoV-2-pandemic were older, frailer, more co-morbid and had an increased risk of mortality.

Correction to: The management of adult appendicitis during the COVID‑19 pandemic: an interim analysis of a UK cohort study (Techniques in Coloproctology, (2020), 10.1007/s10151-020-02297-4)

Unfortunately, few of the collaborators names were incorrectly published in the original publication. The correct names of the collaborators are given below. Talal Majeed Mina Mesri Hannah Byrne Eduardo Raimundo Da Silva Bento Fadzlien Zahari Farah Roslan John R O’Neil Dimitrios Damaskos Jamaal Jackman The original article has been updated.

The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study.

BACKGROUND: Acute appendicitis (AA) is the most common general surgical emergency. Early laparoscopic appendicectomy is the gold-standard management. SARS-CoV-2 (COVID-19) brought concerns of increased perioperative mortality and spread of infection during aerosol generating procedures: as a consequence, conservative management was advised, and open appendicectomy recommended when surgery was unavoidable. This study describes the impact of the first weeks of the pandemic on the management of AA in the United Kingdom (UK). METHODS: Patients 18 years or older, diagnosed clinically and/or radiologically with AA were eligible for inclusion in this prospective, multicentre cohort study. Data was collected from 23rd March 2020 (beginning of the UK Government lockdown) to 1st May 2020 and included: patient demographics, COVID status; initial management (operative and conservative); length of stay; and 30-day complications. Analysis was performed on the first 500 cases with 30-day follow-up. RESULTS: The patient cohort consisted of 500 patients from 48 sites. The median age of this cohort was 35 [26-49.75] years and 233 (47%) of patients were female. Two hundred and seventy-one (54%) patients were initially treated conservatively; with only 26 (10%) cases progressing to an operation. Operative interventions were performed laparoscopically in 44% (93/211). Median length of hospital stay was significantly reduced in the conservatively managed group (2 [IQR 1-4] days vs. 3 [2-4], p < 0.001). At 30 days, complications were significantly higher in the operative group (p < 0.001), with no deaths in any group. Of the 159 (32%) patients tested for COVID-19 on admission, only 6 (4%) were positive. CONCLUSION: COVID-19 has changed the management of acute appendicitis in the UK, with non-operative management shown to be safe and effective in the short-term. Antibiotics should be considered as the first line during the pandemic and perhaps beyond.