The new timing in acute care surgery (new TACS) classification: a WSES Delphi consensus study.

BACKGROUND: Timely access to the operating room for emergency general surgery (EGS) indications remains a challenge across the globe, largely driven by operating room availability and staffing constraints. The "timing in acute care surgery" (TACS) classification was previously published to introduce a new tool to triage the timely and appropriate access of EGS patients to the operating room. However, the clinical and operational effectiveness of the TACS classification has not been investigated in subsequent validation studies. This study aimed to improve the TACS classification and provide further consensus around the appropriate use of the new TACS classification through a standardized Delphi approach with international experts. METHODS: This is a validation study of the new TACS by a selected international panel of experts using the Delphi method. The TACS questionnaire was designed as a web-based survey. The consensus agreement level was established to be ≥ 75%. The collective consensus agreement was defined as the sum of the percentage of the highest Likert scale levels (4-5) out of all participants. Surgical emergency diseases and correlated clinical scenarios were defined for each of the proposed classes. Subsequent rounds were carried out until a definitive level of consensus was reached. Frequencies and percentages were calculated to determine the degree of agreement for each surgical disease. RESULTS: Four polling rounds were carried out. The new TACS classification provides 6 colour-code classes correlated to a precise timing to surgery, defined scenarios and surgical condition. The WHITE colour-code class was introduced to rapidly (within a week) reschedule cancelled or postponed surgical procedures. Haemodynamic stability is the main tool to stratify patients for immediate surgery or not in the presence of sepsis/septic shock. Fifty-one surgical diseases were included in the different colour-code classes of priority. CONCLUSION: The new TACS classification is a comprehensive, simple, clear and reproducible triage system which can be used to assess the severity of the patient and the surgical disease, to reduce the time to access to the operating room, and to manage the emergency surgical patients within a "safe" timeframe. By including well-defined surgical diseases in the different colour-code classes of priority, validated through a Delphi consensus, the new TACS improves communication among surgeons, between surgeons and anaesthesiologists and decreases conflicts and waste and waiting time in accessing the operating room for emergency surgical patients.

Changes in pediatric major trauma epidemiology, injury patterns, and outcome during COVID-19-associated lockdown.

Introduction: The COVID-19 pandemic and its associated preventive measures such as national and regional lockdowns have dramatically changed the epidemiology of pediatric admissions to the emergency department. Nevertheless, there are scant data on the epidemiology and injury patterns of major pediatric trauma injuries during these lockdown periods. Methods: A single-center retrospective study of data obtained from a tertiary level 1 trauma hospital trauma registry. The data included demographics, injury mechanisms, injury severity and type, treatment, and resource utilization in children aged 0-18 years who required trauma team activation upon arrival. The analysis compares the data from the 5-week lockdown period from March to May 2020 in Jerusalem, Israel, to its parallel periods in 2018-2019. Results: A total of 187 trauma visits that required trauma team activation (TTA) were analyzed: 48 visits during the lockdown period vs. 139 in 2018-2019, corresponding to a 40% drop in TTA. There was a significant decrease of 34% in MVA-related injuries (p = 0.0001) but a significant increase of 14% in burns (p = 0.01) and a 16% increase in bicycle-related injuries (p = 0.001). No changes in ISS, injury patterns, admission rate, PICU utilization, or need for interventions were observed. Conclusion: There was a significant decrease in the number of overall pediatric trauma visits during the 2020 lockdown, mainly in MVA-associated trauma, but an increase in burns and bicycle injuries. These findings can thus inform policy makers as to the need to formulate prevention awareness programs alerting the public to indoor hazards and the dangers of activities outside the home. Furthermore, it can inform hospital policy decision-making in future lockdowns. The fact that PICU admissions and the need for operating rooms stayed unchanged suggests that it is vital to maintain trauma team capabilities even during lockdowns.

COVID-19 Lockdown Has No Significant Impact on Trauma Epidemiology and Outcomes in a Tertiary Trauma Center—Retrospective Cohort Study

Background: The aim of this study was to describe the impact of a COVID-19 lockdown on the variation in the volumes and types of injuries at a level one trauma center while focusing on preserving trauma care resources. Methods: A retrospective, descriptive study of prospectively collected data from the Trauma Registry. Data collection included patient demographics, injury mechanism, injury type and treatment required. The time periods studied corresponded with the lockdown period in Israel and a parallel period in 2019. Results: Overall, there was no reduction in all injury-related admissions. There was a significant reduction in pedestrian injuries (p < 0.02) and a non-significant increase in children admissions aged 0–2 years. Compared to the previous years, the severity of injuries during the March–April 2020 lockdown was unchanged. Hospital resources (number and percentage of trauma patients who required an operation, ICU stay and LOS) were not different between the lockdown period compared to the previous 5 years. Less trauma patients arrived with a Trauma Team Activation code during the lockdown period (58, 33% decrease compared to the control), but a significantly higher proportion of those patients required hospitalization (77.6%, p < 0.0001). Conclusions: During a lockdown period, road accidents were still the main cause for major trauma admissions, resulting in prolonged and complex surgeries, and hospitals should continue to provide full services until resource limitations are unavoidable. Maintenance of an effective full-staffed trauma service is vital throughout a COVID-19 lockdown.

Preparedness for Mass Casualty Incidents: The Effectiveness of Current Training Model.

The importance of MCI organization and training was highlighted by the events of September 11, 2001. Training focuses on the management of physical injuries caused by a single traumatic event over a well-defined, relatively short timeframe. MCI management is integrated into surgical and trauma training, with disaster management training involving the emergency services, law enforcement, and state infrastructure agencies. The COVID-19 pandemic revealed gaps in the preparedness of nation states and global partners in disaster management. The questions that arose include 'has training really prepared us for an actual emergency,' 'what changes need to be made to training to make it more effective,' and 'who else should training be extended to?' This article focuses on the importance of involving multiple sectors in mass casualty training and asks whether greater involvement of non-medical agencies and the public, in operational drills might improve preparedness for global events such as the COVID-19 pandemic.

2020 WSES guidelines for the detection and management of bile duct injury during cholecystectomy.

Bile duct injury (BDI) is a dangerous complication of cholecystectomy, with significant postoperative sequelae for the patient in terms of morbidity, mortality, and long-term quality of life. BDIs have an estimated incidence of 0.4-1.5%, but considering the number of cholecystectomies performed worldwide, mostly by laparoscopy, surgeons must be prepared to manage this surgical challenge. Most BDIs are recognized either during the procedure or in the immediate postoperative period. However, some BDIs may be discovered later during the postoperative period, and this may translate to delayed or inappropriate treatments. Providing a specific diagnosis and a precise description of the BDI will expedite the decision-making process and increase the chance of treatment success. Subsequently, the choice and timing of the appropriate reconstructive strategy have a critical role in long-term prognosis. Currently, a wide spectrum of multidisciplinary interventions with different degrees of invasiveness is indicated for BDI management. These World Society of Emergency Surgery (WSES) guidelines have been produced following an exhaustive review of the current literature and an international expert panel discussion with the aim of providing evidence-based recommendations to facilitate and standardize the detection and management of BDIs during cholecystectomy. In particular, the 2020 WSES guidelines cover the following key aspects: (1) strategies to minimize the risk of BDI during cholecystectomy; (2) BDI rates in general surgery units and review of surgical practice; (3) how to classify, stage, and report BDI once detected; (4) how to manage an intraoperatively detected BDI; (5) indications for antibiotic treatment; (6) indications for clinical, biochemical, and imaging investigations for suspected BDI; and (7) how to manage a postoperatively detected BDI.

COVID-19 Changed the Injury Patterns of Hospitalized Patients.

INTRODUCTION: Injury patterns are closely related to changes in behavior. Pandemics and measures undertaken against them may cause changes in behavior; therefore, changes in injury patterns during the coronavirus disease 2019 (COVID-19) outbreak can be expected when compared to the parallel period in previous years. STUDY OBJECTIVE: The aim of this study was to compare injury-related hospitalization patterns during the overall national lockdown period with parallel periods of previous years. METHODS: A retrospective study was completed of all patients hospitalized from March 15 through April 30, for years 2016-2020. Data were obtained from 21 hospitals included in the national trauma registry during the study years. Clinical, demographic, and circumstantial parameters were compared amongst the years of the study. RESULTS: The overall volume of injured patients significantly decreased during the lockdown period of the COVID-19 outbreak, with the greatest decrease registered for road traffic collisions (RTCs). Patients' sex and ethnic compositions did not change, but a smaller proportion of children were hospitalized during the outbreak. Many more injuries were sustained at home during the outbreak, with proportions of injuries in all other localities significantly decreased. Injuries sustained during the COVID-19 outbreak were more severe, specifically due to an increase in severe injuries in RTCs and falls. The proportion of intensive care unit (ICU) hospitalizations did not change, however more surgeries were performed; patients stayed less days in hospital. CONCLUSIONS: The lockdown period of the COVID-19 outbreak led to a significant decrease in number of patients hospitalized due to trauma as compared to parallel periods of previous years. Nevertheless, trauma remains a major health care concern even during periods of high-impact disease outbreaks, in particular due to increased proportion of severe injuries and surgeries.