Colorectal Cancer Care in the Covid-19 Era, Outcomes from a "Mixed Site" Model

Aim: The COVID-19 pandemic has presented many challenges to colorectal cancer (CRC) care. Many organisations opted to perform CRC resections in "cold" sites. Infrastructure in Northumbria Healthcare NHS Foundation Trust (NHCT) necessitated co-locating CRC care with "hot" COVID streams but with additional precautions. This study aimed to evaluate that approach for a consecutive series of CRC cases, diagnosed before and during the COVID-19 pandemic. Method(s): A prospectively populated dataset of CRC patients diagnosed between 01/04/2019 and 30/09/2020 was used. Patients presenting before 01/04/2020 were considered "Pre-COVID" and those subsequently "COVID era". Result(s): Three hundred and forty-four cases were diagnosed in the 12 months "Pre-COVID" and 166 in the 6 months of the "COVID era". The median days from referral to diagnosis (21 vs 20, P = 0.373) and operation (63 vs 61, P = 0.208) were unchanged. The "COVID era" saw an increase in the proportion of radiological diagnoses (39.5% vs 53.0% P = 0.004) with an associated decrease in endoscopic diagnoses (56.7% vs 45.8%, P = 0.021). Rates of inoperable (1.5% vs 1.2%, P = 0.821), obstructing (11.0% vs 16.2%, P = 0.272) and perforated tumours (0.6% vs 1.5%, P = 0.492) remained the same. One patient developed COVID-19 peri-operatively. Rates of laparoscopic operation (59.5% vs 61.8%, P = 0.751), anastomotic leak (6.4% vs 5.9%, P = 0.891), re-operative surgery (10.4% vs 4.4%, P = 0.138), primary stoma (40.5% vs 32.4%, P = 0.244) and 90-day mortality (0.6% vs 1.5%, P = 0.492) did not change. Conclusion(s): With appropriate infection control measures, it may be safe to continue providing standard elective and urgent CRC care without access to a "COVID clean" site.

The implications of a crisis-driven societal shift to online consumption

Currently over half the global population is under some form of social distancing requirement and around 90 countries are experiencing variations of ‘lockdown’. Social Distancing will likely continue for the foreseeable future (until a vaccination is found). Lockdown exit strategies include maintaining social distancing in some form, resulting in a further uptake in technologically enabled consumption. Lockdown and Social Distancing have resulted in a massive shift toward online consumption. This chapter examines the societal implications of this including the effect on the individual, society and the economy. The consumption of goods, services and increasingly experiences online can have significant implications on productivity including querying productivity as an appropriate measure for this connected economy. Individuals find themselves increasingly embedded in a world they don’t necessarily understand whilst at the same time are being disembedded from their familiar consumption patterns. Business models will have to rapidly change and develop to suit this new world. © Philip McCann and Tim Vorley 2021.

Implementing smartphone technology in practice using the Collaborative for Surgical Site Infection Surveillance (CASSIS) project: preliminary finding

Background: Understanding the burden of surgical site infection (SSI) requires comprehensive, reliable and comparable data. However, many hospitals do not routinely collect information on wound healing after the patient leaves hospital. Aim: To evaluate five post-discharge surveillance strategies that collect patient/carer reported outcomes on wound healing following adult and paediatric surgery. Method: Between March 2020 and February 2021, colleagues from five specialist hospitals in England collaborated to collect baseline and compliance data for the different methods of postdischarge surveillance. The five methods included were telephone follow-up;postal questionnaires;postal questionnaires and contacting non-responders by telephone to asking patients to install a postoperative app on their personal smartphone (Medopad, Huma) and using a SSI surveillance text link, which did not need to be installed (Isla, Islacare Ltd). Results: Overall, 1432 patients out of 2116 patients provided information about their wound after discharge. The group of patients who were asked to install an app on their smart device had the lowest return rate for information on their wound, while the system that used a text link and did not need to be installed had one of the highest return rates. Conclusion: Understanding baseline practice and evaluating different methods of discharge surveillance may help to drive improvement in this area. Our early findings suggest that in practice, a SSI surveillance approach using a text link and photos, such as Isla, which is used in hospital before discharge by staff and post-discharge by patients warrants further attention.

New Solutions for the New Normal

The COVID-19 outbreak has disrupted social and economic global norms and accelerated many of the key trends shaping the building industry. The ongoing aftermath of uncertainty has led to a sharp drop in real estate investment volumes and commercial rental prices. Owners/operators and tenants are grappling with several key questions and searching for solutions and strategies on how best to move forward. While the economic impact is unprecedented, with billions of dollars of dry-powder capital in the market and record low interest rates, there are significant possibilities for owners/operators to pivot and take advantage of new opportunities. The design and development community, emerging from the defensive stage of pandemic response to a more forward-looking approach, is responding. This paper explores some of the key questions from the owner/operator community and presents the “New Solutions Toolkit,” a growing collection of holistic, practical solutions for lasting resilience and a roadmap to future opportunity. © 2020, Council on Tall Buildings and Urban Habitat. All rights reserved.

Capturing patient experience to support quality improvement initiatives

Background: Patient experience is core to understanding and improving care. Implementation Science recommends that stakeholders be included in all aspects of Quality Improvement (QI), and extensive involvement of both patients and staff were prioritized in all stages of implementation to date. Patient experience has enhanced QI initiatives of one site within the Spinal Cord Injury (SCI) Implementation and Evaluation Quality Care Consortium. Objective: To describe how patient experience and perspectives were integral to implementation of QI initiatives to support best practices in a tertiary SCI rehabilitation centre. Design: Five Implementation and Evaluation Specialist (IESs) were identified from a range of clinical disciplines to facilitate QI efforts in working with leaders, frontline staff and persons with lived experience. QI in each domain of SCI rehab was started with an iterative process which included patient experience as integral to development and implementation of clinical tools and education materials. It was important to include methods beyond satisfaction ratings, and patient experience was gathered through surveys, interviews, working groups, as well as direct feedback. Participants: Patients in a tertiary academic rehabilitation hospital as well as community members with lived experience. Findings: 106 individuals undergoing inpatient SCI rehabilitation were approached to share their experience, perspectives and personal knowledge of care, to influence QI initiatives and ongoing improvement cycles. Patient experience supported QI in domains of sexual health, tissue integrity and wheeled mobility, as well as for Covid-19 clinical adaptations. Early evidence of success was evident in the documentation completion rates regarding sexual health education, which rose from 30% to 80% upon initial implementation. Tissue integrity and wheeled mobility domains are currently in progress, and patient experience continues to shape QI processes. An unanticipated outcome of IESs' ability to gather patient perspectives in a timely manner was that patient experience could more easily be incorporated into the rapid adaptations in clinical care required during the Covid-19 challenges. Conclusion: Intentionally seeking patient perspectives enabled more meaningful QI activities resulting in a robust foundation for implementing successful practice change and greater staff and patient engagement to ultimately maximize patient and family centred care.

Patient perspectives regarding a 7-day therapy model during the onset of COVID-19

Background: COVID-19 presented unique challenges for patient wellbeing in tertiary SCI rehabilitation settings. Patients had long evening and weekend stretches to occupy themselves while isolated from their family and support network without access to volunteers, peer mentors, recreational outings or weekend passes. Objective: To describe the outcomes of a 7-day therapy model implemented during COVID-19 (Apr-Aug2020) from a patient perspective. Method: The pandemic provided an opportunity to redeploy outpatient staff to the inpatient program, and provide therapy services 7-days/week for 12 hours/day (vs. 5 days/week for 8 hrs) to: 1) enhance physical distancing ;2) intensify inpatient therapy;3) create opportunity to practice skills prior to discharge;4) facilitate daily e-visits (visitor restrictions);5) increase recreation/leisure offerings;and, 6) increase supportive care on units. In total 6 PT's, 4 OT's, 2 Assistive Technology Staff (ATS) were redeployed. Enhanced recreation therapy evening programs (bocce, movies, relaxation, adapted sport, etc.) and extended gym hours were provided. Supports for feeding, laundry, activities of daily living (ADL), 2, and e-visits were established. Leadership team worked extended hours and weekends. Seating clinic staff supported wheelchair prescription and ADP processes. Patient surveys were designed and piloted by the Toronto IES team to evaluate the effectiveness and impact of the enhanced therapy schedule. Data were analyzed by postdoctoral fellows (GJ and RA) using appropriate descriptive statistics or qualitative methods. Participants: Patients & tertiary academic staff. supported wheelchair prescription and ADP processes. Patient surveys were designed and piloted by the Toronto IES team to evaluate the effectiveness and impact of the enhanced therapy schedule. Data were analyzed by postdoctoral fellows (GJ and RA) using appropriate descriptive statistics or qualitative methods. Participants: Patients & tertiary academic staff. Findings: Thirty inpatients, 77% male, 6 paraplegics and 24 tetraplegics, majority of non-traumatic etiology, with a median 57-80 day LOS indicated their preference for a 6-day (vs 7-day) therapy model.Weekend recreational programs had the best attendance, while recreational programming attendance was a predictor of greater program satisfaction. A majority of inpatients indicated their preference for 6-day per week programming indicating they would appreciate a day of relaxation (which could still be therapeutic, just less physical and more recreational perhaps). Conclusion: Temporary redeployment of staff resulted in increased inpatient support services and therapy availability. Study results underscore the importance of role clarity and goal setting, therapeutic recreation services, especially on weekends;the potential value of a 6-day therapy model;and, our reliance on volunteer and family caregiver services, therapeutic and weekend passes as essential components of care.

Colorectal cancer care in the COVID-19 era: outcomes from a 'mixed site' model.

INTRODUCTION: The COVID-19 pandemic has presented many challenges to colorectal cancer (CRC) care. Many organisations opted to perform CRC resections in 'cold' sites. Infrastructure in Northumbria Healthcare NHS Foundation Trust (NHCT) necessitated co-locating CRC care with 'hot' COVID streams but with additional precautions. This study aimed to evaluate that approach for a consecutive series of CRC cases, diagnosed before and during the COVID-19 pandemic. METHODS: A prospectively populated data set of CRC patients diagnosed between 1 April 2019 and 30 September 2020 was used. Patients presenting before 1 April 2020 were considered 'pre-COVID' and those presenting subsequently as 'COVID era'. RESULTS: Some 344 cases were diagnosed in the 12 months 'pre-COVID' and 166 in the 6 months of the 'COVID era'. The median numbers of days from referral to diagnosis (21 vs 20, p=0.373) and operation (63 vs 61, p=0.208) were unchanged. The 'COVID era' saw an increase in the proportion of radiological diagnoses (39.5% vs 53.0%, p=0.004) with an associated decrease in endoscopic diagnoses (56.7% vs 45.8%, p=0.021). Rates of inoperable (1.5% vs 1.2%, p=0.821), obstructing (11.0% vs 16.2%, p=0.272) and perforated tumours (0.6% vs 1.5%, p=0.492) remained the same. One patient developed COVID-19 perioperatively. Rates of laparoscopic operation (59.5% vs 61.8%, p=0.751), anastomotic leak (6.4% vs 5.9%, p=0.891), re-operative surgery (10.4% vs 4.4%, p=0.138), primary stoma (40.5% vs 32.4%, p=0.244) and 90-day mortality (0.6% vs 1.5%, p=0.492) did not change. CONCLUSIONS: With appropriate infection control measures, it may be safe to continue providing standard elective and urgent CRC care without access to a 'COVID clean' site.

Colorectal Cancer Care in the COVID-19 Era;Keep Calm and Carry On?

Background: The COVID-19 pandemic has presented many challenges to Colorectal Cancer (CRC) care. Many organisations opted to perform CRC resections in “cold” sites. Trust infra-structure necessitated co-locating CRC care with “hot” COVID streams, but additional precautions were used (self-isolating pre-operatively, PCR testing of patients and staff and suspension of visiting). Aims: To compare the process of, and outcomes from, care for a consecutive series of newly diagnosed CRC cases before and during the COVID-19 pandemic. Methods: A prospectively populated dataset of CRC patients diagnosed between 01/04/2019 to 30/09/2020. Patients presenting before 01/04/2020 were considered “Pre-COVID” and those on or after that date “COVID era”. Results: Three hundred and forty-four cases were diagnosed in the 12 months “Pre-COVID” and 166 in the 6 months of the “COVID era”. Time to diagnosis and surgical resection were unchanged. The “COVID era” saw an increase in the proportion of radiologically diagnosed CRCs (39.5% vs 53.0% P = 0.004) but a decrease in the proportion of those diagnosed endoscopically (56.7% vs 45.8%, P = 0.021). Rates of inoperable (1.5% vs 1.2%, P = 0.821), obstructing (11.0% vs 16.2%, P = 0.272) and perforated tumours (0.6% vs 1.5%, P = 0.492) remained the same. One patient developed COVID-19 peri-operatively. Rates of laparoscopically completed operation (59.5% vs 61.8%, P = 0.751), anastomotic leak (6.4% vs 5.9%, P = 0.891), re-operative surgery (10.4% vs 4.4%, P = 0.138), primary stoma (40.5% vs 32.4%, P = 0.244) and 90-day mortality (0.6% vs 1.5%, P = 0.492) did not change. Conclusions: With appropriate infection control measures, it may be safe to continue providing standard elective and urgent CRC care.

Identifying the barriers and the solutions to surgical endoscopy training. A national online survey of UK trainee experience

Purpose: Gaining training and accreditation in endoscopy is a challenge for surgical trainees. We aimed to understand the barriers to training by conducting a national survey. Methods: A 39-question online survey was disseminated to higher surgical trainees in the UK using www.surve ymonk ey.com via surgical associations and regional surgical program directors. Results: There were 102 responses, with a 79% completion rate, from across 14 different deaneries in all 4 nations of the UK. 55.7% (54/97) of respondents declared an interest in Colorectal Surgery. 89.7% (70/78) of those surveyed felt that they faced challenges in gaining endoscopy training. The main challenges to training were: On call commitments conflicted with endoscopy training -75.6% (59/78) Effect of the COVID pandemic -89.9% (71/79) Lack of allocated endoscopic sessions on rota -75.6% (59/78) An endoscopy session less than once a week -41.9% (13/31) Lack of dedicated endoscopy training lists -70.5% (55/78) Competition for training opportunities with non-surgical trainees (gastroenterology trainees and nurses) -66.7% (52/78) Insufficient support from the deanery regarding endoscopy training -51.3% (40/78). Lack of access to a certified endoscopic trainer -35% (28/80). No named endoscopic training supervisor -63% (51/81) Need to attend non-training sessions to improve their training -65.4% (51/78) No opportunity for endoscopic training with a medical gastroenterologist -71.3% (57/80) Conclusions: Innovative solutions such as dedicated blocks of training, equity of access to JAG courses, e-learning modules, the development of a Reginal Endoscopy TPD role and Surgical Endoscopy Fellowships are required to tackle this multifactorial issue.

A comparison of clinical and pathological TNM staging in a COVID-19 era

Presented by: Sophie Mills (sophiemills20@outlook.com) Introduction The TNM Classification is the global standard for staging of head and neck cancers. Accurate clinical-radiological staging of tumours (cTNM) is essential to predict prognosis, facilitate surgical planning and determine the need for other therapeutic modalities. This study aims to determine the accuracy of pre-operative cTNM staging using pathological TNM (pTNM) and consider possible causes of TNM stage migration, noting any variation throughout the COVID-19 pandemic. Materials and Methods A retrospective cohort study examined records of patients with surgical management of head and neck cancer at a tertiary head and neck centre from November 2019 to November 2020. Data was extracted from Somerset Cancer Registry and histopathology reports. cTNM and pTNM were compared before and during the first wave of COVID-19, as well as with other potential prognostic factors such as tumour site and tumour stage. Results 119 cases were identified, of which 52.1% (n = 62) were male and 47.9% (n = 57) were female with a mean age of 67 years. Clinical and pathological staging differed in 54.6% (n = 65) of cases. Of the patients with stage migration, 40.4% (n = 23) were up-staged and 59.6% (n = 34) were down-staged compared with pTNM. There was no significant difference in accuracy of cTNM staging compared with age, sex, or tumour site. There was a statistically highly significant (p < 0.001) correlation between cTNM accuracy and tumour stage, with the accuracy of cTNM staging decreasing with advancement of pTNM staging. No statistically significant variation was noted between patients staged prior to and during COVID-19. Conclusions Discrepancies in staging can impact management and outcomes for patients. This study found that the higher the pTNM, the more likely stage migration will occur. These findings are concordant with the oncology literature, which highlights the need to improve the accuracy of cTNM staging for more advanced tumours.

Virtual clinics the future of thrombosis and anticoagulant consultations? A patient preference survey

Content: The COVID-19 pandemic onset in March 2020 resulted in the rapid implementation of virtual clinics throughout the NHS to minimise infection transmission in hospitals. This transformation may become permanent after the pandemic, in line with the NHS Long Term Plan (2019). This envisaged the increasing use of virtual/remote (telephone and video) Attend Anywhere consultations to improve convenience for patients, enhance clinic capacity, and more productive use of consultant time. Despite these potential benefits, there is limited research into the safety, acceptability and suitability of virtual/remote clinics for patients in different clinical services. We evaluated patient preferences and feasibility for the future use of virtual/remote consultations by conducting a telephone survey of patients remotely attending' thrombosis and anticoagulation clinics at a single London NHS Trust during the COVID-19 pandemic. At the end of each telephone consultation, patients were asked two questions: (1) In the current climate of the COVID-19 pandemic, what would your preference be in terms of being seen in future clinics face to face, video or telephone?', (2) Do you have access to a smartphone or computer that you could use with video consultations in the future or can you get support from a family member/friend to do this?' Patient preferences were analysed by median age group, gender, and new/follow-up status. A total of 51 patients [23 females (45.1%) and 28 males (54.9%)] were surveyed. Median age was 65.5 years (range 23 100 years). There were 16 new and 35 follow-up patients with 42 patients attending consultant-led thrombosis clinics and 9 attending nurse/pharmacist-led anticoagulant clinics. 42 patients were seen because of venous thromboembolism (VTE), 6 because of atrial fibrillation (AF), and 3 for other conditions. 45 patients (88.2%) preferred a specific type of consultation and 6 patients (11.8%) showed no preference. 33 of 45 patients (64.7%) preferred virtual/remote consultation, whereas 12 patients (23.5%) preferred face-to-face contact. Out of the 33 patients who preferred a virtual/remote consultation, 17 (33.3%) preferred only telephone, 8 (15.7%) preferred only video, and 8 (15.7%) preferred either video or telephone. These proportions were similar in females and males, aged under and over 65, and new compared to follow-up patients. 37 patients (72.5%) had access to a smartphone or computer. Median age of patients who had access was 65.5 years (range 23-91 years), and in patients who did not have access was 76.0 years (range 29-100 years). The majority of patients preferred virtual/remote consultations for the future. Telephone consultations appeared more popular than video consultations, despite most patients having access to a smartphone or computer. The findings may be influenced by the methodology of the survey being conducted at the end of a phone consultation and during the COVID-19 pandemic. Remote/virtual thrombosis clinics seem likely to continue for many patients after the COVID pandemic. Further research is needed to identify the factors that determine individual patient preferences and the clinical implications and safety of different types of consultation.

Performance of urodynamics during the COVID-19 pandemic: A questionnaire survey

Aims The principal aim of this multicentre, international cohort study is to explore the safety concerns of clinicians when performing urodynamic studies (UDS) during the COVID-19 pandemic. This study will also assess provider preference on personal protective equipment (PPE) during UDS and awareness of relevant international guidelines. The outcome is to offer a practical means of reducing the risk of aerosol transmission during UDS, to include a protocol for screening patients, and to consider safer methods of inducing urethral leak-point pressure. Methods A 14-point, multiple-response, online questionnaire was designed through Survey Monkey. This was dis-tributed to healthcare workers involved in UDS via email, WhatsApp, and Twitter. This included, of varying experience;urologists, urogynaecologists, clinical nurse specialists, and clinical scientists across the United Kingdom (UK), United States of America (USA), Australia, Europe, and Middle-East. Results The study was conducted over two weeks and there were 104 responses to the survey. The majority of respondents were consultants (60%) and 73% of respondents performed UDS regularly. There were 56.7% of respondents who felt that UDS was safe to be re-instated and there were 52.8% who did not feel coughing was safe during the procedure. At the time of the survey, 83.5% were unaware of any national or international urological guidelines on the best practice for urodynamics during this era and 52.8% of clinicians stated they would wear PPE during UDS if it were reinstated. Conclusion The majority of respondents felt safe to reinstate UDS;however, they felt more official guidance and recommendation is needed. Our proposed protocol can provide a safe and practical approach that keeps healthcare workers and patients safe.