Demographic Disparity in Use of Telemedicine for Ambulatory General Surgical Consultation During the COVID-19 Pandemic: Analysis of the Initial Public Health Emergency and Second Phase Periods.

BACKGROUND: Surgical patients with limited digital literacy may experience reduced telemedicine access. We investigated racial/ethnic and socioeconomic disparities in telemedicine compared with in-person surgical consultation during the coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Retrospective analysis of new visits within the Division of General & Gastrointestinal Surgery at an academic medical center occurring between March 24 through June 23, 2020 (Phase I, Massachusetts Public Health Emergency) and June 24 through December 31, 2020 (Phase II, relaxation of restrictions on healthcare operations) was performed. Visit modality (telemedicine/phone vs in-person) and demographic data were extracted. Bivariate analysis and multivariable logistic regression were performed to evaluate associations between patient characteristics and visit modality. RESULTS: During Phase I, 347 in-person and 638 virtual visits were completed. Multivariable modeling demonstrated no significant differences in virtual compared with in-person visit use across racial/ethnic or insurance groups. Among patients using virtual visits, Latinx patients were less likely to have video compared with audio-only visits than White patients (OR, 0.46; 95% CI 0.22-0.96). Black race and insurance type were not significant predictors of video use. During Phase II, 2,922 in-person and 1,001 virtual visits were completed. Multivariable modeling demonstrated that Black patients (OR, 1.52; 95% CI 1.12-2.06) were more likely to have virtual visits than White patients. No significant differences were observed across insurance types. Among patients using virtual visits, race/ethnicity and insurance type were not significant predictors of video use. CONCLUSION: Black patients used telemedicine platforms more often than White patients during the second phase of the COVID-19 pandemic. Virtual consultation may help increase access to surgical care among traditionally under-resourced populations.

Effect of COVID-19 Pandemic Restructuring on Surgical Volume and Outcomes of Non-COVID Patients Undergoing Surgery.

OBJECTIVES: COVID-19 has caused significant surgical delays as institutions minimize patient exposure to hospital settings and utilization of health care resources. We aimed to assess changes in surgical case mix and outcomes due to restructuring during the pandemic. METHODS: Patients undergoing surgery at a single tertiary care institution in the Deep South were identified using institutional ACS-NSQIP data. Primary outcome was case mix. Secondary outcomes were post-operative complications. Chi-square, ANOVA, logistic regression, and linear regression were used to compare the control (pre-COVID, Mar 2018-Mar 2020) and case (during COVID, Mar 2020-Mar 2021) groups. RESULTS: Overall, there were 6912 patients (control: 4,800 and case: 2112). Patients were 70% white, 29% black, 60% female, and 39% privately insured. Mean BMI was 30.2 (SD = 7.7) with mean age of 58.3 years (SD = 14.8). Most surgeries were with general surgery (48%), inpatient (68%), and elective (83%). On multivariable logistic regression, patients undergoing surgery during the pandemic were more likely to be male (OR: 1.14) and in SIRS (OR: 2.07) or sepsis (OR: 2.28) at the time of surgery. Patients were less likely to have dyspnea with moderate exertion (OR: .75) and were less dependent on others (partially dependent OR: .49 and totally dependent OR: .15). Surgeries were more likely to be outpatient (OR: 1.15) and with neurosurgery (OR: 1.19). On bivariate analysis, there were no differences in post-operative outcomes. CONCLUSION: Surgeries during the COVID-19 pandemic were more often outpatient without differences in post-operative outcomes. Additional analysis is needed to determine the impact of duration of operative delay on surgical outcomes with restructuring focusing more on outpatient surgeries.

Telemedicine in surgery during COVID-19 pandemic: are we doing enough?

INTRODUCTION: The aim of this systematic review was to report and to analyze if there is and what is the impact of telemedicine in the surgical practice during COVID-19 pandemic. Many authors have posited that the pandemic urged a high implementation of the telemedicine service even in surgical specialties, however, the impact of this change of the clinical practice has been variably reported and its utilization in general surgery is uncertain. EVIDENCE ACQUISITION: All articles from any country written in English, Italian, Spanish, or French, about the use of telemedicine for indication to surgical treatment or for 30-day postoperative follow-up in general surgery during the COVID 19 outbreak, from the March 1, 2020, to December 1, 2020, were included. EVIDENCE SYNTHESIS: Two hundred nine articles were fully analyzed, and 207 further articles were excluded. Finally, 2 articles, both published in October 2020, were included in the present systematic review. CONCLUSIONS: In conclusion, the rapid spread of SARS-CoV-2 pandemic has forced to review the traditional methods to deliver surgical assistance and urged surgeons to find alternative methods to continue their practice. The literature about this topic is yet scarce and many questions regarding its efficacy in improving patients' health, cost-effectiveness and user satisfaction remain unsolved.

The Association between Nursing Skill Mix and Mortality for Adult Medical and Surgical Patients: Protocol for a Systematic Review.

Skill mix refers to the number and educational experience of nurses working in clinical settings. Authors have used several measures to determine the skill mix, which includes nurse-to-patient ratio and the proportion of baccalaureate-prepared nurses. Observational studies have tested the association between nursing skill mix and patient outcomes (mortality). To date, this body of research has not been subject to systematic review or meta-analysis. The aim of this study is to systematically review and meta-analyse observational and experimental research that tests the association between nursing skill mix and patient mortality in medical and surgical settings. We will search four key electronic databases-MEDLINE [OVID], EMBASE [OVID], CINAHL [EBSCOhost], and ProQuest Central (five databases)-from inception. Title, abstract, and full-text screening will be undertaken independently by at least two researchers using COVIDENCE review management software. We will include studies where the authors report an association between nursing skill mix and outcomes in adult medical and surgical inpatients. Extracted data from included studies will consist measures of nursing skill mix and inpatient mortality outcomes. A meta-analysis will be undertaken if there are at least two studies with similar designs, exposures, and outcomes. The findings will inform future research and workforce planning in health systems internationally.

Are surgical and non-operating room intervention safe in the COVID-19 pandemic? A retrospective study.

Little is known about the impact of COVID-19 on the outcomes of patients undergoing surgery and intervention. This study was conducted between 20 March and 20 May 2020 in six hospitals in Istanbul, and aimed to investigate the effects of surgery and intervention on COVID-19 disease progression, intensive care (ICU) need, mortality and virus transmission to patients and healthcare workers. Patients were examined in three groups: group I underwent emergency surgery, group II had an emergency non-operating room intervention, and group III received inpatient COVID-19 treatment but did not have surgery or undergo intervention. Mortality rates, mechanical ventilation needs and rates of admission to the ICU were compared between the three groups. During this period, patient and healthcare worker transmissions were recorded. In total, 1273 surgical, 476 non-operating room intervention patients and 1884 COVID-19 inpatients were examined. The rate of ICU requirement among patients who had surgery was nearly twice that for inpatients and intervention patients, but there was no difference in mortality between the groups. The overall mortality rates were 2.3% in surgical patients, 3.3% in intervention patients and 3% in inpatients. COVID-19 polymerase chain reaction positivity among hospital workers was 2.4%. Only 3.3% of infected frontline healthcare workers were anaesthesiologists. No deaths occurred among infected healthcare workers. We conclude that emergency surgery and non-operating room interventions during the pandemic period do not increase postoperative mortality and can be performed with low transmission rates.

Impact of the COVID-19 Pandemic on Emergency Adult Surgical Patients and Surgical Services: An International Multi-center Cohort Study and Department Survey.

OBJECTIVES: The PREDICT study aimed to determine how the COVID-19 pandemic affected surgical services and surgical patients and to identify predictors of outcomes in this cohort. BACKGROUND: High mortality rates were reported for surgical patients with COVID-19 in the early stages of the pandemic. However, the indirect impact of the pandemic on this cohort is not understood, and risk predictors are yet to be identified. METHODS: PREDICT is an international longitudinal cohort study comprising surgical patients presenting to hospital between March and August 2020, conducted alongside a survey of staff redeployment and departmental restructuring. A subgroup analysis of 3176 adult emergency patients, recruited by 55 teams across 18 countries is presented. RESULTS: Among adult emergency surgical patients, all-cause in-hospital mortality (IHM) was 3.6%, compared to 15.5% for those with COVID-19. However, only 14.1% received a COVID-19 test on admission in March, increasing to 76.5% by July.Higher Clinical Frailty Scale scores (CFS >7 aOR 18.87), ASA grade above 2 (aOR 4.29), and COVID-19 infection (aOR 5.12) were independently associated with significantly increased IHM.The peak months of the first wave were independently associated with significantly higher IHM (March aOR 4.34; April aOR 4.25; May aOR 3.97), compared to non-peak months.During the study, UK operating theatre capacity decreased by a mean of 63.6% with a concomitant 27.3% reduction in surgical staffing. CONCLUSION: The first wave of the COVID-19 pandemic significantly impacted surgical patients, both directly through co-morbid infection and indirectly as shown by increasing mortality in peak months, irrespective of COVID-19 status.Higher CFS scores and ASA grades strongly predict outcomes in surgical patients and are an important risk assessment tool during the pandemic.

Characterizing the social media footprint of general surgery residency programs.

BACKGROUND: The medical community has increasingly embraced social media for a variety of purposes, including trainee education, research dissemination, professional networking, and recruitment of trainees and faculty. Platform choice and usage patterns appear to vary by specialty and purpose, but few studies comprehensively assess programs' social media presence. Prior studies assessed general surgery departments' Twitter use but omitted additional social media platforms and residency-specific accounts. OBJECTIVE: This study sought to broadly characterize the social media footprint of U.S. general surgery residency programs. METHODS: Using a protocolized search of program websites, social media platforms (Twitter, Facebook, Instagram, LinkedIn), and internet search, cross-sectional data on social media usage in March 2020 were collected for programs, their affiliated departments, their program directors (PDs), and their assistant/associate PDs (APDs). RESULTS: 318 general surgery residency programs, 313 PDs, and 296 APDs were identified. 47.2% of programs had surgery-specific accounts on ≥1 platform. 40.2% of PDs and APDs had ≥1 account on Twitter and/or LinkedIn. Program type was associated with social media adoption and Twitter utilization, with lower usage among university-affiliated and independent programs (p<0.01). CONCLUSIONS: Most general surgery residencies, especially non-university-based programs, lacked any department or residency accounts across Twitter, Facebook, and Instagram by March 2020. These findings highlight opportunities for increased social media engagement and act as a pre-pandemic baseline for future investigations of how the shift to virtual trainee education, recruitment, conferences, and clinical care affect social media use.

Adapting an emergency general surgery service in response to the COVID-19 pandemic.

INTRODUCTION: In response to the COVID-19 pandemic, our emergency general surgery (EGS) service underwent significant restructuring, including establishing an enhanced ambulatory service and undertaking nonoperative management of selected pathologies. The aim of this study was to compare the activity of our EGS service before and after these changes. METHODS: Patients referred by the emergency department were identified prospectively over a 4-week period beginning from the date our EGS service was reconfigured (COVID) and compared with patients identified retrospectively from the same period the previous year (Pre-COVID), and followed up for 30 days. Data were extracted from handover documents and electronic care records. The primary outcomes were the rate of admission, ambulation and discharge. RESULTS: There were 281 and 283 patients during the Pre-COVID and COVID periods respectively. Admission rate decreased from 78.7% to 41.7%, while there were increased rates of ambulation from 7.1% to 17.3% and discharge from 6% to 22.6% (all p<0.001). For inpatients, mean duration of admission decreased (6.9 to 4.8 days), and there were fewer operative or endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39) and telephone reviews (0 to 39), while early computed tomography scan was increasingly used to facilitate discharge (5% vs 34.7%). There were no differences in 30-day readmission or mortality. CONCLUSIONS: Restructuring of our EGS service in response to COVID-19 facilitated an increased use of ambulatory services and imaging, achieving a decrease of 952 inpatient bed days in this critical period, while maintaining patient safety.

Operative Shutdown and Recovery: Restructuring Surgical Operations During the SARS-CoV-2 Pandemic.

BACKGROUND: During the 2020 SARS-CoV-2 outbreak in New York City, hospitals canceled elective surgeries to increase capacity for critically ill patients. We present case volume data from our community hospital to demonstrate how this shutdown affected surgical care. METHODS: Between March 16 and June 14, 2020, all elective surgeries were canceled at our institution. All procedures performed during this operating room shutdown (ORS) were logged, as well as those 4 weeks before (PRE) and 4 weeks after (POST) for comparison. RESULTS: A total of 2,475 cases were included in our analysis, with 754 occurring during shutdown. Overall case numbers dropped significantly during ORS and increased during recovery (mean 245.0 ± 28.4 PRE versus 58.0 ± 30.9 ORS versus 186.0±19.4 POST cases/wk, P< 0.001). Emergency cases predominated during ORS (26.4% PRE versus 59.3% ORS versus 31.5% POST, P< 0.001) despite decreasing in frequency (mean 64.5 ± 7.9 PRE versus 34.4 ± 12.1 ORS versus 58.5 ± 4.0 POST cases/wk, P< 0.001). Open surgeries remained constant in all three phases (52.2-54.1%), whereas laparoscopic and robotic surgeries decreased (-3.4% and -3.0%, P< 0.001). General and/or vascular surgery, urology, and neurosurgery comprised a greater proportion of caseload (+9.5%, +3.0%, +2.8%), whereas orthopedics, gynecology, and otolaryngology/plastic surgery all decreased proportionally (-5.0%, -4.4%, -5.9%, P< 0.001). CONCLUSION: Operative volume significantly decreased during the SARS-CoV-2 outbreak. Emergency cases predominated during this time, although there were fewer emergency cases overall. General/vascular surgery became the most active service and open surgeries became more common. This reallocation of resources may be useful for future crisis planning among community hospitals.

Impact of a global pandemic on surgical education and training- review, response, and reflection.

The catastrophic effects of the coronavirus disease-2019 global pandemic have revolutionised human society. The unprecedented impact on surgical training needs to be analysed in detail to achieve an understanding of how to deal with similar situations arising in the foreseeable future. The challenges faced by the surgical community initiated with the suspension of clinical activities and elective practice, and included the lack of appropriate personal protective equipment, and the self-isolation of trainees and reassignment to coronavirus patient-care regions. Together, all these elements had deleterious effects on the psychological health of the professionals. Surgical training irrespective of specialty is equally affected globally by the pandemic. However, the global crisis inadvertently has led to a few constructive adaptations in healthcare systems, including the development of tele-clinics, virtual academic sessions and conferences, and increased usage of simulation. The current review article was planned to highlight the impact of corona virus disease on surgical training and institutions' response to the situation in order to continue surgical training, and lessons learnt from the pandemic.

The volume of general surgery emergency cases in a government hospital during the COVID-19 pandemic and two other periods: a comparative, retrospective study.

BACKGROUND: During March and April 2020, reductions in non-COVID-19 hospital admissions were observed around the world. Elective surgeries, visits with general practitioners, and diagnoses of medical emergencies were consequently delayed. OBJECTIVE: To compare the characteristics of patients admitted to a northern Israeli hospital with common surgical complaints during three periods: the lockdown due to the COVID-19 outbreak, the Second Lebanon War in 2006, and a regular period. METHODS: Demographic, medical, laboratory, imaging, intraoperative, and pathological data were collected from electronic medical files of patients who received emergency treatment at the surgery department of a single hospital in northern Israel. We retrospectively compared the characteristics of patients who were admitted with various conditions during three periods. RESULTS: Patients' mean age and most of the clinical parameters assessed were similar between the periods. However, pain was reportedly higher during the COVID-19 than the control period (8.7 vs. 6.4 on a 10-point visual analog scale, P < 0.0001). During the COVID-19 outbreak, the Second Lebanon War, and the regular period, the mean numbers of patients admitted daily were 1.4, 4.4, and 3.0, respectively. The respective mean times from the onset of symptoms until admission were 3, 1, and 1.5 days, P < 0.001. The respective proportions of surgical interventions for appendiceal disease were 95%, 96%, and 69%; P = 0.03. CONCLUSIONS: Compared to a routine period, patients during the COVID-19 outbreak waited longer before turning to hospitalization, and reported more pain at arrival. Patients during both emergency periods were more often treated surgically than non-operatively.

The reduction in clinical and surgical exposure of trainees during COVID-19 and its impact on their training.

OBJECTIVE: To assess the impact of coronavirus disease on surgical training. Methods: The cross-sectional study was conducted at the General Surgery Department of Liaquat National Hospital, Karachi, from August 2019 to May 2020, and comprised surgical trainees from year 1 to 4. The subjects were interviewed and inquired about their opinion regarding the impact of coronavirus disease on their training. Data was prospectively collected in two equal phases of 5 months each, separating the phases on the basis of the application of preventive measures and changes relating to coronavirus disease. Data of cases from log books was divided into major and minor cases. RESULTS: Of the 24 surgical trainees available, 18(75%) participated; 12(66.6%) females and 6(33.3%) males. There was a significant difference between the two phases, with the number of surgical case going down drastically in the second phase (p=0.005), affecting the training process. CONCLUSIONS: Considering the ongoing pandemic, it may be worthwhile to look into the possibility of increasing the duration of training.

Impact of the SARS-CoV-2 pandemic on emergency surgery services-a multi-national survey among WSES members.

BACKGROUND: The SARS-CoV-2 pandemic is a major challenge for health care services worldwide. It's impact on oncologic therapies and elective surgery has been described recently, and the literature provides guidelines regarding appropriate elective patient treatment during the pandemic. However, the impact of SARS-CoV-2 pandemic on emergency surgery services has been poorly investigated up to now. METHODS: A 17-item web survey had been distributed to emergency surgeons in June 2020 around the world, investigating the impact of SARS-CoV-2 pandemic on patients and septic diseases both requiring emergency surgery and the time-to-intervention in emergency surgery routine, as well as experiences with surgery in COVID-19 patients. RESULTS: Ninety-eight collaborators from 31 countries responded to the survey. The majority (65.3%) estimated the impact of the SARS-CoV-2 pandemic on emergency surgical patient care as being strong or very strong. Due to the pandemic, 87.8% reported a decrease in the total number of patients undergoing emergency surgery and approximately 25% estimated a delay of more than 2 h in the time-to-diagnosis and another 2 h in the time-to-intervention. Fifty percent make structural problems with in-hospital logistics (e.g. transport of patients, closed normal wards etc.) mainly responsible for delayed emergency surgery and the frequent need (56.1%) for a triage of emergency surgical patients. 56.1% of the collaborators observed more severe septic abdominal diseases during the pandemic, especially for perforated appendicitis and severe septic cholecystitis (41.8% and 40.2%, respectively). 62.2% had experiences with surgery in COVID-19-infected patients. CONCLUSIONS: The results of The WSES COVID-19 emergency surgery survey are alarming. The combination of an estimated decrease in numbers of emergency surgical patients and an observed increase in more severe septic diseases may be a result of the fear of patients from infection with COVID-19 and a consecutive delayed hospital admission and diagnosis. A critical delay in time-to-diagnosis and time-to-intervention may be a result of changes in in-hospital logistics and operating room as well as intensive care capacities. Both reflect the potentially harmful impact of SARS-CoV-2 pandemic on emergency surgery services.

Prioritizing resident and patient safety while maintaining educational value: emergency restructuring of a Canadian surgical residency program during COVID-19.

Summary: Surgical programs are facing major and fluctuating changes to the resident workforce because of decreased elective volumes and high exposure risk during the coronavirus disease 2019 pandemic. Rapid restructuring of a residency program to protect its workforce while maintaining educational value is imperative. We describe the experience of the Division of General Surgery at the University of Ottawa in Ontario, Canada. The residency program was restructured to feature alternating "on" and "off" weeks, maintaining a healthy resident cohort in case of exposure. Teams were restructured and subdivided to maximize physical distancing and minimize resident exposure to pathogens. Educational initiatives doubled, with virtual sessions targeting every resident year and incorporating intraoperative teaching. The divisional research day and oral exams proceeded uninterrupted, virtually. A small leadership team enabled fast and flexible restructuring of a system for patient care while prioritizing resident safety and maintaining a commitment to resident education in a pandemic.

Dramatic decrease of surgical emergencies during COVID-19 outbreak.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) outbreak, a general decrease in surgical activity was observed. There is perception that this phenomenon has involved also surgical emergency, but no extensive data have been presented to date. The aim of this study was to analyze the real number of admissions and procedures for emergency surgical disease during COVID-19 pandemic. METHODS: This is a multicenter study including 18 general surgery units performing emergency surgery in hospitals of the "Red Zone" in Lombardy. Data about admissions from emergency department and surgical emergency procedures performed during March 2019 and March 2020 were collected in an online database. Additional data were collected according to the different indications for surgical treatment. The primary outcomes were the overall rate of admissions for emergent surgical disease and the overall rate of emergency surgical procedures in the study periods. The secondary outcome was the overall surgical rates (among all the diagnosed surgical diseases). RESULTS: Emergency surgical admissions and surgical operations significantly decreased with a fall in value of 45% (p < 0.001) and 41% (p = 0.001), respectively. This reduction was confirmed by the analysis according to different surgical indications, with the exceptions of admissions and operations for gastrointestinal bleeding and operations for abdominal trauma. The overall ratio between surgical procedures and diseases was not significantly different (54% vs. 63%; p = 0.619). This ratio was significantly different only for bowel obstruction and for gastrointestinal perforation. CONCLUSIONS: It seems correct to consider "true" the dramatic decrease of surgical problems during COVID-19 outbreak, despite any therapeutic strategies and logistic difficulties. LEVEL OF EVIDENCE: Epidemiological, level III.

Spine Surgery in Italy in the COVID-19 Era: Proposal for Assessing and Responding to the Regional State of Emergency.

In December 2019, coronavirus disease 2019 (COVID-19) was discovered in Wuhan, Hubei province, from where it spread rapidly worldwide. COVID-19 characteristics (increased infectivity, rapid spread, and general population susceptibility) pose a great challenge to hospitals. Infectious disease, pulmonology, and intensive care units have been strengthened and expanded. All other specialties have been compelled to suspend or reduce clinical and elective surgical activities. The profound effects on spine surgery call for systematic approaches to optimizing the diagnosis and treatment of spinal diseases. Based on the experience of one Italian region, we draw an archetype for assessing the current and predicted level of stress in the health care system, with the aim of enabling hospitals to make better decisions during the pandemic. Further, we provide a framework that may help guide strategies for adapting surgical spine care to the conditions of epidemic surge.