COVID-19: Adapting to change, general surgery at a district general hospital in the United Kingdom

The Coronavirus pandemic has caused major change across the world and in the National Health Service. In order to cope and help limit contagion, numerous institutions recognised the need to adjust clinical practice quickly yet safely. In this paper, we aim to describe the changes implemented in a general surgery department at a district general hospital in the United Kingdom. Across the surgical specialties, frameworks, protocols and guidelines have been established locally and nationally. The aerosol generating procedures involved in general surgery required us to alter our daily activities. Modifications to patient management were necessary to try and reduce viral spread. Staff wellbeing was heavily promoted in order to help maintain the frontline workforce. A holistic approach was required.

Impact of COVID-19 on maintenance peritoneal dialysis patients and providers: A review.

The COVID-19 pandemic exerted complex pressures on the nephrology community. Despite multiple prior reviews on acute peritoneal dialysis during the pandemic, the effects of COVID-19 on maintenance peritoneal dialysis patients remain underexamined. This review synthesizes and reports findings from 29 total cases of chronic peritoneal dialysis patients with COVID-19, encompassing 3 case reports, 13 case series, and 13 cohort studies. When available, data for patients with COVID-19 on maintenance hemodialysis are also discussed. Finally, we present a chronological timeline of evidence regarding the presence of SARS-CoV-2 in spent peritoneal dialysate and explore trends in telehealth as they relate to peritoneal dialysis patients during the pandemic. We conclude that the COVID-19 pandemic has underscored the efficacy, flexibility, and utility of peritoneal dialysis.

Impact of the COVID-19 pandemic on the management and outcomes of emergency surgical patients: A retrospective cohort study.

INTRODUCTION: The COVID-19 pandemic has led to drastic measures being implemented for the management of surgical patients across all health services worldwide, including the National Health Service in the United Kingdom. It is suspected that the virus has had a detrimental effect on perioperative morbidity and mortality. Therefore, the aim of this study was to assess the impact of the COVID-19 pandemic on these outcomes in emergency general surgical patients. METHODS: Emergency general surgical admissions were included in this retrospective cohort study in one of the COVID-19 hotspots in the South East of England. The primary outcome was the 30-day mortality rate. Secondary outcomes included the length of stay in hospital, complication rate and severity grade and admission rates to the ITU. RESULTS: Of 123 patients, COVID-19 was detected in 12.2%. Testing was not carried out in 26%. When comparing COVID-positive to COVID-negative patients, the mean age was 71.8 + 8.8 vs. 50.7 + 5.7, respectively, and female patients accounted for 40.0 vs. 52.6%. The 30-day mortality rate was 26.7 vs. 3.9 (OR 6.49, p = 0.02), respectively. The length of stay in hospital was 20.5 + 22.2 vs. 7.7 + 9.8 (p < 0.01), the rate of complications was 80.0 vs. 23.7 (OR 12.9, p < 0.01), and the rate of admission to the ITU was 33.3 vs. 7.9% (OR 5.83, p = 0.01). CONCLUSION: This study demonstrates the detrimental effect of COVID-19 on emergency general surgery, with significantly worsened surgical outcomes.

‘Feel Good Factor’: Positive recognition impacted staff morale, encouraged juniors and led to the overall departmental development during the COVID-19 pandemic

Aims Low doctor morale and mental well-being is associated with poor patient care, especially during the COVID-19 pandemic. We report on a local initiative, Feel Good Factor (FGF), and its impact on doctors and the department. Methods FGF is a monthly presentation at the departmental meeting implemented at WHH, started in December 2019;where kind acts are applauded. A 10-item questionnaire was distributed to doctors working in two Surgery Departments (WHH and QEQM) in May 2021. Questionnaires collected demographic data, awareness of both positive/negative events and mental well-being using Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS). Data was collected on audits, QIP's, sickness due to mental health, junior progression and publications. Results 48 doctors responded (58.3% QEQM). There was no significant difference in overall WEMWBS score. Doctors in the WHH department were more decisive (70% vs 25%, p = 0.043);positive incident reporting was higher at WHH (25.0% vs 0.0%, p = 0.025). A trust-wide record number of 45 audits, 22 publications, 6 national studies and 11 juniors progressed in 2020. Patient clinical marker of NELA mortality was one of the least. There was no sickness leave due to mental health. FGF was also shortlisted for the annual BMJ awards. Conclusion FGF is associated with increased awareness of positive events. Improved doctor morale led to widespread participation in projects and departmental output leading to national recognition. Initiatives such as FGF should be encouraged and advertised to other departments, to improve the hospital rating.

Moynihan Prize 3 Financial implications of gallstone-related complications whilst awaiting elective cholecystectomy: a single institution experience of 900 patients

Aims Over 65,000 cholecystectomies are performed each year in the United Kingdom with increasing waiting-list times due to the COVID-19 pandemic. This study set out to understand the cost to the NHS of complications experienced whilst awaiting cholecystectomy. Methods A retrospective cohort study was carried out for all patients who had been awaiting elective cholecystectomy for more than 20 weeks on the 17th September 2021 at a large NHS Foundation Trust. Demographic data was collected at the time of listing. Re-admission data was collected from patient notes. It included clinical history, blood results and imaging investigations. Associated costs were calculated. Results 900 patients included in the study (median age 56 years, 71.7% female). 138 patients (15.3%) re-presented to hospital whilst on the waiting list with complications of gallstone disease. Of these, 51 had more than one presentation to hospital with 18 patients having more than three presentations. This was equivalent to 625 days in hospital, with only 79 same day discharges, and multiple investigations were performed (ultrasound scan = 79;CT scan = 31, MRCP = 47, ERCP = 21). This was estimated to have cost a minimum of £364,917. Assuming an average time for an elective cholecystectomy of 90 mins at a cost of £1,200 per hour, 202 additional cholecystectomies could have been performed. Conclusion This study highlights the enormous potential to reduce patient suffering by increasing the number of elective cholecystectomy lists, and at no overall additional cost to the trust.

Acute General Surgical Emergency and COVID-19 Is a Pandemic Challenge for Surgeons: A United Kingdom-Based Practical Experience.

Transmission of coronavirus (COVID-19) is a considerable risk during the perioperative period of emergency surgery. A prospective observational study was performed between March 30, 2020, and June 30, 2020, at a large District General Hospital in England. The primary outcome was perioperative COVID-19-related complications, and secondary outcome measures included incidence of COVID-19 infections among the acute surgical patients, doctors, and healthcare workers. A total of 584 patients admitted through the emergency surgical pathway and 43% (n = 253) underwent surgical intervention. Approximately 5% (n = 30) patients contracted COVID-19 during the perioperative period and 6 of them died. Eight surgical doctors and 11 theater staff were confirmed for COVID-19 by swab test. Acute surgical emergencies and perioperative management of the urgent surgical patients during the COVID-19 pandemic is a global challenge, but adequate preparedness and strategic plan to adjust the surgical services can reduce the exposures to this highly contagious virus.

'Hot gall bladder service' by emergency general surgeons: Is this safe and feasible?

BACKGROUND: Despite NICE/AUGIS recommendations, the practice of early laparoscopic cholecystectomy (ELC) has been particularly poor in the UK offered only by 11%-20% surgeons as compared to 33%-67% internationally, possibly due to financial constraints, logistical difficulties and shortage of expertise, thus, reflecting the varied provision of emergency general surgical care. To assess whether emergency general surgeons (EGS) could provide a 'Hot Gall Bladder Service' (HGS) with an acceptable outcome. PATIENTS AND METHODS: This was a prospective HGS observational study that was protocol driven with strict inclusion/exclusion criteria and secure online data collection in a district general hospital between July 2018 and June 2019. A weekly dedicated theatre slot was allocated for this list. RESULTS: Of the 143 referred for HGS, 86 (60%) underwent ELC which included 60 (70%) women. Age, ASA and body mass index was 54* (18-85) years, II* (I-III) and 27* (20-54), respectively. 86 included 46 (53%), 19 (22%), 19 (22%) and 2 (3%) patients presenting with acute calculus cholecystitis, gallstone pancreatitis, biliary colic, and acalculus cholecystitis, respectively. 85 (99%) underwent LC with a single conversion. Grade of surgical difficulty, duration of surgery and post-operative stay was 2* (1-4) 68* (30-240) min and 0* (0-13) day, respectively. Eight (9%) required senior surgical input with no intra-operative complications and 2 (2%) 30-day readmissions. One was post-operative subhepatic collection that recovered uneventfully and the second was pancreatitis, imaging was clear requiring no further intervention. CONCLUSION: In the current climate of NHS financial crunch, COVID pandemic and significant pressure on inpatient beds: Safe and cost-effective HGS can be provided by the EGS with input from upper GI/HPB surgeons (when required) with acceptable morbidity and a satisfactory outcome. *Median.

Does CT help in reducing RT-PCR false negative rate for COVID-19?

BACKGROUND: Early detection is the key to contain the ongoing pandemic. The current gold standard to detect SARS CoV2 is RT-PCR. However, it has a high false negative rate and long turnaround time. PURPOSE: In view of the high sensitivity of CT in detection of lower respiratory tract pathologies, a study of 2581 patients comparing RT-PCR status with CT findings was undertaken to see if it augments the diagnostic performance. MATERIALS AND METHODS: A multi centre prospective study of consecutive cases was conducted. All CT studies suggestive of COVID 19 pneumonia were collated and evaluated independently by three Radiologists to confirm the imaging diagnosis of COVID-19 pneumonia. The RT-PCR values were retrospectively obtained, based on the RT-PCR values, CT studies were categorised into three subgroups, positive, negative and unknown. CT features from all three groups were compared to evaluate any communality or discordance. RESULTS: Out of the 2581 patients with positive CT findings for COVID pneumonia, 825 were females and 1,756 were males in a wide age group of 28-90 years. Predominant CT features observed in all the subgroups were Ground glass densities 94.8%, in mixed distribution (peripheral and central) (59.12%), posterior segments in 92% and multilobar involvement in 70.9%. The CT features across the three subgroups were statistically significant with a P value <0.001. CONCLUSION: There was a communality of CT findings regardless of RT-PCR status. In a pandemic setting ground glass densities in a subpleural, posterior and basal distribution are indicative of COVID 19. Thus CT chest in conjunction to RT PCR augments the diagnosis of COVID 19 pneumonia; utilization of CT chest may just be the missing link in closing this pandemic.

The important role of in-situ simulation in preparing surgeons for the COVID-19 pandemic.

BACKGROUND: Effective training is vital when facing viral outbreaks such as the SARS Coronavirus 2 (SARS-CoV-2) outbreak of 2019. The objective of this study was to measure the impact of in-situ simulation on the confidence of the surgical teams of two hospitals in assessing and managing acutely unwell surgical patients who are high-risk or confirmed to have COVID-19. METHODS: This was a quasi-experimental study with a pretest-posttest design. The surgical teams at each hospital participated in multi-disciplinary simulation sessions to explore the assessment and management of a patient requiring emergency surgery who is high risk for COVID-19. The participants were surveyed before and after receiving simulation training to determine their level of confidence on a Visual Analog Scale (VAS) for the premise stated in each of the nine questions in the survey, which represented multiple aspects of the care of these patients. RESULTS: 27 participants responded the pre-simulation survey and 24 the one post-simulation. The level of confidence (VAS score) were statistically significantly higher for all nine questions after the simulation. Specific themes were identified for further training and changes in policy. CONCLUSION: In-situ simulation is an effective training method. Its versatility allows it to be set up quickly as rapid-response training in the face of an imminent threat. In this study, it improved the preparedness of two surgical teams for the challenges of the COVID-19 pandemic.

COVID-19 and ESKD, A Rapid Review.

In 2020, the COVID-19 pandemic has ravaged the world. Individuals with end-stage kidney disease (ESKD) are at higher risk due to impaired immunity, comorbid conditions, and dependence on travel to medical care settings. We review the salient features of COVID-19 in this population, including the risk of infection, disease course, changes in dialysis unit management, use of investigatory medications, access considerations, home dialysis, and capacity planning.

Performance Characteristics of a High-Throughput Automated Transcription-Mediated Amplification Test for SARS-CoV-2 Detection.

The COVID-19 pandemic caused by the new SARS-CoV-2 coronavirus has imposed severe challenges on laboratories in their effort to achieve sufficient diagnostic testing capability for identifying infected individuals. In this study, we report the analytical and clinical performance characteristics of a new, high-throughput, fully automated nucleic acid amplification test system for the detection of SARS-CoV-2. The assay utilizes target capture, transcription-mediated amplification, and acridinium ester-labeled probe chemistry on the automated Panther system to directly amplify and detect two separate target sequences in the open reading frame 1ab (ORF1ab) region of the SARS-CoV-2 RNA genome. The probit 95% limit of detection of the assay was determined to be 0.004 50% tissue culture infective dose (TCID50)/ml using inactivated virus and 25 copies/ml (c/ml) using synthetic in vitro transcript RNA targets. Analytical sensitivity (100% detection) was confirmed to be 83 to 194 c/ml using three commercially available SARS-CoV-2 nucleic acid controls. No cross-reactivity or interference was observed with testing of six related human coronaviruses, as well as 24 other viral, fungal, and bacterial pathogens, at high titers. Clinical nasopharyngeal swab specimen testing (n = 140) showed 100%, 98.7%, and 99.3% positive, negative, and overall agreement, respectively, with a validated reverse transcription-PCR nucleic acid amplification test (NAAT) for SARS-CoV-2 RNA. These results provide validation evidence for a sensitive and specific method for pandemic-scale automated molecular diagnostic testing for SARS-CoV-2.