A prolonged wait: The impact of COVID-19 on elective surgeries in India, a prospective study

Introduction

The World Health Organization (WHO) declared Coronavirus Disease 2019 (COVID-19) to be a pandemic on March 11, 2020.¹ The government of India had adopted several measures to limit and stop the pandemic, including a nationwide lockdown, infection control standards including usage of masks and personal protective equipment (PPE) and social distancing.^2,3 The pandemic created a massive impact on healthcare systems all around the world. Several healthcare practitioners were redirected to COVID management. Furthermore, due to resource reallocation and economic constraints, hospitals throughout the world have been compelled to restructure to offer the best possible treatment for patients while avoiding the transmission of the coronavirus among patients and healthcare personnel. Hospital visits have decreased as a result of the cancellation of elective surgeries and routine outpatient department (OPD) treatments and Institutes, hospitals have cancelled in-person lectures, clinical rounds, seminars, and other educational events during the pandemic.⁴ This has had a significant impact on learning and teaching for post-graduates (PG) during COVID-19. Elective operations are not optional procedures, but rather non-urgent procedures. In 50% of patients, cancelling or delaying elective surgery has unanticipated repercussions that might result in severe morbidity and mortality because of the pandemic.^5,6

Furthermore, while emergency and critical care professionals have received a lot of attention, surgeons are frequently overlooked. Extremely high baseline rates of burnout, and a worldwide pandemic could worsen any existing effects has been reported.^7,8

Methods

A cross-sectional study was carried out from June 2021 to July 2021 in Kasturba Medical college, through an online cross-sectional survey questionnaire (Google forms) consisting of 15 questions circulated across India primarily to surgeons practising in six states of India that were most severely affected by the pandemic according to recent statistics and also to surgeons in other states of India. This was done through E-mail or any online messaging service. The questionnaire was made by the researchers, no specific program was used and no validity/reliability test was done.

The study was approved by the Institutional Human Ethics Committee (IHEC) clearance from Kasturba Medical College via letter no. KIMS/IHEC/APPROVAL/08/2021/03 dated September 7th, 2021.

Due to the low risk nature of this study and the effects of COVID-19, retrospective ethical approval was obtained. The study was originally submitted to the IHEC at KIMSHEALTH on the 14th of August 2021. At KIMSHEALTH, there are two committees: the Scientific and Research Committee and the Ethics Committee. The Ethics Committee meets once every three months, while the Scientific Committee meets frequently. The Scientific and Research Committee’s approval allows the principal investigators of these projects to begin patient recruitment. For the purposes of the present study, surgeons across India—not patients—were the population under consideration and there were no ethical issues involved so before the study began we submitted it to the Scientific and Research Committee, which has been given the authorization to review and approve medical research and other observational studies. Three members of the Ethics Committee are represented on the committee to ensure that all ethical guidelines and rules are strictly followed. The Scientific and Research Committee approved the start of the study. The committee’s decision was then ratified by the Ethics Committee at a later date.

Results

In this present study, a total of 320 participants were enrolled. The age groups were divided into 25-40 years old (170 participants), 40-60 years old (135 participants), and 15 participants were >60 years old (Table 1).³² A total of 241 participants were male and 79 were female (Table 2). In this study, various surgeons participated from various states in India, namely; Bihar (14), Delhi (16), Karnataka (89), Kerala (133), Maharashtra (14), Uttar Pradesh (20), and other states (34) (Table 3, Figure 1). Surgeons from various specialities have participated in this study, and the distribution was as follows: Cardiothoracic vascular surgery (CTVS), 5; General Surgery, 71; Neurosurgery, 5; Obstetrics and Gynaecology, 27; Ophthalmology, 17; Oral and Maxillofacial surgery, 20; Otorhinolaryngology, 31; Paediatric Surgery, 3; Plastic Surgery, 7; Surgical Oncology, 8; Trauma and Orthopaedic Surgery, 93; and Urology, 33 (Table 4).

Figure 1. Shortage of PPE kits in the hospital.

PPE, personal protective equipment.

Dissatisfaction from patients or bystanders was directed towards 70.4% of participants who agreed that there was an oxygen deficit, whereas 29.6% of participants who responded that there was no oxygen shortage also had this negative impact. This indicated a statistically significant relationship with a p-value of less than 0.001 (Tables 2 and 3).

Overall, 78.8% of those participants who agreed that there was a shortage of PPE kits also faced the brunt of patient or bystander’s dissatisfaction; whereas 21.2% of those who reacted that there was no shortage of PPE kits also faced the brunt of patient or patient bystanders dissatisfaction. With a p-value <0.001, this showed a statistically significant association (Figure 1 and Table 4).

Guidelines for the care of acute OMFS and trauma patients have been issued by NHS England and NHS Improvement.²⁰ They recommend that senior team members make decisions about patient care at the initial point of contact with the patient in order to prevent unnecessary admissions and reduce nosocomial infections. Moreover, results showed that doctors found it challenging to get accustomed to the new pre-op guidelines in line with the pandemic (Figure 2).

Figure 2. A change in pre-op guidelines during a pandemic.

Overall, 60.7% of those participants who agreed that there was a delay in procurement of surgical implants also faced the brunt of patient or bystander’s dissatisfaction, whereas 40.3% of those who reacted that there was no delay in procurement of surgical implants also faced the brunt of patient or bystander’s dissatisfaction. With a p-value of 0.041, this showed a statistical association (Tables 5 and 6).

A total of 64% of participants also agreed that the COVID-19 pandemic had affected the post-graduate teaching program due to loss of direct contact classes, decrease in faculty strength due to sickness, lack of bed side clinical teaching (Figure 3).

Figure 3. Impact on PG teaching programmes.

PG, post-graduates.

More than half of the participants agreed to the fact that they were affected by the fear of contracting COVID-19 during high-risk invasive procedures and there was an increase in the rate of post-operative complications in surgically operated COVID-19 patients. Overall, 74.7% of surgeons felt that there was a decline in aerosol generating procedures during the pandemic. A total of 54.1% of surgeons felt that deferral of surgeries in patients with comorbidities led to ‘grave consequences’. Most of the surgeons did not face a personal financial crisis during the pandemic. Overall, 46.6% of doctors noticed deterring influence on surgical skills due to abstinence from conducting surgeries whereas, the rest were not affected by it. Surgeons identified that hospital administration made significant changes in healthcare and employment policies during the pandemic.

Discussion

Sahu et al.²⁷ performed a study of 611 orthopaedic doctors from 140 Indian cities. Twenty-six orthopaedic doctors stated that they were very worried 22.5% of the time and very stressed 40.5% of the time. As age decreased, the percentage of orthopaedic surgeons who said they were “certainly stressed out” increased.138 (77.5) PG trainees took part in the survey by Upadhyaya et al.,²⁸ and 65.1% of them stated that there aren't any clinical classes being held right now. The vast majority (94%) concurred that COVID-19 had an effect on their clinical and surgical training. In total, 71.6% of students were having trouble finishing their dissertations, and 96% were concerned about their mental health.

Haleem A et al.,⁴ have ranked the priorities in order of significance for retaining emergency surgery skills, safeguarding and conserving the surgical workforce, performing substitute surgical tasks, and, if necessary, performing substitute non-surgical activities. COVID-19 has created a serious problem that is quickly resulting in a huge number of patients. Despite the increased danger of contracting the illness, healthcare professionals need to be prepared to collaborate in order to meet this challenge and save humanity. According to Hope et al.'s⁵ systematic study, there has been a decrease in operating room experience. In 17 of the studies, knowledge learning was moved to online platforms, and 7 of them indicated that trainees were spending more time on academic and educational pursuits. The studies that discuss mental health all show negative correlations between higher levels of stress and training, ranging from 54.9% to 91.6%. Overall, 74.7% of surgeons in our study also felt that this was important.

According to McBride et al.,²⁹ there was a 26% decrease in both elective and emergency surgical procedures between February and September of 2019 and 2020 in a reference center located in Australia. Using Presl et al., a Emergency surgical procedures decreased by 42.5% in Additionally contrasting 2019 and 2020 with Austria, so that emergency abdominal wall hernia repairs Lower percentages of cholecystectomies (69 and 39%) correspondingly.³⁰

In a study by Khan et al.,³¹ 15 (53.6%) of the 44 trainees that answered (28/44; 63.6%) were CST/IST. A total of 15 (53.6%) participants worked in general surgery, while 14 (50.0%) were employed by teaching hospitals. In total, 20 participants (71.4%) believed they had less opportunities to serve as the primary surgeon as a result of the pandemic. Only 21 participants (75.0%) had never visited an outpatient clinic. Eight people (28.6%) had no access at all to the laparoscopic box-trainer. Overall, 20 (71.4%) people thought that their degree of trust in their ability to perform surgical skills had been lowered. In total, 18 (64.3%) people felt it challenging to show improvement in their portfolio. A total of 21 trainees (75.0%) had not participated in any instruction. Overall, 10 (35.7%) trainees missed class due to illness. Eight (286%) trainees reported feeling somewhat or much more pressured.

Conclusions

The surgical care has suffered because of the pandemic. The impact grows every day as a result of the postponed surgical procedures coexisting with regularly scheduled treatments, leading to increases in expenses and resource demands. Long waiting lists will continue to exist, but patient and procedure segmentation could lead to better healthcare delivery. Additionally, in order to address the rising need for surgery following the epidemic, research on health regulations and guidelines may be prompted by the pandemic.