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

Guidelines implemented during the pandemic by various surgical specialities

Oncological surgery

It is important to rationalise every surgery performed because standard surgical procedures have been disrupted due to workforce issues. This is crucial in cancer surgery, when the physician must weigh the risks of both potential viral transmission to the surgical team and potential cancer patient progression.⁸ In the first instance, patients should be moved to hospitals with more financial resources available for operations, and it is suggested that local “COVID-19 free” surgical hubs be established to continue oncological surgery. General factors must also be taken into account for patients with cancer. Most complicated elective surgical procedures are frequently followed by post-operative care in a hospital ward. Patients occasionally experience postoperative problems that necessitate Intensive Therapy Unit (ITU) admission and/or re-operation, which could be difficult given the rising number of COVID-19 patients needing Level 3 care. It is advised to keep length of stay (LoS) to a minimal, particularly in critical care.^9,10

General surgery

The provision of emergency general surgery is a crucial component of the planning of surgical services. Wherever possible, it is crucial to maintain the status quo for both COVID-19-infected patients and those who are not.¹¹ To prevent nosocomial infections in COVID-negative patients, it has been suggested that separate “clean” and “dirty” emergency operating rooms be created. If conservative therapy has failed, poses a risk to the patient’s health, is likely to lengthen hospitalisation, or raises the possibility of readmission at a later time, operations or procedures should be carried out.¹² Additionally, surgeons need to be on the lookout for a potential decline in the supply of blood products. Resources are already running out in the UK as a result of rising demand as well as a decline in blood donors brought on by social isolation and quarantine regulations.¹³ Therefore, it is advised that each particular centre should monitor the regional blood availability and, if necessary, support a restrictive transfusion strategy in both the operating room and the intensive care unit¹⁴ or intraoperative cell preservation.¹⁵

Cardiothoracic surgery

The impact of COVID-19 on cardiothoracic practise was inevitable. All elective and non-urgent surgeries have been delayed in the US and the UK, and resources have been shifted to the emergency and urgent cardiothoracic care. Additionally, cardiothoracic surgeons are excellent candidates for redeployment since they have general abilities that are typically transferrable to ITU. Based on the stage of the COVID-19 pandemic, the NHS in the UK has released recommendations on the management of cardiothoracic surgeries.¹⁰

Urology

Classification of urological surgery into oncological, emergency, and benign procedures by Ahmed et al.,¹⁶ included a number of prioritising suggestions. To reduce the impact on resource utilisation and labour shortages caused by the redeployment of anaesthetists, these recommendations include the extensive use of local anaesthesia and day-case surgery whenever possible. Additionally, they recommended the establishment of parallel urology services, with “hot” hospitals treating suspected COVID-19 patients and “cool” hospitals handling oncological and emergency work. Additionally, although the extent of urinary viral shedding is still not entirely understood, there is some preliminary evidence that SARS-CoV-2 Viral RNA can be detected in the urine, indicating that urology services must still take care.¹⁷

Ophthalmology

These procedures should be carried out as day cases whenever it is safe to do so. The surgical treatment with the shorter postoperative recovery duration and fewer postoperative follow-up visits should be chosen. Additionally, whenever possible, local anaesthesia is preferred to general anaesthesia.¹⁸

Oral and maxillofacial surgery (OMFS)

NHS England and NHS Improvement have produced recommendations for treating OMFS and trauma patients.¹⁹ 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.

Plastic surgery

To assist in the care of patients undergoing plastic surgery during COVID-19, the British Association of Plastic Surgery (BAPRAS) and NHS England have offered advice to its members. A plastic and reconstructive surgery escalation strategy has been published by the association.²⁰ This offers advice to hospitals on how to handle an increase in COVID-19 prevalence. High prevalence requires limiting emergency surgery and ceasing all elective surgery. Minor surgeries should be carried out in outpatient clinics, where all emergency injuries should be triaged for treatment. Guidelines have been developed for the management of burns, breast reconstruction, and melanoma-specific issues, and advice has been developed to direct local services in order to deal with the anticipated significant reduction in clinical and surgical facilities. A referral letter is still necessary for patients whose melanoma diagnosis is suspected, and it will be examined by a multidisciplinary team (MDT). A recommendation will be made based on the image. The patient may then be immediately sent for surgery to remove the lesion after the pathology has been reviewed, and the results will be telephoned to them.²¹ NHS England has also provided details on how burn injuries during the COVID-19 epidemic should be managed.²²

Paediatric surgery

According to the American College of Surgeons, the fundamental goal of paediatric surgery during the COVID-19 pandemic is to treat children with urgent surgical needs with the proper care while efficiently using patient care resources and safeguarding healthcare professionals. To prevent extended hospital stays or additional readmissions to the hospital, non-urgent surgery should only be done when absolutely necessary.²³ Additionally, NHS England has advised against performing elective paediatric procedures on children unless they are ASA Grade 1 patients, with the exception of cancer situations.^24,25 Paediatric surgical care should prioritise the efficient management of emergency situations, delaying any necessary elective procedures as possible. In order to shorten the preoperative period and guarantee an early discharge, this will provide greater access to theatres and an increase in staff capacity. While minimising the risk of infection transmission, the paediatric surgical team should provide ongoing management of urgent surgical situations. The utilisation of telemedicine as well as reorganising into two groups—one that works in hospitals and the other that operates remotely—are examples of such tactics. The attendance of parents during surgery should be taken into consideration whenever it is safe to do so.²³

The purpose of this study is to see how the COVID pandemic affected elective operations, surgeon skills, and post-graduate training.

Ethical considerations

The forms were sent to various surgeons across India. The responses we received from them were considered as their consent to participate in the study. The study was approved by the Institutional Human Ethics Committee (IHEC) clearance from KIMSHEALTH 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.

Inclusion criteria

Surgeons in the various surgical specialities in six states across India (Bihar, Delhi, Karnataka, Kerala, Maharashtra and Uttar Pradesh) that were most severely affected by the pandemic as per recent statistics and also other states in India.

Exclusion criteria

Non-surgical medical practitioners were excluded from the study.

Recruitment

In this study, the questionnaires were sent as Google forms to surgeons via Gmail and WhatsApp platform, out of which 320 responses were received by us, which became the primary data source. The combined responses were recorded and analysed statistically by the authors.

Statistical analysis

Frequency and percentage were used to represent categorical variables, whereas the mean and standard deviation were used to represent continuous values. The Chi-squared test was used to examine associations between categorical variables. Unpaired t-test analysis was used to compare quantitative data between two groups. The ANOVA analysis was used to compare continuous variables between more than two groups. Comparison of continuous variable among more than two group was analysed by ANOVA with Post hoc tests of multiple comparison -LSD. p<0.05 was regarded as statistically significant. IBM SPSS Statistics (RRID:SCR_016479) version 24 was used for data analysis.

Recommendations

Some of the suggestions and recommendations put forth by the participating surgeons include: i) Anticipation and better preparation for future pandemic waves; ii) at least 10% of GDP to be allotted for health care sector in India; iii) decentralization of COVID care and monitoring system; iv) to promote good COVID appropriate sanitation habits like hand washing; v) prompt completion of all vaccination doses; vi) postponement of elective surgeries (Figure 10, Table 19); vii) adopt newer methods for teaching in the medical education department; viii) reduce the length of hospital stay; ix) parallel training of more health care workers and paramedics to handle pandemics in future; x) peripheral healthcare centres are to be better equipped; and xi) transparency of documentation, periodic pandemic evaluation and amendment of policies and protocols based on evidence-based medicine.