A multi-centre analysis of cardiac surgery referral patterns and resource allocation during the COVID-19 pandemic

Background and aims: The COVID-19 pandemic caused a dramatic shift in the provision of cardiac surgical services in the United Kingdom (UK) with all elective surgery suspended. We sought to explore referral patterns, changes in clinical decision making and resource allocation to adult cardiac surgical services in the UK during the first wave of the pandemic. Methods: Data from 11 UK centres on referrals and available health resources (operating theatre and bed capacity) for urgent or emergency adult cardiac surgery between the 1st March 2020 and the 1st August 2020 was collated, and securely transferred to the lead centre for analysis. Results: 1113 patients were referred for cardiac surgery over the study period. Following UK lockdown in March 2020 the number of referrals initially fell to 39% of pre-lockdown levels before recovering to 211% of that seen prior to the pandemic. A change in treatment strategies was observed with a trend towards deferring surgery entirely or favouring less invasive, non-surgical treatments. At the peak of the pandemic in April 2020, theatre availability and bed capacity fell to 26% and 54% of pre-lockdown levels, respectively. Provision for emergency surgery was maintained throughout at 1 to 2 emergency lists per unit weekly. Conclusion: During the first wave of the UK COVID-19 pandemic cardiac surgical operative activity dropped acutely before increasing over the next four months. Despite this drop, provision for emergency surgery was retained throughout. In the event of further waves of COVID-19 pandemic, maintaining essential cardiac surgical services should be prioritised.

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Abstract 16873: Association of Preoperative Cell-Free DNA Levels and Outcome Following Pediatric Cardiopulmonary Bypass

Circulation ◽

10.1161/circ.142.suppl_3.16873 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Justinn Tanem ◽

John Scott ◽

George M Hoffman ◽

Robert A Niebler ◽

Aoy TOMITA-MITCHELL ◽

...

Keyword(s):

Cardiac Arrest ◽

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Primary Outcome ◽

Clinical Decision Making ◽

Treatment Strategies ◽

Clinical Decision ◽

Related Factors ◽

Cell Free Dna ◽

Free Dna

Introduction: Preoperative risk stratification in congenital cardiac surgery includes patient and procedure related factors, which may be used in clinical decision making as well program performance evaluation. Despite these tools, unidentified factors contribute to wide variation in outcomes both within and between centers. Identification of latent physiologic risk factors may strengthen predictive models. Hypothesis: Total cell-free DNA (TCF) functions as a biomarker for cellular injury as well as a pro-inflammatory cytokine. We hypothesized that elevated preoperative TCF would be associated with poor outcome following pediatric cardiac surgery requiring cardiopulmonary bypass (CPB). Methods: Prospective observational study of children age < 18 yr and wt > 3 kg undergoing planned CPB surgery. The Children’s Wisconsin Institutional Review Board approved the protocol . A serum TCF sample was obtained after induction of anesthesia prior to surgical incision. The primary outcome measure was a composite of postoperative cardiac arrest, ECMO, or death (CAED). Association of outcome to TCF was assessed by logistic regression with a cutpoint chosen by ROC curve exploration. Odds ratios with 95% CI were calculated. Results: Data were available in 117 patients, median age 0.9 years (range 0-17.4), median weight 7.8kg (range 3.2-98). The primary outcome (CAED) was met in 6/117 (5.1%). Table 1 summarizes characteristics of patients with and without CAED. Risk of CAED was 2% with TCF<20 ng/ml, and 27% with TCF>20 ng/ml (OR=18.2, CI 2.2- 212, p<0.01). Elevated TCF was associated to fewer hospital free days (GLM p<0.01). Data in table reported as median [IQR]. Conclusions: Preoperative TCF has an important association with postoperative cardiac arrest, ECMO, and death. Alternative or intensified treatment strategies could be considered in patients with elevated preoperative TCF.

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The value of a consultant physiotherapist within a primary care musculoskeletal interface service: part of the spinal multidisciplinary team

International Journal of Therapy and Rehabilitation ◽

10.12968/ijtr.2019.0057 ◽

2021 ◽

Vol 28 (1) ◽

pp. 1-10

Author(s):

Michelle L Angus ◽

Victoria Dickens ◽

Naveed Yasin ◽

James Greenwood ◽

Irfan Siddique

Keyword(s):

Primary Care ◽

Clinical Decision Making ◽

Clinical Decision ◽

Tertiary Referral Centre ◽

Allied Health Professionals ◽

Convenience Sample ◽

Surgical Services ◽

Pain Pathway ◽

The Uk ◽

Case Based

Background/aims The national low back pain pathway in the UK suggests practitioners managing patients with spinal pathology should be specifically trained to do so and have the ability to link with tertiary spinal services when required. The aim of this study was to ensure referrals through to a tertiary spinal surgical centre are appropriate and patients get the correct advice early in their management pathway. Methods A retrospective review of 700 cases were discussed at a spinal case-based discussion meeting in a primary care interface service, compared to services without this model. A convenience sample of cases were analysed with the consultant physiotherapist and those referred from other allied health professionals into the tertiary spinal surgical centre. Case-based team discussion took place before every referral into the tertiary spinal service, with spinal surgical discussion where required. Results Patients referred from other interface services were more likely to require further work-up such as investigations, or be discharged from clinic on their first attendance than those who had been through the case-based discussion. Conclusions A consultant physiotherapist working as part of the spinal team of a tertiary referral centre can help advanced practitioners with their clinical decision making to help prevent unnecessary referrals to spinal surgical services.

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UK Health Care Workers' Experiences of Major System Change in Elective Surgery during the COVID-19 Pandemic: Reflections on Rapid Service Adaptation

10.1101/2021.04.14.21255415 ◽

2021 ◽

Author(s):

Georgina Singleton ◽

Anna Dowrick ◽

Louisa Manby ◽

Harrison Fillmore ◽

Aron Syversen ◽

...

Keyword(s):

Decision Making ◽

Elective Surgery ◽

Rapid Change ◽

Surgical Care ◽

Systems Change ◽

System Level ◽

Framework Analysis ◽

Surgical Services ◽

The Uk ◽

Service Adaptation

Background The COVID-19 pandemic disrupted the delivery of elective surgery in the UK. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the UK, with the aim of developing lessons for future major systems change. Methods Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. We also carried out a policy review of the guidance developed for those delivering surgical services in pandemic conditions. We used framework analysis to organise and interpret findings. Results Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started. Conclusion Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decision-making and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of major systems change is essential for the sustainability of change processes.

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1118 The Role of Emergency Surgery in Diverticular Strictures of Those Who Were Initially Managed Conservatively

British Journal of Surgery ◽

10.1093/bjs/znab259.420 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

P Jayawardena ◽

O Jayawardena ◽

R Peris ◽

A Rafie

Keyword(s):

Medical Treatment ◽

Emergency Surgery ◽

Medical Records ◽

Elective Surgery ◽

Bowel Perforation ◽

Safety Net ◽

Undergo Emergency Surgery ◽

The Uk ◽

Surgical Admission

Abstract Aim The presence of diverticulosis can lead to several different complications including formation of strictures. However, the literature concerning management of diverticular strictures is poor. The purpose of this study is to evaluate the patients who were initially treated non surgically and had to undergo emergency surgery. Method A retrospective study was performed using a cohort of patients between 2016 and 2020 where 84 patients with diverticular strictures were identified and followed up. Data on the management of diverticular stricture was captured using the hospital’s electronic medical records. Results Out of 84 patients with diverticular strictures, 9 had elective surgery without any medical treatment while 75 had medical treatment first. Out of the 75 patients who were medically treated, 12 underwent emergency surgery while 2/75 underwent elective surgery after receiving medical treatment due to ongoing symptoms. Out of the 12 patients that underwent emergency surgery, 9 patients presented with obstruction while 3 had a bowel perforation. 6 patients had Hartmann’s procedure, 5 had defunctioning colostomy and 1 patient had adhesiolysis. No patient deaths were recorded at 12 months. Conclusions Although medical management remains the preferred method of managing diverticular strictures in the UK, it is not without its complications. 1 in 5 patients had an acute surgical admission requiring emergency surgery. This raises the importance of a good ‘safety net’ in those managed non-surgically, to reduce delays associated with seeking medical advice. We also appreciate the importance of carrying out more extensive studies to establish the best way to manage diverticular strictures.

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P-BN45 The Impact of Covid-19 on Benign Upper GI Operations in England During 2020

British Journal of Surgery ◽

10.1093/bjs/znab430.043 ◽

2021 ◽

Vol 108 (Supplement_9) ◽

Author(s):

Laura Sandland-Taylor ◽

Barbara Jenkins ◽

Ian Beckingham

Keyword(s):

Bile Duct ◽

Elective Surgery ◽

Demographic Data ◽

National Level ◽

Emergency Operations ◽

Surgical Services ◽

Upper Gi ◽

Level Data ◽

The Uk ◽

The Impact

Abstract Background Since the cancellation of elective surgery in early 2020 due to the threat of Covid-19, surgical provisions in England have continued to be affected by the Covid-19 pandemic. Elective surgery makes up the majority of surgical procedures performed in England and therefore cancelled operation lists and increased demand for ITU beds has had a significant impact upon the surgical services delivered to patients through out 2020. The following research looks at the impact of Covid-19 on benign upper GI surgery in England and reviews the relationship between Covid-19 deaths and operations performed throughout England and analyses the data at a regional level. Methods Data relating to operation numbers was taken from The Surgical Workload Outcomes Audit (SWORD) database. The SWORD database was interrogated for the years 2017 – 2020. A mean number of operations was calculated using the 2017-2019 data and compared to data from 2020. Operations performed and other demographic data was analysed regionally and compared to Covid-19 deaths throughout England. Covid-19 data was obtained from the national government dashboards. Results The results show that there is a correlation with increasing Covid deaths and lower rates of elective surgery. Furthermore, elective surgery was worse hit than emergency surgery with a slower recovery overall. Cholecystectomies were reduced by a total of 20817 (31.4%) for the year 2020 with a greater reduction seen in elective operations (35.6%). However, similar reductions were seen in both laparoscopic (31.4%) and open (37.5%) Similarly, bile duct explorations and elective splenectomy were reduced by 34.4% and 23.4% respectively. Comparatively, both paraumbilical and inguinal hernias also saw reductions of greater than 40% in 2020 when compared to the mean of the previous 3 years. Regional variances were seen between operation numbers performed and Covid-19 rates, however the overall trend remained the same for national level data. Conclusions Overall, the Covid-19 pandemic has had a significant impact on operations, particularly on those deemed as benign and ‘less urgent’. Whilst a global impact across all benign operations was seen, greater reductions were seen in elective operations compared to emergency operations. Hernia operations and bile duct exploration saw greater overall reductions compared to cholecystectomies and splenectomies, which suggests that whilst operation numbers were reduced, efforts were made to prioritise operations with greater clinical need throughout the pandemic. On analysis of the data in relation to Covid-19 rates and deaths, variation was seen across the regions in the UK, however overall the trend remained the same. Centres and regions worse hit by Covid-19 performed less operations during 2020. However, further qualitative research to investigate why certain centres maintained higher levels of performance during the pandemic would be beneficial for planning for future waves and future pandemics.

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Contextualizing genetic risk score for disease screening and rare variant discovery

Nature Communications ◽

10.1038/s41467-021-24387-z ◽

2021 ◽

Vol 12 (1) ◽

Author(s):

Dan Zhou ◽

Dongmei Yu ◽

Jeremiah M. Scharf ◽

Carol A. Mathews ◽

Lauren McGrath ◽

...

Keyword(s):

Complex Traits ◽

Genetic Basis ◽

Clinical Decision Making ◽

Genetic Risk Score ◽

Sufficient Conditions ◽

Clinical Decision ◽

Generative Models ◽

Variant Discovery ◽

Models Of Disease ◽

The Uk

AbstractStudies of the genetic basis of complex traits have demonstrated a substantial role for common, small-effect variant polygenic burden (PB) as well as large-effect variants (LEV, primarily rare). We identify sufficient conditions in which GWAS-derived PB may be used for well-powered rare pathogenic variant discovery or as a sample prioritization tool for whole-genome or exome sequencing. Through extensive simulations of genetic architectures and generative models of disease liability with parameters informed by empirical data, we quantify the power to detect, among cases, a lower PB in LEV carriers than in non-carriers. Furthermore, we uncover clinically useful conditions wherein the risk derived from the PB is comparable to the LEV-derived risk. The resulting summary-statistics-based methodology (with publicly available software, PB-LEV-SCAN) makes predictions on PB-based LEV screening for 36 complex traits, which we confirm in several disease datasets with available LEV information in the UK Biobank, with important implications on clinical decision-making.

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Balancing scarce hospital resources during the COVID-19 pandemic using discrete-event simulation

Health Care Management Science ◽

10.1007/s10729-021-09548-2 ◽

2021 ◽

Author(s):

G.J. Melman ◽

A.K. Parlikad ◽

E.A.B. Cameron

Keyword(s):

Resource Allocation ◽

Discrete Event Simulation ◽

Elective Surgery ◽

Discrete Event ◽

Specific Patient ◽

Event Simulation ◽

The Impact ◽

Allocation Decisions ◽

Allocation Strategies ◽

Resource Allocation Decisions

AbstractCOVID-19 has disrupted healthcare operations and resulted in large-scale cancellations of elective surgery. Hospitals throughout the world made life-altering resource allocation decisions and prioritised the care of COVID-19 patients. Without effective models to evaluate resource allocation strategies encompassing COVID-19 and non-COVID-19 care, hospitals face the risk of making sub-optimal local resource allocation decisions. A discrete-event-simulation model is proposed in this paper to describe COVID-19, elective surgery, and emergency surgery patient flows. COVID-19-specific patient flows and a surgical patient flow network were constructed based on data of 475 COVID-19 patients and 28,831 non-COVID-19 patients in Addenbrooke’s hospital in the UK. The model enabled the evaluation of three resource allocation strategies, for two COVID-19 wave scenarios: proactive cancellation of elective surgery, reactive cancellation of elective surgery, and ring-fencing operating theatre capacity. The results suggest that a ring-fencing strategy outperforms the other strategies, regardless of the COVID-19 scenario, in terms of total direct deaths and the number of surgeries performed. However, this does come at the cost of 50% more critical care rejections. In terms of aggregate hospital performance, a reactive cancellation strategy prioritising COVID-19 is no longer favourable if more than 7.3% of elective surgeries can be considered life-saving. Additionally, the model demonstrates the impact of timely hospital preparation and staff availability, on the ability to treat patients during a pandemic. The model can aid hospitals worldwide during pandemics and disasters, to evaluate their resource allocation strategies and identify the effect of redefining the prioritisation of patients.

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The Impact of COVID-19 on Surgical Training: the Past, the Present and the Future

Indian Journal of Surgery ◽

10.1007/s12262-021-02964-2 ◽

2021 ◽

Author(s):

Marina Yiasemidou

Keyword(s):

Infection Control ◽

Surgical Training ◽

New Technologies ◽

Negative Impact ◽

Elective Surgery ◽

Control Measures ◽

Negative Consequences ◽

Surgical Services ◽

The World ◽

The Impact

AbstractThe COVID-19 pandemic and infection control measures had an unavoidable impact on surgical services. During the first wave of the pandemic, elective surgery, endoscopy, and ‘face-to-face’ clinics were discontinued after recommendations from professional bodies. In addition, training courses, examinations, conferences, and training rotations were postponed or cancelled. Inadvertently, infection control and prevention measures, both within and outside hospitals, have caused a significant negative impact on training. At the same time, they have given space to new technologies, like telemedicine and platforms for webinars, to blossom. While the recovery phase is well underway in some parts of the world, most surgical services are not operating at full capacity. Unfortunately, some countries are still battling a second or third wave of the pandemic with severely negative consequences on surgical services. Several studies have looked into the impact of COVID-19 on surgical training. Here, an objective overview of studies from different parts of the world is presented. Also, evidence-based solutions are suggested for future surgical training interventions.

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Comprehensive Comparisons among Inotropic Agents on Mortality and Risk of Renal Dysfunction in Patients Who Underwent Cardiac Surgery: A Network Meta-Analysis of Randomized Controlled Trials

Journal of Clinical Medicine ◽

10.3390/jcm10051032 ◽

2021 ◽

Vol 10 (5) ◽

pp. 1032

Author(s):

Wei-Cheng Chen ◽

Meng-Hsuan Lin ◽

Chieh-Lung Chen ◽

Ying-Chieh Chen ◽

Chih-Yu Chen ◽

...

Keyword(s):

Cardiac Surgery ◽

Randomized Controlled Trials ◽

Renal Dysfunction ◽

Systolic Function ◽

Meta Analysis ◽

Treatment Strategies ◽

Controlled Trials ◽

Protective Effects ◽

Renal Protection ◽

Randomized Controlled

Several kinds of inotropes have been used in critically ill patients to improve hemodynamics and renal dysfunction after cardiac surgery; however, the treatment strategies for reducing mortality and increasing renal protection in patients who underwent cardiac surgery remain controversial. Therefore, we performed a comprehensive network meta-analysis to overcome the lack of head-to-head comparisons. A systematic database was searched up to 31 December 2020, for randomized controlled trials that compared different inotropes on mortality outcomes and renal protective effects after cardiac surgery. A total of 29 trials were included and a frequentist network meta-analysis was performed. Inconsistency analyses, publication bias, and subgroup analyses were also conducted. Compared with placebo, use of levosimendan significantly decreased the risks of mortality (odds ratio (OR): 0.74; 95% confidence interval (CI): 0.56–0.97) and risk of acute renal injury (OR: 0.61; 95% CI: 0.45–0.82), especially in low systolic function patients. Use of levosimendan also ranked the best treatment based on the P-score (90.1%), followed by placebo (64.5%), milrinone (49.6%), dopamine (49.5%), dobutamine (29.1%), and fenoldopam (17.0%). Taking all the available data into consideration, levosimendan was a safe renal-protective choice for the treatment of patients undergoing cardiac surgery, especially for those with low systolic function.

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668 The Consequences to Emergency Surgery During COVID19 Pandemic in a UK District General Hospital in The North East of England

British Journal of Surgery ◽

10.1093/bjs/znab134.075 ◽

2021 ◽

Vol 108 (Supplement_2) ◽

Author(s):

R Evans ◽

C Ng

Keyword(s):

Surgical Treatment ◽

General Hospital ◽

Emergency Surgery ◽

Early Identification ◽

District General Hospital ◽

Public Confidence ◽

Surgical Services ◽

North East ◽

The North ◽

Initial Reduction

Abstract Aim COVID19 pandemic has significantly affected surgical services. We aim to review its effects on our theatre output and risk of encountering COVID 19 cases. Method Serial record of operations performed locally were reviewed from start of UK COVID19 pandemic lockdown on 23rd March 2020 to 13th July 2020 after it was lifted. A weekly average by month of operations and the percentage of COVID19 cases diagnosed within 30 days of the procedure were noted. Results 733 operations performed through this period. In March, 33 operations/week performed, 88.4% emergency and 7% diagnosed with COVID19. April, 31 operations /week performed, 95.9% emergency and 10.6% diagnosed with COVID19. May 46 operations /week performed, 94.5% emergency and 3.3% diagnosed with COVID19. June 56 operations /week, 80.9% emergency and less than 0.01% diagnosed with COVID19. By July 80 operations/week, 59.4% emergency and none diagnosed with COVID 19. Since testing capacity increased, only 6 of the 27 operated were diagnosed with COVID19. Conclusions There was initial reduction to non-emergency workload. However, this has gradually shifted as protocols are in place improve public confidence to return for surgical treatment. Mandatory admission testing allows early identification and remains essential for planning of services and protecting the workforce.

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