Clinical Scorecard: Surgical Procedures During the COVID-19 Crisis: A Prospective Cohort Analysis from Nottingham

At a Glance

Key Highlights

• Over 28 million operations deferred globally during the COVID-19 peak, with post-operative COVID-19 mortality reported over 20% in confirmed cases.
• A multidisciplinary COVID Cancer Surgery group was formed to prioritize urgent and cancer surgeries, balancing clinical need with resource constraints and infection risk.
• Clean surgical sites were established in independent hospitals with pre-operative COVID-19 screening and separate pathways to minimize nosocomial transmission.

Guideline-Based Recommendations

Diagnosis

• Screen elective surgical patients on the day of surgery for COVID-19 symptoms including temperature, cough, anosmia, and fever.
• Use PCR testing for COVID-19 pre-operatively when available to identify asymptomatic infections.

Management

• Suspend non-urgent surgeries during peak pandemic phases to preserve critical care capacity.
• Prioritize urgent and cancer surgeries based on clinical need, likelihood of cure, and availability of alternatives.
• Allocate surgical cases daily according to available anaesthetic staff, critical care beds, and theatre capacity.
• Establish clean sites for surgery with separate pathways for COVID-19 negative patients.

Monitoring & Follow-up

• Audit surgical outcomes prospectively to detect excess COVID-related morbidity and mortality.
• Monitor local COVID-19 infection rates and adjust surgical prioritization accordingly.

Risks

• Increased risk of mortality and complications in patients developing COVID-19 post-operatively.
• Potential harm from delays in cancer surgery balanced against risks of COVID-19 exposure and resource limitations.

Patient & Prescribing Data

Patients undergoing urgent and cancer-related surgery during the COVID-19 pandemic at Nottingham University Hospitals and independent sector sites.

Flexible daily prioritization and scheduling of cases allowed continuation of critical surgeries with comparable outcomes across NHS and independent sites while minimizing COVID-19 risk.

Clinical Best Practices

• Form multidisciplinary groups including clinical, operational, infection control, and ethics representatives to oversee surgical prioritization during pandemics.
• Implement daily case submission and prioritization processes aligned with resource availability and local infection rates.
• Use symptom screening and PCR testing to create COVID-19 clean surgical pathways and sites.
• Obtain informed consent including discussion of COVID-19 infection risks and potential increased mortality.
• Continuously audit outcomes to ensure safety and equity across different hospital sites.

References

• Global surgery deferral estimate
• Initial reports of post-operative COVID-19 mortality
• International and National perioperative COVID-19 guidance
• UK suspension of non-urgent surgeries
• Nottingham University Hospitals COVID Cancer Surgery group formation
• Separate COVID-19 pathways and clean sites