Re: Kristian D. Stensland, Todd M. Morgan, Alireza Moinzadeh, et al. Considerations in the Triage of Urologic Surgeries During the COVID-19 Pandemic. Eur Urol 2020;77:663-6: The Forgotten Urological Patient During the COVID-19 Pandemic: Patient Safety Safeguards.

The COVID-19 pandemic has overwhelmed many health care systems worldwide. As described by Stensland et al [1], urology services have been reduced significantly, with manpower and resources redeployed and reallocated to frontline departments, focusing attention to urgent-only cases during the COVID-19 pandemic [2]. In this letter, we add to the considerations provided by Stensland et al by highlighting important patient safety strategies and safeguards used at a tertiary urological centre amid the climate of resource scarcity during this pandemic.

Patient safety is defined as “the avoidance, prevention, and amelioration of adverse outcomes or injuries stemming from the processes of healthcare” [3]. Our three-pronged strategy includes: maintaining a strong safety culture, maintaining core services, and mitigating the risk of transmission for vulnerable patient groups.

Maintaining a strong safety culture

Amid the reduction of manpower and resources, patient safety may be compromised by deviations away from standard safety protocols because of fatigue or mental lapses, with disastrous consequences. All staff were reminded to adhere strictly to existing safety protocols (eg, surgical “timeout”) and to readily report new areas of potential weakness as a result of resource shortage.

Owing to team segregation, patients were cared for by different teams in the inpatient and outpatient settings. Proper patient handovers between teams were made routine for inpatients and complex outpatient cases.

While triaging the acuity of surgeries and outpatient visits, all cases were meticulously reviewed by a senior resident with consultant input to ensure appropriate case review. Organ-preserving and oncological surgeries were continued. All rescheduled surgeries and clinic visits were carefully tracked to ensure no patients were lost to follow-up.

Patients were informed about service disruptions, updated individualised care plans, and avenues for seeking urgent care. Foreign patients who have received care at our regional referral centre were sent letters to prompt them to seek a urological opinion in their home country for urgent matters.

Maintaining core services

Forgotten ureteric stents can cause significant morbidity [4]. During a pandemic, patients may be unable or unwilling to return for management of their ureteric stents. Our centre maintained close monitoring of all patients with ureteric stents using an existing standardised electronic registry, which prompted physicians once stents were due for removal. Patients who missed procedures for stent removal were recalled at the earliest opportunity.

Core uro-oncology services were maintained during this period as benefits from cancer treatment were higher than the COVID-19 mortality risk. Selected patients were converted to longer treatment intervals (eg, 6-mo vs 1- or 3-mo androgen deprivation therapy) or longer surveillance intervals (eg, bladder cancer surveillance cystoscopies).

We maintained specialist consultant cover for urological emergencies around the clock despite reductions in manpower resources due to team segregation and staff redeployment.

Mitigating the risk of transmission for vulnerable patient groups

Transplant patients and patients with renal failure represent one of the most vulnerable patient groups during this pandemic [5]. Our National University Centre for Organ Transplantation maintained our cadaveric-donor and living-donor kidney transplantation programmes during this period, with rigorous protocols to screen donors and recipients for COVID-19 to prevent transmission to these immunocompromised patients. Patient autonomy was also protected: patients on our national transplant recipient waiting list who had concerns about participating in transplants during the pandemic were not penalised if they rejected a transplant during this period.

Elderly patients and patients with comorbidities have higher mortality from COVID-19 and represent a large majority of our patients. Visits for non- urgent conditions were postponed, and we ensured that supplies of their long-term medications were continued, with free delivery as an option. The use of teleconsultations preserved outpatient clinic capabilities and reduced unnecessary visits.

With the global focus on patients affected by COVID-19, appropriate levels of urological care must be maintained as patient safety safeguards, especially for certain vulnerable populations.

The authors have nothing to disclose.

CRediT authorship contribution statement

Yi Quan Tan: Conceptualization, Writing - original draft. Jirong Lu: Conceptualization, Writing - review & editing. Edmund Chiong: Conceptualization, Writing - review & editing, Supervision.