An invited commentary on "Liu Z, Ding Z, Guan X, Zhag Y, Wang X, Khan JS. Optimizing response in surgical systems during and after COVID-19 pandemic: Lessons from China and the UK - Perspective. Int J Surg 2020 May 4;78:156-159.″.

The COVID-19 pandemic, attributed to the novel coronavirus SARS-CoV-2, has posed unprecedented challenges to the global healthcare infrastructure. Modified and new pathways of healthcare delivery are being devised instantaneously in these extraordinary circumstances in order to minimize the risk of disease transmission among patients and healthcare workers. In this setting, Liu et al. have written a very timely and relevant article exploring various triaging methods along with intraoperative and postoperative protocols to safely administer time-sensitive surgical treatments while reducing the likelihood of COVID-19 spread among all medicine stakeholders [1].

In December 2019, Chinese authorities described a cluster of pneumonia cases in Wuhan, Hubei Province. A few weeks later, these cases were determined to be associated with SARS-CoV-2 [2]. Since then, the disease has spanned beyond national boundaries, manifesting itself in all of the continents now, except for Antarctica. As of May 4, 2020, the Johns Hopkins University COVID-19 dashboard listed 3,578,301 confirmed cases and 251,059 total fatalities across the world [3]. Aerosolized droplets and contact are the two main routes of transmission of the COVID-19 virus [4]. Many medical procedures (including those involving the gastrointestinal and respiratory tracts) and the process of intubation are aerosol-producing, therefore healthcare workers are at high risk of getting infected in the hospital setting. While masks are traditionally incorporated as a component of droplet precautions, some health authorities have significantly delayed recommending face coverage as a preventive action. Testing is not widely and readily available, and lack of personal protective equipment is generating significant pressure for healthcare workers on the frontline.

Given these factors, most healthcare centers are delaying elective non-urgent procedures and even cancer screenings have been stopped. However, not all procedures can be postponed. For patients requiring emergent surgical interventions, Liu et al. describe possible tools to implement in the surgical ecosystem.

Some of the strategies discussed in the paper include triaging of febrile patients at separate clinics with exclusive staff, reduction of outpatient visits, implementation of distancing and personal protective equipment guidelines, geographic assignment to dedicated wards with corresponding staff, utilizing frequent disinfection processes, and testing and self-quarantine for those employees who are symptomatic or at high risk due to exposure. A special emphasis is placed on testing and imaging of patients, due to the risk of transmission from asymptomatic carriers. A combination of nucleic acid testing, antibody testing, and CT scan of the chest is proposed by the authors. One pivotal recommendation highlighted in this article for critical but stable patients is repeating the nucleic acid test within 24 hours. This is important to overcome false negative test results. Once in the operating room, the investigators recommended limiting the number of staff to the bare minimum, exercising extreme caution during the intubation and extubation procedures, and considering specialized filters to reduce transmission of aerosolized particles [1].

The aforementioned practices can be applied to the field of gastroenterology as well. Many important and necessary procedures, including but not limited to upper endoscopies, colonoscopies, and endoscopic ultrasounds, have been postponed, causing delays of treatment plans for the patients [5,6]. The other area with multiple procedures affected by COVID-19 is interventional cardiology. In the event of ST-Elevation Myocardial Infarction (STEMI), invasive coronary angiography is required in all patient with possible, probable or positive COVID-19 infection [7]. Transesophageal echocardiography (TEE) should be limited to conditions such as aortic dissection which would highly impact patient outcome [8].

As outlined by different societies [5,6,8], the authors of this commentary recommend using N95 masks during all procedures involving the respiratory and the gastrointestinal tracts, including endoscopies as well as when intubating the patients. Patient need to wear mask all the time if does not interfere with the care. Moreover, we insist on the separation of COVID-19 screening units from COVID-19-positive units. There is a concern that room-to-room transmission may inadvertently occur, especially when a healthcare personnel simultaneously takes care of a COVID-19-positive patient and patients who are being screened.

As the world begins to address the resumption of medical procedures in a post-COVID-19 landscape, the ideas put forth in this paper can serve as a launching pad for such plans. Following the pathways outlined in this article can help minimize the risk of virus transmission among patients and healthcare workers while effectively providing appropriate disease workup and management. The authorities should quickly and thoroughly enact plans to have rapid point-of-care testing (which were already announced months ago) available at clinics and hospitals.

Provenance and peer review

Invited Commentary, internally reviewed.