Hospital organization and thoracic oncological patient management during the coronavirus disease-2019 outbreak: a brief report from a nationwide survey of the Italian Society of Thoracic Surgery.

The current coronavirus disease 2019 (COVID-19) pandemic has made us aware of the weaknesses and often the inadequacies of our current technologies and practices and has presented us with a huge challenge: to reorganize the way we work and sometimes even think, in order to ensure the safety of our patients. The Italian Society of Thoracic Surgery has launched various initiatives in response to the COVID-19 pandemic, aimed at facilitating the exchange of information, strategies and personal experiences between institutions. This article presents the results of a survey amongst all Italian thoracic surgery units accredited to SICT, with the aim of providing a glimpse of the current working conditions in these units, and an understanding of the impact of COVID-19 on their daily activities and patient care.

INTRODUCTION

The global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the resulting coronavirus disease 2019 (COVID-19) quickly escalated into a critical situation for healthcare systems worldwide [1]. From 23 February to 3 June 2020, Italy recorded 234 013 documented cases and >33 600 people died from COVID-19 [2, 3].

Giving absolutely priority to the treatment of COVID-19 patients, the national health system has devoted most of its structural and human resources to the fight against the pandemic, which lead to a reorganization of structures dedicated to cancer treatment.

National and international oncologic associations (e.g. AIOM, NCCN, ESMO [4-6]) published over time recommendations to treat patients with cancer. In this context, the Italian Society of Thoracic Surgery (SICT) promoted the present survey that is fully part of the SICT-COVID-19 project, which will end with a recommendation document addressed to specialists. In this brief report, we aim to report a realistic photograph of what happened in Italian thoracic surgery units during the last 3 months; furthermore, the document serves to explain, as detailed as possible, the overall hospital and departmental reorganization that has become necessary, with particular attention to oncological surgical indications, which can serve as experience for the countries that are now in the pandemic phase in which we were up to about a couple of weeks ago.

METHODOLOGY OF THE SURVEY

SICT-accredited general thoracic surgery centres were invited by the secretary of the society to complete a survey consisting of 36 questions regarding the reorganization of their department and oncological patient management during the COVID-19 pandemic. The questionnaire was in Italian; an English-translated version is provided in Supplementary Material, Appendix 1. The survey was composed of 4 sections: (i) hospital characteristics and organization; (ii) personal protective equipment during surgery; (iii) department activity during the COVID-19 pandemic; and (iv) surgical indications.

The survey, elaborated by a group of SICT-members, was sent on 28 April by e-mail to all chief physicians of accredited centres and a reminder e-mail was sent on 13 May. The questions were designed to be easy understandable, serving the goals of the survey and fast to respond.

SURVEY RESULTS AND DISCUSSION

The final sample consisted of 53 out of 70 (75.7%) completed surveys of SICT-accredited thoracic surgery centres. Supplementary Material, Appendix 1 contains the English version of the survey.

Section 1: hospital characteristics and organization

The thoracic surgery units responding to the present survey were located in north (28, 52.8%), central (13, 24.5%) and south (12, 22.7%) Italy. It should be noted that the pandemic in Italy hit the northern regions with greater intensity. About 80.3% of all positive cases and 86% of all deaths related to COVID-19 were recorded in the north [3]. Accordingly, this survey is representative of all parts of the country, especially of the northern part of Italy where the pandemic was more impressive.

During the COVID-19 outbreak, about 85% of structures were changed to hybrid hospitals where departments, for infected and uninfected patients, coexisted; 5.7% of hospitals were completely dedicated to COVID-19 management and only 9.4% remained COVID free. At time of maximum pandemic exposure, which peaked in Italy between 20 and 29 March (depending on the region), 75% of the surveyed hospitals faced a dramatic situation with a very large number of COVID-19 patients, which required substantial modification in the hospital organization with the exclusive destination of resources (human, ICU beds and ventilators) to treat these patients. In the same period, about 50% of hospitals reported that beds dedicated to COVID-19 patients were >150 per hospital, requiring to suspend elective thoracic surgical activities in favour for emergencies only (71.7%), and consequently surgeons were relocated to COVID-19 departments or triage (about 30%) (Supplementary Material, Fig. S1).

Section 2: personal protective equipment during surgery

A total of 77% of the chief physicians of accredited centres responded that the pandemic required to change the access to the surgical theatre and to adjust individual protective habits during surgery. The majority (80%) of medical staff interviewed received the possibility for a nasopharyngeal swab, of these only 28% for preventive purposes and at regular time intervals. Of note, about 34% of the thoracic units had at least 1 member of the team positive to COVID-19, of these 83% worked in centres where scheduled screening did not apply. Two issues emerge from this result: first, thoracic surgery units were departments at high risk of contagion in Italy, representing a kind of ‘reservoir’ for the pandemic (likely more than other departments), and second, prevention of COVID infection appeared to be belated and/or inadequate (Supplementary Material, Fig. S2).

Section3: department activity during the COVID-19 pandemic

Over 90% of the centres participating in the SICT survey communicated a remarkable reduction in surgical activity, of which 37.7% decreased their usual activity over 50%. Of these, 65% are located in the north. Unfortunately, in about 56% of cases, a planning delay of thoracic oncological surgical procedures occurred due to the stop of elective activity, which continued regularly only in 28.3% of the centres.

All the centres surveyed implemented a patient screening system, which is based in >96% of cases on nasopharyngeal swabs; in about 40% of hospitals, swabs were combined with other diagnostics (chest X-ray 15%, chest CT 17%, serology 7.5%); the majority of the centres screened patients at least 24 h before admission.

Interestingly, multi-disciplinary meetings continued to play a relevant role in thoracic surgical activities even during the pandemic (see Supplementary Material, Appendix 1). The majority of the cases discussed were urgent, which allowed to create specific operating lists.

Part of the delays in surgical planning is attributable to the suspension of services necessary for staging and for preoperative functional evaluation: 30% of the centres registered delays or suspensions of CT/PET-fluorodeoxyglucose or endoscopic examinations (endobronchial ultrasound, transbronchioal fine-needle aspiration) and 21% of the centres experienced delays or unavailability of functional respiratory assessments (spirometry, cardiopulmonary exercise test). Approximately 85% of the centres interviewed reported a reduction in outpatient and specialist consultancy activities. These results are in line with a recent analysis of the COVIDSurg Collaborative Group, who calculated that 2 367 050 surgeries have been cancelled/delayed per week in the UK, of which 37.7% were oncological surgical procedures [7]. The authors concluded (and we agree with them) that if a country increases their normal surgical volume by 20% post-pandemic, it would take a median of 45 weeks to clear the backlog of operations resulting from COVID-19 disruption. Therefore, we may hope that resources will be reallocated in the early post-pandemic era to increase thoracic surgical activities to catch up the delay accumulated during the pandemic (Figs 1 and 2 and Supplementary Material, Fig. S3).

Figure 1:

Survey results: department activity during the coronavirus disease 2019 pandemic.

Figure 2:

Survey results: department activity during the coronavirus disease 2019 pandemic. COVID-19: coronavirus disease 2019.

Section 4: surgical indications

Indications for lung cancer surgery

A total of 52.8% of the centres interviewed agree to reschedule interventions for stage I lung cancer [even beyond 30 days (with limits reported above)], ground glass opacities and partially solid tumours with solid component <50% (73.6%). A large majority considered priority for stage II and higher cancers, solid or with solid component >50% (92.5% of centres), tumours with lymph node involvement, N+ (84.9%) and in 100% of cases of post-neo-adjuvant chemotherapy tumours; therefore, to be performed within 30 days after diagnosis, even during the pandemic (Supplementary Material, Fig. S4).

Surgical indications for other non-lung cancer cases

Interestingly, 58.5% of responders agree on the possibility of rescheduling the same tumours when less aggressive (i.e. early-stage thymoma). Diagnostic and metastatic lung resections are a priority for ∼65% and 68% of the centres, respectively. A similar agreement has been highlighted to treat oesophageal cancer (62%).

In the context of considerable resource reduction to thoracic surgical departments, factors mainly influencing the decision to proceed with surgery were the need for intensive care, shortage of blood components (a dramatic reduction in them was observed at the peak of pandemic) and patients’ age. All these factors highlight how the COVID-19 pandemic affected not only infected patients but also other patients, especially those in oncology, through the saturation of hospital resources.

CONCLUSION

The fast-spreading COVID-19 pandemic poses new questions, challenges and opportunities for healthcare systems worldwide. With the need to allocate resources to the care of COVID-19 patients, prioritizing a part of resources to be distributed to other equally fatal diseases (in the short and medium term) without being crushed by the weight of the pandemic.

Cancer represents an often non-deferrable pathology, which must remain central in hospital reorganizations. The national scientific societies (surgical and oncological) and the individual structures pertaining to them play an essential role in dictating recommendations that allow us to continue surgical activities and to obtain safe and timely treatment for patients. We hope that our brief report can serve countries that are now in the pandemic phase in which we were a couple of weeks ago.

The pandemic has changed our lifestyles and our daily habits and we must adapt to this new situation without giving 1 inch on the field of the treatment of oncological diseases. To do this, we need a collective and collaborative vision to concentrate individual efforts in the same direction.

SUPPLEMENTARY MATERIAL

Supplementary material is available at ICVTS online.

Conflict of interest: none declared.

Author contributions

Domenico Viggiano: Writing–original draft. Filippo Lococo: Conceptualization; Writing–original draft. Andrea Dell'Amore: Data curation; Formal analysis; Investigation; Methodology. Roberto Crisci: Project administration; Supervision; Validation. Massimo Torre: Data curation; Project administration; Validation. Federico Rea: Data curation; Investigation; Methodology; Validation. Giovanni Muriana: Conceptualization; Funding acquisition; Resources; Writing–original draft. Italian Thoracic Surgery Society (SICT) Task Force on COVID-19 Pandemic: Data curation.

Reviewer information

Interactive CardioVascular and Thoracic Surgery thanks Georges Decker and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.

Click here for additional data file.