Impact of the COVID-19 pandemic on the management of surgical patients presenting in an emergency setting -Report from a tertiary referral centre.

Introduction: At the onset of the first wave of COVID-19 pandemic, the publications on managing surgical emergencies were sparse. Health care personnel were facing an unprecedented problem with limited information. On this background, we have reviewed the operational challenges faced and the protocols followed by us while managing emergency surgical patients. The clinical presentations, RT-PCR testing rates, trend of COVID-19 positivity in emergency surgical patients and its comparison to the general population, swab positivity among screen positive and negative patients, grade of COVID-19 affection, the outcomes in emergency surgical patients, and COVID-19 affection in treating personnel is studied. Patients and
Methods: A protocol for triaging patients at presentation into screen positive or negative for COVID-19 was instituted. A proforma for all admitted patients over the period of March 2020 to August 2020 was maintained. A retrospective review of this data was carried out after Institutional Ethics Committee permission.
Results: A total of 222 patients presented to the surgical emergency, of which 110 required admission. Of the admitted patients, 28 were COVID-19 positive. The positivity amongst admitted and operated patients increased to 50% and 66.67%, respectively in August. The difference in mortality rate amongst the operated COVID-19 positive (11.1%) and negative (14.28%) patients was nonsignificant. None of the treating doctors had to be quarantined during this period. Conclusions: The number of COVID-19 positive patients rose serially over the study period. The outcome was not affected by the COVID-19 status in mild cases. A high rate of COVID-19 positivity was seen in patients requiring emergency surgery. Universal precautions ensured delivering treatment to emergency patients in standard time. Testing should continue for all as screening alone is not effective as the virus spreads into the population. Proper protocols helped us to protect the health care workers.

Introduction

The World Health Organization declared the SARS-CoV-2 novel coronavirus as a “Pandemic” on 11th March 2020. Working at The King Edward VII Memorial Hospital, Mumbai, we were concerned that we would come across probable COVID-19 affected patients even before any official response system was in place. During that time, testing facilities were limited hence there were stringent criteria for testing any patient. Though we wished to test every patient for COVID-19, it was not possible. Surgeons are particularly at risk as the operation theatres (OTs) are closed spaces where the surgeons, anesthetists, and patient are in close proximity to each other while performing surgical and aerosolizing procedures. There were worrying reports of high morbidity and mortality in surgical patients and doctors.[12] Lancet reported a 23% mortality in surgical patients diagnosed with COVID-19 perioperatively. In order to provide uninterrupted emergency surgical services, it was necessary for us to develop protocols and policies to safeguard our workforce. The existing data on managing surgical emergencies during a pandemic was scarce when we went into the first lockdown in March 2020. Most available publications were in the form of guidelines and recommendations based on experiences.[345] Lack of knowledge and information while facing an unprecedented emergency such as this, was causing significant anxiety regarding the delivery of appropriate treatment for patients as well as the safety of the health care team.

Since that time, there have been many publications discussing the postoperative outcomes in COVID-19 patients as well as asymptomatic untested COVID-19 carriers.[6789] Isolated reports describing the institutional organization to allow continuation of emergency surgical activities, have come up later in 2020.[10] No publication has discussed chronological positivity rate in surgical patients.

In this paper, we have reviewed the operational challenges faced and the protocols followed by our unit while managing the patients presenting in surgical emergency. The study period was from 25th March to 24th August 2020 during which there were 22 on-call days. We have analyzed the reverse transcriptase- polymerase chain reaction (RT-PCR) testing rates, the trend of COVID-19 positivity amongst admitted patients over the period, swab positivity amongst patients who were positive and negative for the screening protocol, grade of COVID-19 affection, and the outcomes in emergency surgical patients. We also studied the incidence of unprotected exposure leading to quarantine or symptomatic affection by the virus amongst the health care providers of our unit during the study period.

Operational challenges

Our challenges began by giving up our regular emergency surgical room (ESR) and ICU and thereafter all our general wards. The ESR was relocated to a distant place and had a significant shortage of infrastructure and equipment. Due to space constraints, it was difficult to isolate suspected patients before their swab reports were available. One-third of our workforce was diverted for COVID-19 duties leading to manpower shortage. At the outset, RT-PCR testing was not freely available; hence, we had to rely on screening protocol and highresolution CT(HRCT) findings. In addition, personal protective equipment (PPE) was scarce.

Policies implemented

From 14th March 2020, we restricted our elective lists to cases that could be performed under regional anesthesia. Residents of the unit were divided into two teams, that took turns working in wards and emergencies. Regular use of N95 masks, caps, gloves, and face shields was adopted. Adequate distancing from patients and minimal handling of fomites was observed. We followed a policy of maximum testing. By around 3rd May 2020, the facility for testing was ramped up. Thereafter, we could test every patient admitted to our unit for RT-PCR to rule out COVID-19. Before this, there were stringent criteria to conduct testing and even if we wished to, testing every patient was not allowed.

We used a screening protocol to categorize patients referred to us into screen positive and screen negative based upon the findings. [Figure 1] This algorithm was based on guidelines by the American College of Surgeons[4] and the Royal College of Physicians[5] as well as those by the Ministry of Health and Family Welfare. This primary surgical triage allowed us to identify screen-positive patients at the first point of contact. [Figure 1] All residents working in the triage, as well as ESR, were provided with a full complement of PPE.

Figure 1

Algorithm for screening at the triage area

In the routine course of events, the results of RT-PCR were available after about an 18–24 h delay. For surgical emergencies, waiting for this period would mean increased morbidity and mortality. So, most of the emergency surgeries were performed before the swab result was available. As a policy, all patients were considered as COVID-19 positive, and OT cleaning protocols were managed accordingly. One OT was dedicated to operating upon proven COVID-19 positive patients. Pre-operative anesthetic check-up was done immediately before the surgery inside the operation theatre. All anesthetists, surgeons, nurses, and workers wore full PPE. The minimum number of surgeons necessary would scrub for the surgeries. Surgeons entered the OT after intubation and vacated during extubation. The use of cautery was minimized, and cautery smoke was evacuated at its origin using suction tubing.

Postoperatively all patients were kept in ESR while awaiting swab results. The patients who were clinically suspected to be COVID-19 positive were kept isolated in the rooms available in ESR. Those who tested positive were transferred to a COVID-19 isolation ward. The patients who tested negative were then transferred to either general wards or surgical ICU depending upon their clinical condition. Local sanitization was carried out as per institutional protocol.

As per the institutional guideline, an incident report of every COVID-19 positive patient was sent to the Department of Community Medicine with details of protective protocols followed by the team during treatment. If they encountered a breach of protocol or risk of exposure, quarantine would be recommended.

Patients and Methods

A proforma for all patients admitted through the ESR on our call days was maintained. Details of clinical presentation, management, the result of RTPCR if done, grade of COVID-19, and outcome were recorded. The grade of COVID-19 affection was decided based upon the Journal of Heart and Lung Transplantation classification which is being used in our institution. Stage 1 is the early phase and 2 is pulmonary, in which, 2a is without hypoxia and 2b with hypoxia.[11]

Based on the data collected, we reviewed the following: total patients triaged, total admitted, clinical presentation, operative procedures performed, number of screen positive and RT-PCR positive cases, and COVID-19 grading of swab positive cases. The chronological screen and swab positivity were determined, and the positivity of operated patients was compared to that of the general population. The cause of mortality was studied.

Ethics

Approval from the Institutional Ethics Committee was obtained to carry out a retrospective review of this prospectively maintained database.

Results

Of the 222 patients presenting in emergency surgical ward during the study period, 54 were screen positive. Twenty-three of these were from the outpatient group and were referred to emergency medicine department. Figure 2 gives the spectrum of clinical presentations amongst all the screened patients (N = 222). Inpatient care was needed for 110 patients. The month-wise clinical presentations amongst the admitted patients (n = 110) are shown in Figure 3. Abdominal complaints were the most common presentation. The chronological distribution of cases of trauma (63 of the 222) is shown in Figure 4. There were no cases of trauma in the month of April.

Figure 2

Clinical presentations of all patients examined in emergency surgical ward (N = 222); DVT = deep vein thrombosis

Figure 3

Month-wise distribution of clinical presentations of indoor patients (N = 110)

Figure 4

Month-wise distribution of trauma cases amongst all screened patients

Of the 110 admitted patients, 31 were screen positive and 79 were screen negative. Eight out of these 31 screens positive and 20 out of 79 screen negative patients, tested positive on RT-PCR. Altogether, 28 out of 110 patients were RT-PCR positive. [Figure 5] The difference in RT PCR positivity between screen positive and screen negative patients was statistically not significant. (25.8 vs 25.3% P = NS).

Figure 5

Symptom and swab positivity in admitted patients over the study period

Table 1 shows the clinical diagnoses of the nonoperated patients (N = 50). In 60 patients, the intervention required was either surgical (54) or endoscopic (6). Surgical procedures included septic procedures (28), laparotomies (24), and craniotomies (2). Ten out of 14 procedures in June (71.4%) were for septic conditions like diabetic foot (5), peripheral vascular disease (2), abscesses (2), and infected hematoma (1). These were in the form of amputations (5), debridements (2), abscess drainage (2), and infected groin hematoma evacuation (1). In May and July, they constituted 53.8% of all procedures each, and in August procedures for septic conditions went down to 16.67% (1 of 6).

Table 1

Spectrum of diagnosis of nonoperated patients (n=50)

Diagnosis	Number of patients
Polytrauma	11
Biliary calculi	5
Pancreatitis	4
Subacute intestinal obstruction	4
Other acute abdominal complaints	7
Head Injury	9
DVT (including iliac and renal vein thrombosis)	5
Non healing ulcer	3
Per Rectal bleed	1
Blunt abdominal trauma	1

Of the 28 COVID-19 positive patients, 14 underwent surgery and 4 required endoscopy (n = 18).

Seventy percent of the admitted patients were tested for RT-PCR, and 36.36% of those yielded positive results. Table 2 shows monthly data of the number of patients screened, admitted, tested, positive, as well as positivity in operated patients.

Table 2

Total patients screened, admitted, operated, tested, the result of the test, and rate of positivity

Month*	Total patients screened	Patients Admitted	Patients Tested for COVID	COVID Positive	Operated patients**	COVID Positive operated patients	Positivity in total admissions	Positivity in operated patients
April	18	18	3	0	14	0	0	0
May	33	18	11	2	13	2	11.1%	15.4%
June	49	28	21	7	14	5	25%	35.7%
July	90	30	26	11	13	7	36.67%	53.8%
August	32	16	16	8	6	4	50%	66.67%
Total	222	110	77	28	60	18

*The nomenclature used for the months includes the time period beginning from the 25th of the previous month up to the 24th of that month, e.g., April includes 25th March-24th April **Operated patients includes all surgical interventions and endoscopies

The positivity rate amongst operated patients was consistently higher than that of nonoperated patients and of the general population, as depicted in Table 1 and Figure 6.

Figure 6

Positivity amongst surgical patients vs the general population

Table 3 shows the demographic and clinical profile of the COVID-19 positive patients. Of the 28 positive patients, 17 were stage 1 (mild COVID-19 severity), 8 were stage 2a, and 3 were stage 2b.[11]

Table 3

Clinical and demographic profile of COVID-19 positive patients (n=28)

Parameter	Value
Age range	20-65
Sex Ratio	M:F=1.5:1
Presentations
Abdominal	7
Septic	8
Vascular	4
Trauma	5
Other	4
History of COVID
Newly diagnosed COVID	24
Previously treated but RT-PCR positive again	3
RT-PCR turned positive during hospitalization	1
COVID Staging
1	17 (14+3*)
2a	8
2b	3
Treatment
Conservative	10
Operative	14
Endoscopic	4
Outcome
Discharged	24
Death	4
Total Positive	28

*For three patients who were intubated on admission, no clinical symptom screening was possible; however, history, X-ray, and CT chest findings were negative hence grouped into grade I

Total mortality was 14 out of 110 (12.72%). [Figure 7]. There were four deaths among 28 COVID-19 positive patients with an age range of 35–50. Only one of these had comorbidity of hypertension with a past history of cerebrovascular accident. This patient also had chest CT findings of ground-glass opacities classical of COVID-19. In this case, mortality might have been due to pulmonary complications. In the rest, the cause of death was a severe underlying surgical condition. Mortality between the operated COVID-19 positive and proven COVID-19 negative patients was 2/18 (11.1%) and 3/21 (14.28%), respectively. The difference between the two was not statistically significant.

Figure 7

Mortality distribution amongst all admitted patients

None of the resident doctors or faculty members were advised quarantine during this period. They also did not become symptomatic or need testing for COVID-19.

Discussion

The Department of General Surgery at KEM Hospital has been at the forefront in managing the Mass Casualty Incidents as well as Medical Disasters in Mumbai in the past.[1213] The COVID-19 pandemic, however, posed a challenge to us just as to health care systems all over the world. Being a major pillar of the healthcare infrastructure of Municipal Corporation of Greater Mumbai, our hospital had to step in and scale up from 0 to 494 COVID-19 beds by the end of April. This led to the restructuring of our ESR and ICU with the shortage of beds, equipment, and personnel. As our hospital was not declared as a dedicated COVID-19 facility, we had to continue providing emergency surgical care to the untested general population amidst this shortage.

Our policy of limiting resource use by dividing residents into teams helped to reduce the exposure of the workforce. Other papers have also discussed such protocols for restructuring the department.[14] All the precautions taken during pre-, intra-, and postoperative care were directed towards reducing the following: unnecessary patient movement, time spent by the health care workers in an uncontrolled environment, chances of accidental exposure, and amount of exposure during surgery.

Till the first week of May, the facility for testing was limited, and though we would have preferred to test all the emergency surgical patients, we were unable to do so. Knisely et al.[8] report similar logistical problems from New York, where universal testing was only available at a later date. Additionally, the RT-PCR test was reported to have a false-negative rate as high as 30%.[15] Due to these factors, we chose to consider all patients as COVID-19 positive till their swab results were available. This approach reinforced the precautions to be taken and proper use of PPEs. We could hence undertake surgical interventions within the routine time frame even during the pandemic.

Screening at the surgical triage helped identify patients highly suspected of COVID-19. In such patients, if the surgical problem was minor or secondary, the patients were directly referred to Emergency Medicine Department. Knisely et al.[8] did not use any screening protocol and found a significant difference in COVID-19 detection rate before and after routine use of RT-PCR as the only screening tool (7.7% vs. 65%). We identified 54 patients as screen positive in the entire group of 220; 23 patients were from outpatients and 31 patients from the 110 patients who required admission. Thus, screening helped to identify and isolate them thereby reducing our exposure.

Based on a screening protocol, the number of patients suspected of COVID-19 was highest in the month of April. Subsequently, the screen positivity decreased serially. The swab positivity amongst the screen positive and negative patients was nearly the same: 25.8% (8 out of 31) vs. 25.31% (20 of 79). This shows that screening by itself was not sufficient to suspect COVID-19 infection. It may be postulated that as the virus spreads in the community, the screening protocols are ineffective in identifying high-risk cases. This underlines the need to test all patients admitted for surgical purposes and continue precautions with masks, face shields, and PPE where necessary. Nahshon et al.[9] have found a 27.5% mortality rate for preoperatively asymptomatic patients, who were diagnosed only in the postoperative period and had severe pulmonary complications. They too advocate testing all patients preoperatively.

Owing to the strict lockdown in India and the unavailability of public transport, only 18 patients presented over 4 call days from 24th March to 23rd April. There was a steady rise in the percentage of admitted patients testing positive for COVID-19 from 0% in April, to 11.1%, 25%, 36.67%, and 50%, in May, June, July, and August, respectively. The proportion of operated cases testing COVID-19 positive rose serially from 0% in April to 15.4% in May, 35.7% in June, 53.8% in July, and a peak of 66.67% in August. The swab positivity rate of an average symptomatic resident of Mumbai was 18.3% at the time.[16] Hence, we observed that the COVID-19 positivity amongst the patients admitted during the surgical emergency and especially those requiring surgery far exceeded the general population rates of Mumbai city.

The commonest presentations were abdominal complaints followed by trauma and septic cases. A total of 71.4% of the operative interventions done in June in COVID-19 positive patients were for septic illnesses. In May and July too, this percentage was 53.8% of the total procedures. This reflects an impact of the lockdown which prevented diabetics and other immunocompromised patients from following up for routine care. This parallels an Italian study that found that amputations in diabetics had increased significantly during their lockdown.[17]

The pattern of trauma also reflects the impact of national lockdown on population movement. The admissions were 0 in April and in May, June, and July were 6, 17, and, 31 respectively. A similar study attributed a decrease in trauma admissions to the lockdown.[18]

Few COVID-19 positive patients had vascular presentations in unusual clinical settings. Deep venous thromboses, acute arterial thromboses, and ischemic bowel disease due to thrombosis without any other prothrombotic conditions were encountered. Considering the pathophysiology of COVID-19, such presentations should be viewed with suspicion by the first responders.

In 27 out of 28 COVID-positive patients, the swab at admission was positive. This means that the patients had come with infection from the community. In only one case, did a patient test positive for COVID-19 on Day 12 of admission after two prior negative RT-PCR reports. He had undergone significant in-hospital movement, like multiple CT scans, shifting to OT and ICU. Whether this was an occurrence of hospital-acquired coronavirus or a case of earlier false-negative swab report, is a matter of speculation.

Three of the 28 patients who tested positive when they presented to us with surgical complaints had been discharged from a COVID-19 ward within the prior month. All were swab negative at the point of discharge. The unreliable sensitivity of the swab and the unpredictability in the shedding of the live/dead-virus for unknown periods of time may lead to such confounding results. This stresses the need of creating awareness about the variability of RT-PCR results later in the course.

The overall mortality of the group was 12.7%. Mortality between operated COVID-19 positive and COVID-19 negative patients did not differ statistically. Three out of four deaths in COVID-19 positive patients were due to severe underlying surgical conditions and not due to acute respiratory distress syndrome (ARDS). In one patient, chest complications could have contributed to mortality. It is important to note that most of these patients had milder grades of COVID-19. The high rate of COVID-19 positivity amongst emergency surgical patients, did not translate into increased mortality. This is as opposed to other studies which have found surgical mortality in COVID-19 positive patients close to 25%.[1] However, this study from Lancet has a mixed population of patients diagnosed with COVID-19 both pre- and postoperatively undergoing both elective and emergency surgeries. In the subgroup of emergency operations on perioperatively diagnosed COVID-19 with no pulmonary complications, the mortality was around 8%. Thus, it is the presence of pulmonary complications, which is the source of higher mortality in these cases. Many other studies have also found very high postoperative mortality in COVID-19 patients.[6789]

Many publications and surgical societies have advised delaying intervention till the availability of swab reports and have advocated conservative management if possible.[13] However, this may be harmful to cases of trauma and acute abdominal catastrophes. All our emergency surgical procedures were performed before obtaining the RT-PCR report. Thus, we were unaware of the COVID-19 status of patients at the time of surgery. Yet, because of the policies instituted, none of the surgeons of our unit were inadvertently exposed or infected. As per the institutional policies laid down by Community Medicine Department, none of them required to be quarantined as they had followed all proper protocols for avoiding exposure. Similar reports have been published with very low mortality in an essential emergency as well as elective cases by establishing proper protocols, robust screening, and testing.[1019]

Conclusions

The overall policies adopted by our unit ensured that none of our surgeons were inadvertently exposed, or infected with COVID-19, and this ensured smooth functioning despite constant rotations for COVID-19 duties. A screening protocol may help to identify high-risk patients and has to be supplemented with testing. It is advisable to test all patients preoperatively. As per our data, there is a high positivity amongst patients requiring emergency surgical intervention. A mandatory RT-PCR for all patients on admission, continued regular use of PPEs at surgical receiving points and the operation theatres, the institution of strict isolation, and OT sanitation between cases should continue in the future. Unusual vascular presentations should be viewed with suspicion. Mortality for operated COVID-19 positive patients does not differ significantly from the COVID-19 negative group in milder grade patients. Hence, in milder grades of affection, it is not necessary to delay emergency interventions. Also, with proper protective protocols, the risk of infection amongst health care workers is minimal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.