Commentary: Coronavirus disease 2019 (COVID-19): Adaptive realignment makes me want to work eight days a week.

Richard Lazzaro, MD, FACS, and Matthew Inra, MD

Adaptive realignment allows hospitals and health systems to adapt to the system strains encountered by future pandemics and maintain surgical volume for better patient care and hospital fiscal health.

See Article page 378.

In this month's issue of the Journal, Villena-Vargas and colleagues report on the “safety of lung cancer surgery during COVID-19 in a pandemic epicenter.” The authors retrospectively reviewed a prospective database and identified 57 patients who underwent lung cancer resection before the pandemic (January 1, 2020, to March 10, 2020), and 41 patients during the initial phase of the pandemic (March 11, 2020, to June 10, 2020) who underwent lung cancer resection, with a primary end point of acquisition of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the first 90 days after surgery. Both 90-day perioperative morbidity and mortality were recorded as secondary end points. Acquisition of SARS-CoV-2 infection during the first 90 days after surgery was not significantly different between the 2 groups but tended to be more frequently acquired during the pandemic; 3.5% (2/57) of patients operated on before the pandemic and 7.3% (3/41) of patients during the initial phase of the pandemic acquired SARS-CoV-2 infection. Consistent with previous reports, acquisition of SARS-CoV-2 infection is associated with high mortality.

The pandemic has affected all of us. A surgeon often reflects about quality, volume, academics, and mentoring. Experience leads to good judgment. We had no experience with SARS-CoV-2 before the pandemic and witnessed health systems and hospitals adapt immediately to an unknown foe. Intensive care units filled quickly to capacity, personal protective equipment was scarce, and resources to deliver patient care required limitations to elective surgery. “Shortage of ICU beds during the peaks → cancelling scheduled surgeries due to the lack of beds → hospital financial losses → staff furloughs → exacerbated shortage of staffed hospital beds coupled with ED overcrowding → delays in resuming elective surgeries and intensified financial strain.”

Villena-Vargas and colleagues not only advocate that patients undergo preoperative testing for coronavirus disease 2019 (COVID-19) but also that patients maintain mask-wearing and social distancing postdischarge to limit the risk of community-acquired SARS-CoV-2 infection. Restoring surgical services safely during the pandemic allows us to deliver care to those who require it, when there are no suitable alternatives and a delay in care would negatively impact that patient's well-being. Many surgeons and hospitals prefer to operate early in the week so that patients are discharged home by the weekend. Critical to ensuring safe delivery of surgical care to patients “lies in smoothing surgical case volume across all weekdays (and, ideally, across 7 days a week where possible).” “Hospitals that have streamlined their patient flow have enjoyed multimillion-dollar annual savings and substantial improvements in patient care.”

Redeployment of hospital staff and resources must be evaluated with a collective goal to maintain elective surgery, with equitable daily case distribution to avoid “artificially induced and uneven demand for hospital resources.” Sir Paul McCartney once asked a chauffeur how he was doing. The chauffeur remarked, “working hard … eight days a week.” The time is appropriate for adaptive realignment (universally streamline services and optimize resources) so that hospitals and health care workers can work 8 days a week.