Recommendations and Guidelines during COVID-19 in Britain
On 20th March 2020, the Royal college of Surgeons
(RCS) published its initial, brief guidance for surgeons who were
working during the COVID-19 pandemic, emphasizing the safety of the
working force as well as the maintenance of emergency surgical workforce
and capabilities (5). The detailed guidance came into force on
26th of March 2020 outlining the scope of patient
selection and flow of surgical practice across the UK. Since then, the
guidelines have been updated four times, lastly on 5thJune 2020.
The initial guidance involved cancellation of all elective operating
cases, with focus on operating on urgent/emergency and otherwise
life-saving procedures (6). Patients were categorised into four levels
according to their need for surgery:
- Priority level 1a Emergency - operation needed within 24 hours
- Priority level 1b Urgent - operation needed with 72 hours
- Priority level 2 Surgery that can be deferred for up to 4 weeks
- Priority level 3 Surgery that can be delayed for up to 3 months
- Priority level 4 Surgery that can be delayed for more than 3 months
With the gradual decline in the cases of COVID-19, the service gradually
resumed its activities, slowly re-introducing elective surgery on a
phased basis. Elective cases were prioritised as Red, Amber, Green (RAG
rating) with red been classified as “urgent elective”.
With a similar approach but at a more specialized level, the SCTS
introduced national guidelines on the performance of cardiac surgery. As
its initial response, the society introduced a clear cardiothoracic
surgery escalation framework on 16th and
18th March 2020; which outlined the routine practice
of operating theatres, clinics and the running of multi-disciplinary
team (MDT) meetings (7). It classified cardiothoracic patients in 4
areas, the obligatory in-patients, which required surgical intervention,
the alternative (non-surgical) pathways including inpatients and those
to be managed by ambulatory base services, the day-cases and, finally,
the outpatients, whose hospital visits were to be kept at the minimum
safe level. The society also developed a clear pathway for patient
selection during the initial lockdown and to smooth the gradual
resumption of elective activity. The guidelines not only included
patient selection but also focused on triage methods of such cohort,
COVID-19 screening methods and tests, the use of PPE and the management
of operating theatres. These guidelines were implemented nationwide and
helped in containing the spread of COVID-19 in cardiac surgery patients.
(8) The society’s latest guideline on resumption of elective activity
eliminates the requirement for pre-operative radiological screening if
they have been self-isolating for 14 days prior to surgery, provided
that they have no COVID-19 related symptoms and have negative COVID-19
nasopharyngeal swab within 72 hours of surgery date. (9)
The NHS also issued several, nationwide guidelines to provide insights
on speciality practice during COVID-19 pandemic. Most of the clinical
guidelines and recommendations were interlinked with the work of the RCS
and SCTS. The NHS and PHE recognized that cardiothoracic surgery, like
any other speciality, needed service modification which depended on the
unit and the region of service, considering that some cardiothoracic
units are incorporated as part of a large trauma centres while others
are tertiary units without emergency department service (10). The NHS
categorized the patients into 6 major groups:
1. Obligatory in-patients : Those patients who need immediate
admission and surgical intervention
2. Alternative pathways : this is categorized into two
subgroups:
a. In-patient: the condition can reasonably be managed on an
ambulatory basis after a more limited in-patient stay than normal; eg
ambulatory chest drain management.
b. Ambulatory: the condition can reasonably be managed on an
ambulatory basis.
3. Day-cases : Surgery can be safely undertaken for a large
number of conditions.
4. Surgery and interventional care that can be postponed
5. Trauma surgery.
6. First contact and clinics.
In addition to above, the work of the cardiothoracic team was expanded
to have a consultant led service, including patient assessment, daily
reviews and decision-making process. The NHS also advised to restructure
training and education needs during this time period to give priority to
COVID-19 patients care provision (12,13). In its latest guide, the NHS
advised to utilize a remote consultation, where appropriate. However,
when face-to-face consultations were needed, patients were brought in
for further assessment in a controlled and organized manner (11).
PHE, NHS, SCTS and RCS eventually merged their statements to restructure
the daily practice of cardiac surgery including modification of hospital
setups, patient selection and screening process as well as standards for
intubation, operating and provision of perioperative care for such
patients. The joint statements were released in accordance to the
severity of COVID-19 pandemic within the UK general population and the
phase of the disease.