Restoration of Colorectal Services in the Recovery Phase of the COVID-19 Pandemic: A view from Oxford

The coronavirus pandemic has signicantly disrupted the way we deliver healthcare worldwide. We have been exible and creative in order to continue providing elective colorectal cancer operations and to restart services for benign cases during the recovery period of the pandemic. In this paper, we describe the impact of coronavirus on our elective services and how we have implemented new patient pathways to allow us to continue providing patient care. Methods Data on major colorectal elective resections was prospectively collected in an Enhanced Recovery After Surgery (ERAS) database. Data on the number of proctology cases and telemed appointments were collected from the hospital theatre information management system and electronic patient record system respectively.


Abstract Background
The coronavirus pandemic has signi cantly disrupted the way we deliver healthcare worldwide. We have been exible and creative in order to continue providing elective colorectal cancer operations and to restart services for benign cases during the recovery period of the pandemic. In this paper, we describe the impact of coronavirus on our elective services and how we have implemented new patient pathways to allow us to continue providing patient care.

Methods
Data on major colorectal elective resections was prospectively collected in an Enhanced Recovery After Surgery (ERAS) database. Data on the number of proctology cases and telemed appointments were collected from the hospital theatre information management system and electronic patient record system respectively.

Results
During the pandemic, there was a complete shift towards cancer cases, with benign services and proctology cases being placed on hold. Hospital length of stay was reduced. We implemented earlier hospital discharge and more intense telephone follow up after elective major surgery. This has not resulted in an increase in post-operative complications, nor any increase in readmission into hospital.
During the recovery phase, we have introduced a higher proportion of telemed consultations, including one-stop telemed proctology clinics, resulting in straight to tests or investigations.

Conclusions
We have created a streamlined multi-disciplinary pathway to reinstate our elective colorectal services as soon as possible and to minimise potential harm caused to patients whose treatment have been delayed.
We anticipate many of these changes will be permanently incorporated into our clinical practice once the pandemic is over. Background COVID-19 has had a signi cant global impact on the delivery of elective colorectal surgery. (1)(2)(3)(4)(5) There has been a huge challenge in delivering safe care in the treatment of patients with colorectal cancer, and even modest delays can lead to signi cant impact on survival (6,7). During the peak of the pandemic, hospitals have been prioritising elective surgery for patients with cancer and delaying all non-essential surgery for benign conditions. Much of the literature has focussed on guidelines and strategies to maintain services for colorectal cancer throughout the pandemic. (8)(9)(10)(11) In the UK, we are now entering the recovery phase of the pandemic, and we are gradually opening up our elective services to meet the clinical needs of all our patients. In this paper, we describe our strategy and the implementation of new patient pathways to help streamline our service.
We are fortunate that our Trust has split sites and therefore we have been able to segregate patients into COVID-positive and negative cohorts allowing for safer and more streamlined patient care. (12,13) The John Radcliffe hospital is for emergencies and for COVID-positive patients, where our Surgical Emergency Unit (SEU) is based. The Churchill hospital is for COVID-negative patients who are screened prior to elective surgery. We are performing day case proctology procedures in COVID-negative screened patients in an independent hospital in Banbury (Foscote hospital). This has allowed us to safely continue our elective cancer surgery during the pandemic peak and gradually increase our benign colorectal service during the recovery phase of the pandemic.

Methods
The data on major colorectal elective resections was prospectively collected in an Enhanced Recovery After Surgery (ERAS) database. The data on the number of proctology cases was collected from the hospital theatre information management system (TIMS). The data on the number of telemed appointments was collected from the electronic patient record system (EPR, Cerner Millennium). All data points were anonymised prior to analysis. Data was analysed using GraphPad Prism 8. Mann Whitney test was performed on non-parametric data.

Elective Major Resections
Overall, from 1 st March to 31 st June 2019, in our centre there were 192 elective patients undergoing major surgery, of which 117 were for cancer, 50 for IBD and 25 for benign disease. For the same 5-month period in 2020, there were 133 elective patients, of which 107 were for cancer, 17 for IBD and 9 for benign disease ( Figure 1). Although overall numbers of elective patients were reduced during the pandemic, we were able to maintain a similar number of cancer operations. After UK national lockdown on 23 rd March 2020, we prioritised cancer operations and this was re ected in an increased number of cancer operations in March 2020 and all elective operations in April 2020 were for cancer ( Figure 2). In May 2020, there was a reduced number of cancer operations as there were fewer referrals being made through clinic, and fewer cancers being diagnosed due to a reduction in endoscopy services. During the recovery phase of the pandemic, from May to June 2020, we have managed to restart our services for IBD and benign colorectal conditions.
During the peak period, we focussed on cancer patients and dual consultant operating was implemented to increase the throughput of cancer operations. The patient case-mix changed and the proportion of patients undergoing operations for IBD and other benign disease reduced, in accordance with ACPGBI guidelines (14). In view of the signi cantly raised mortality and pulmonary complications in patients undergoing surgery with coronavirus (15), when this was discussed with patients with benign disease, many opted to defer their operation to a later date. From a management perspective, the patients who were offered a date for surgery but who declined due to risks associated with COVID still counted towards some of the main NHS targets, including the 52-week target.
The median length of stay for patients was 5 days in the March-July 2019, compared to 4 days in 2020 (IQR 4-8 vs 3-6, Mann Whitney test p<0.0001). (Figure 3) To investigate if this was due to a change in case mix and that we were performing fewer complex IBD operations during the pandemic, we also examined the median length of stay for cancer patients only. This was 6 days for March-July 2019, and 4 days for 2020 (IQR 4-9 vs 3-6, Mann Whitney test p<0.0001). (Figure 3) The reduction of hospital length of stay was achieved by discharging patients earlier and following them up carefully in a daily virtual ward round by telephone. These patients also underwent more frequent telephone follow up by our ERAS nurse specialists upon discharge. Patients were discharged from telephone follow up when both the patients and clinicians were happy with their recovery progress.
For the same cohort of patients, the readmission rate to SEU was 23/192 (12.0%) in 2019 and 10/133 (7.5%) in 2020, (Chi-square test p=0.19) (Figure 4). Our patients underwent more frequent telephone follow up by our clinicians and by our ERAS nurse specialists with the aim to offer earlier support, advice and enable escalation of any complications or concerns. Overall, we found that our readmission rate during the COVID peak and recovery phase was not statistically different compared to the corresponding period in 2019.
The reduction in reattendance rate may be due to patient anxiety about attending hospital during the peak period. It may also be due to improved ERAS telephone support following discharge from hospital, where patients were signposted to GP for assessment and antibiotic prescriptions for surgical site infections and urinary tract infections, and for wound reviews remotely by the ERAS team.
Examining the readmissions and reattendances data on a monthly basis, we observed a reduction in numbers of patients being readmitted and reattending SEU during the peak months of April and May 2020, with a gradual return to pre-COVID-19 levels during the recovery phase of the pandemic ( Figure 5). This dip in numbers does mirror the reduced number of operations we were performing during the same time period, but it could also be due to patient anxiety about attending hospital during the pandemic. Overall morbidity and mortality were similar across both time periods in 2019 and 2020. (Figure 6 In April and May 2020, there were virtually no proctology cases performed apart from urgent biopsies and cases suspicious for cancer. The number of proctology cases gradually increased during the recovery period of June and July 2020.

The Patient Pathway with Benign Conditions in the Recovery Phase of the Pandemic
Due to the widespread disruption of clinical activity and outpatient services, speci c patient pathways have been devised to streamline our service during the recovery period of the pandemic (Figure 8).
Telemed appointments are increasingly used to triage patients and to minimise foot fall in hospital. We are also able to provide ongoing virtual colorectal services to selected patients. The outcomes of telemed appointments include bringing patients to clinic face to face, straight to test (CT/ MRI / FIT/ endoscopy), listing patients for surgery, further telemed appointment, and discharge, for patients that have previously been seen in clinic.
We have also introduced one stop triaging and telemed clinics for proctology patients. (Figure 9) For patients who have symptoms of rectal bleed with no colonic symptoms, and over the age of 40, they are booked straight for exible sigmoidoscopy. For patients that are under the age of 40, with no colonic symptoms +/-symptoms of rectal bleed, they would be offered an initial telemed consultation. If their history is suggestive of a rectal prolapse, we would arrange for them to have a exible sigmoidoscopy +/banding, and refer to our pelvic oor nurse specialists for pelvic oor assessment if required. For patients with haemorrhoids, we would arrange for them to also have a exible sigmoidoscopy +/-banding. For patients with an unexplained anal mass, we would see them in clinic face to face urgently. For an acute history suggestive of anal ssure, we would trial conservative measures and use of 0.4% GTN or 2% diltiazem cream and review again in telemed after 2 months. For patients with chronic anal ssures, anal stula or pilonidal disease, we would arrange for them to have an EUA +/-proceed. These pathways are only guidelines. For example, a patient who has had multiple unsuccessful bands previously may bene t from a HALO procedure and therefore would be booked for a day case procedure rather than another exible sigmoidoscopy and banding.
Once patients are listed for surgery, they are strati ed according to their clinical need and they are also assigned a COVID vulnerability score (i.e. the likelihood of a patient having excess mortality due to COVID-19) ( Figure 10). A fail-safe date for each patient is also documented, ensuring that patients are reviewed by a certain time frame if they have not been operated on or seen again in clinic. These actions enable our department to ensure patients are managed in an appropriate timeframe in order to limit the risk of harm.
Prior to surgery, a patient health screening questionnaire is performed via telephone. In accordance to the latest NICE guidelines, the patient undergoes comprehensive social-distancing for 14 days prior to their scheduled procedure (16). They will also undergo a coronavirus swab test within three days prior to admission at a drive-in facility to minimise hospital contact, and they are advised to self-isolate from the day of the test until the day of admission.
Pattern of telemed consultation usage during the pandemic Virtually all face to face clinic appointments were cancelled immediately after UK national lockdown on 23 rd March 2020. During the peak of the pandemic, there was a complete shift towards telemed consultation, unless a patient needed to be reviewed or seen face to face. (Figure 11) During the recovery phase of the pandemic, we have seen a gradual restoration of face to face appointments, but telemed appointments still play an important role for patients who are unable to come to hospital for shielding or personal reasons.
There were also signi cant changes in the provision of stoma specialist nursing. Prior to lockdown, the majority of stoma patients (82/98, 83%) were seen face to face with the remainder followed up by telemed appointments. Since lockdown in March 2020, virtually all appointments have been telemed. In lieu of formal face to face clinic appointments, most patients have been happy to use digital photography to email their stoma pictures for opinion. We are also in the process of starting video consultation with our patients (17). During the recovery phase of the pandemic, stoma nurses have been arranging ad hoc face to face meetings with patients to tie in with any other hospital appointments they have, for example in the radiology department or oncology outpatients, thereby streamlining the patient's hospital journey There has also been an increased use of telemed and virtual consultation in our patients on the ERAS programme. Prior to the onset of COVID-19, there was an emphasis on patient optimisation prior to surgery. Plans to launch phase 1 of the ERAS Prehabilitation programme have now been put on hold, and resources have been directed towards supporting more intense ERAS nurse led follow up. Wound reviews are now done by email with patients sending in photos which are later uploaded onto their electronic patient record. Patients are now more engaged with their own care, management and recovery, and are eager to be discharged quickly. They feel more empowered and many are doing their own wound management rather than relying on district/practice nurses.
One potential drawback of the increased use of telemedicine is that it does carry a risk of wrong or delayed diagnosis. However, if we were not to offer telemedicine at all, it runs the risk of delaying seeing patients who are otherwise shielding and would not be able to come for a face to face clinic appointment.
On balance of probabilities, we believe that telemedicine can be a useful tool to help restart services during the recovery period.

Conclusions
The coronavirus pandemic has signi cantly disrupted the way we deliver health care. We have created a streamlined multi-disciplinary pathway in an attempt to reinstate our elective colorectal services as soon as possible and to minimise potential harm caused to patients whose treatment have been delayed.
We have been exible and creative in order to continue providing elective colorectal cancer operations and to restart services for benign cases during the recovery period of the pandemic. Earlier hospital discharge and more intense telephone follow up after elective major surgery have not resulted in an increase in post-operative complications, nor any increase in readmission into hospital.
We have also introduced a higher proportion of telemed consultations, including one-stop telemed proctology clinics, resulting in straight to tests or investigations. We anticipate many of these changes will be permanently incorporated into our clinical practice once the pandemic is over.

Declarations
Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing interests: The authors declare that they have no competing interests Funding: Not applicable