Surgical care in Poland after COVID-19 outbreak: a national survey

: B a c k g r o u nd: During COVID-19 pandemic, it is necessary to collect and analyze data concerning management of hospitals and wards to work out solutions for potential future crisis. The objective of the study was to investigate how surgical wards in Poland are managing during rapid development of the COVID-19 pandemic. M e t h o ds: An anonymous, online survey was designed and distributed to surgeons and surgery residents working in surgical departments during pandemic. Responders were divided into two groups: Group 1 (responders working in a “COVID-19-dedicated” hospital) and Group 2 (responders working in other hospitals).Results: Overall, 323 responders were included in the study group, 30.03% of which were female. Medical staff deficits were reported by 21.15% responders from Group 1 and 29.52% responders from Group 2 (p = 0.003). The mean number of elective surgeries performed weekly prior to the pandemic in Group 1 was 40.37 ± 46.31 and during the pandemic was 13.98 ± 37.49 (p <0.001). In Group 2, the mean number of elective surgeries performed weekly before the start of the pandemic was 26.85 ± 23.52 and after the start of the pandemic, it was 7.65 ± 13.49 (p <0.001). There were significantly higher reported levels of preparedness in Group 1 in terms of: theoretical training of the staff, equipping the staff and adapting the operating theater to safely perform procedures on patients with COVID-19. Overall, 62.23% of responders presume being infected with SARS-CoV-2. C o n c l u s i o ns: SARS-CoV-2 pandemic had a significantly negative impact on surgical wards. Despite the preparations, the number of responders who presume being infected with SARS-CoV-2 during present crisis is high.


Introduction
The SARS-CoV-2 virus outbreak began in Wuhan in December 2019. It spread quickly throughout China and other countries. Since then, the epidemic has evolved rapidly, and COVID-19 was recognized by the World Health Organization (WHO) as a global pandemic in March 2020 [1]. By April the 8th, 2020 Polish Ministry of Health reported 5205 confirmed cases of SARS-CoV-2 infections in Poland with 159 deaths due to COVID- 19 [2]. At that time WHO reported over 1300000 cases globally [3].
The pandemic affected all fields, especially medicine [4]. We had to re-evaluate our work and health priorities. Hospitals and wards, including surgical departments are being reorganized globally to face the current pandemic and better prepare for potential future crisis [5]. Currently, it is necessary to collect and analyze data on this subject in order to work out better solutions for the future. There are reports from around the world, that the COVID-19 pandemic significantly affects the activity of surgical wards [6][7][8][9].
We aimed to investigate how surgical wards in Poland are managing during the COVID-19 pandemic.

Study design
Study was conducted under the patronage of the The Association of Polish Surgeons (TChP) and Polish National Consultant in General Surgery. An anonymous online survey was designed and published on the official website of TChP. Invitation for the study was also sent to all active members of TChP by email with instructions how to complete the survey. Data was collected between March the 30th and April the 6th of 2020. Online survey included single choice and open-ended questions. Response to every question was not obligatory. After data analysis responders were divided into two groups: Group 1 (responders currently working in a "COVID-19-dedicated" hospital, which was transformed by Polish Ministry of Health during SARS-CoV-2 pandemic into institution designated only for SARS-CoV-2 patients, including those developing symptoms and quarantined) and Group 2 (responders currently working in "non-COVID-19-dedicated" hospital).

Inclusion criteria
The study group included Polish surgeons and surgery residents working in surgical departments during pandemic, who granted an informed consent to participate in the study. Retired surgeons, physicians and residents with non-surgical specializations, medical interns, medical students, other health-care professionals were excluded from this study.

Survey
The survey included 44 questions and comprised four parts: 1. Study group characteristics (four single choice and three open-ended questions) 2. Status of surgical wards during the pandemic (three single choice) 3. Impact of the pandemic on conducting surgery (eight single choice and ten open-ended questions) 4. SARS-CoV-2 prevention (eight single choice and ten open-ended questions). The survey is presented in Appendix 1.

Statistical analysis
All data were analyzed using Statistica version 13.1PL (StatSoft Inc., Tulsa, OK, USA). The normal distribution was checked using a Shapiro-Wilk test. The results are presented as number and percentage, a mean with standard deviation (SD) or median with interquartile range (IQR), when appropriate. A comparison of quantitative data was made using Student's t-test or Mann-Whitney's test. Results were considered statistically significant at p <0.05.

Ethical considerations
The designed survey was fully anonymous. Personal data of participants collected during study, was not disclosed at any stage. The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments (Fortaleza). Participants were informed about the aim of the study and informed consent was obtained electronically prior to the beginning of the survey. The study was approved by the Bioethics Committee of the Jagiellonian University (1072.6120.103.2020).

Status of surgical wards during the pandemic
Among responders from Group 1, SARS-CoV-2 positive patients were hospitalized in 45 (86.54%) cases and in Group 2 in 102 (37.64%) cases (p <0.001). In Group 1, 42 (80.77%) responders reported smaller than usual number of patients being hospitalized on their ward, 1 (1.92%) reported usual number of patients on the ward, 2 (3.85%) reported full occupancy of the ward, 1 (1.92%) reported occupancy, which significantly exceeds the availability of beds and 1 (1.92%) reported the need to conduct a triage of patients requiring intensive care. In Group 2, 237 (87.45%) responders reported smaller than usual number of patients on the ward, 23 (8.49%)  Table 2).

Impact of the pandemic on conducting surgery
The mean number of elective surgeries performed weekly prior to the pandemic in Group 1 was 40.37 ± 46.31 and during the pandemic it was 13.98 ± 37.49 (p <0.001).
In Group 2, the mean number of elective surgeries performed weekly before the start of the pandemic was 26.85 ± 23.52 and after the start of the pandemic, it was 7.65 ± 13.49 (p <0.001). The mean number of emergency surgeries performed weekly prior to the pandemic in Group 1 was 12.12 ± 9.67 and after the start of the pandemic it was 5.38 ± 6.13 (p <0.001). In Group 2, the mean number of emergency surgeries before the pandemic was 8.74 ± 6.97 and after the start of the pandemic it was 6.74 ± 5.61  Table 3). Majority of surgeons participating in our study preferred laparoscopic access during COVID-19 pandemic -157 (48.61%) and believed it was a safe choice on a SARS-CoV-2 positive patients -160 (49.54%) (Appendix 3).

Discussion
This study was conducted during the sudden outbreak of the COVID-19 pandemic. Distributing the survey using internet allowed us to gather a large number of respondents. We observed significant changes in functioning of surgical wards, both in terms of occupancy of beds as well as in number of performed operations. It is important to notice, that our results concerning the preparation and security of personnel are not optimistic. Management of a hospital and a surgical ward during COVID-19 pandemic needs to quickly adapt. Bed capacity, especially on intensive care units can be rapidly depleted [10]. Additionally, providing continues coverage in terms of medical staff on infectious wards can be a challenge, due to high infection risk of medical staff and other circumstances associated with pandemic (i.e. closing schools, which results in members of medical staff being absent due to child care) [11]. In this study, respon- ders reported most often a smaller than usual number of patients on the ward. Deficiency of the medical staff was reported by over 21% of responders in Group 1 and 29% of responders from Group 2. It is important to notice that Poland at this point has not reached the peak of pandemic and this country was not hit by the pandemic as hard as, for instance Italy, Spain or USA [12]. Currently, multiple guidelines, reviews and directives are being published to improve the quality of care during the pandemic [13][14][15][16]. Cohen et al. propose, that among COVID-19 positive patients we should postpone elective surgery until the patient has recovered [17]. Unfortunately, not every kind of procedure can be postponed indefinitely. When it comes to oncological procedures -time is of the essence. Postponing procedures can possible result in increased mortality, although reasonable delay, for example in case of colon cancer is acceptable [18,19]. According to article by Tuech et al. it is important to balance the risk of pandemic and the risk of deferring the oncological procedure [20]. Our results present a major drop during the pandemic in reported mean number of performed elective surgeries weekly (28.99 vs. 8.69), which was not observed for emergency surgery (9.42 vs. 6.49). Oncological surgery was less frequently postponed, than bariatric, vascular or plastic operations. This results seem to be consistent with current recommendations [21]. In our study, most commonly performed operations on SARS-CoV-2 positive patients were emergency and oncological operations, which is consistent with available guidelines [22].
Although there is no scientific consensus, there are suspicions that laparoscopy, due to using pressured gas can potentially increase the risk of transmission of an aerosolized virus from infected patient to the operating theater staff [23]. Nevertheless, in this study, 48.61% of responders preferred using laparoscopy during the COVID-19 pandemic and 49.54% believed it is safe to perform on a SARS-CoV-2 positive patient.
COVIDSurg Collaborative advices to undertake pandemic preparations as part of routine hospital planning, before the emergence of crisis [24]. Majority of responders from both Group 1 and Group 2 reported that measures to prevent staff infection with SARS-CoV-2 were introduced before admitting the first patients with COVID-19 (65.38% and 54.61%, respectively). A recent report by Hasan et al. emphasizes the need to start training medical staff prior to the local start of the pandemic [11]. According to Al-Nsour et al. training programs should cover rapid response teams, points of entries, contact tracing, lab and sample management, infection control, cases management, and other processes [25]. Standardized training is immensely helpful in time of crisis by improving the clinical abilities of practitioners, which is reflected in better preparation for dealing with emergencies [26]. In this study, the level of knowledge about diagnosis and conservative treatment of COVID's-19 patients was comparable between groups but responders from Group 1 had higher level of knowledge concerning surgical treatment. Moreover, participants of Group 1 reported higher levels of preparedness in terms of theoretical training, equipping staff with appropriate PPE and adapting the operating theater to safely perform procedures in patients with COVID-19. Unfortunately, present crisis has shown, that global stockpile of PPE is insufficient [27]. Nevertheless, preventive measures are key and using PPEs (gloves, medical masks, goggles or a face shield, gowns, etc.) appropriately is absolutely essential to decrease the risk of infecting individuals in health-care, including those working on surgical wards [28].
COVID-19-dedicated hospitals in Poland were supposed to be the first-line of defense during the fight with COVID-19 pandemic. Other hospitals were also involved in treatment of patients, however those institutions continued their work without complete reorganization. Our results report, that COVID-19-dedicated hospitals were less overwhelmed with the total number of hospitalized patients and less frequently reported deficits of the medical personnel. This results from discontinuing majority of admissions concerning non-COVID-19 patients and transferring them to other institutions. Surgeons working there had significantly more chances to operate on infected patients, including emergency and oncological operations. Responders from Group 1 were also significantly better prepared to treat infected patients. This may have resulted from training, which was conducted more often in those centers.
Unfortunately, despite the preparation and training we observed that a worrisome percentage of responders believe they will be infected with SARS-CoV-2 because of working on a surgical ward during this pandemic, which was higher in non-COVID-19-dedicated centers (51.92% vs. 64.21%).
This study is associated with several limitations. The study group consisted of 323 responders, only from Poland. Therefore, it is difficult to generalize our results to other countries. The study was conducted before the pandemic has reached its peak in Poland, therefore situation could have change. The survey used an unvalidated questionnaire. Moreover, due to rapid development of pandemic using a validated survey was impossible. Major limitation was also self-assessment of knowledge by participants in the study. Our results are based on subjective opinions of responders and therefore are prone to bias. Future studies should be conducted on larger and more diverse study groups.
In conclusion, although vast majority of surgeons participating in this study reported usual or smaller then usual number of surgical patients on the ward, deficiency of medical staff was reported by a relatively large number of responders. SARS-CoV-2 pandemic had a significantly negative impact on the number of surgical procedures, which got postponed. Unfortunately, despite the preparation, the number of responders who presume being infected with SARS-CoV-2 during present crisis is over 60%.
What percentage of the norm, in terms of oncological surgery operations, is performed during the COVID-19 pandemic in your institution? [Number] What percentage of the norm, in terms of bariatric surgery operations, is performed during the COVID-19 pandemic in your institution? [Number] What percentage of the norm, in terms of vascular surgery operations, is performed during the COVID-19 pandemic in your institution? [Number] What percentage of the norm, in terms of plastic surgery operations, is performed during the COVID-19 pandemic in your institution? Assess your level of knowledge (on a scale from 1 to 10) concerning treatment of patients diagnosed with COVID-19: Assess your level of knowledge (on a scale from 1 to 10) concerning preparation for surgery on a patient with suspected / confirmed COVID-19 and provision of appropriate PPE during the procedure: Assess the level of preparedness (on a scale from 1 to 10) in your institution in terms of [Number] Assess the level of preparedness (on a scale from 1 to 10) in your institution in terms of theoretical training of the staff: Assess the level of preparedness (on a scale from 1 to 10) in your institution in terms of equipping staff with appropriate PPE: [Number] Surgical care in Poland after COVID-19 outbreak: a national survey Assess the level of preparedness (on a scale from 1 to 10) in your institution in terms of adapting the operating theater to safely perform procedures in patients with suspected / confirmed COVID-19: