Triage and treatment of non-emergency patients
In the resumption period, all non-emergency patients undergo a screening for COVID-19 before being admitted. Before patients seeing their doctors in the outpatient clinic, they are primarily triaged by symptoms and epidemiologic history regarding COVID-19. Those asymptomatic women with no contact history are allowed to visit doctors, who are under defenselevel II. If patients need ambulatory surgery or hospitalization, they will be subjected to COVID-19 triple tests, i.e. nucleic acid test combined with chest computerized tomography (CT) scan and serologic test for specific antibodies to SARS-CoV-2, which take 4-6 hours. Only the patients without any positive results can be admitted, while those with confirmed or suspected COVID-19 are send to designated outpatient clinics.
The gynecologic wards are under closed management, banning visits. After admission, patients live first in buffering wards for at least three days, which are single rooms physically separated from normal wards. During the buffering, a secondCOVID-19 triple-testis performed with a time interval of more than 24 hours to the previous test, and respiratory symptoms and body temperature are daily monitored. Thereafter, if no positive finding is present, patients are transferred to regular wards for receiving further disease-related treatment. During hospitalization, emerging fever (≥37.3℃ for three days or longer) or any respiratory syndromes are indications for a quarantine-in-place and a repeated screeningprogram. In addition, the antibody test is repeated every seven days during hospitalization routinely (Figure 1).
As regard to elective surgery, a higher priority is given to patients with malignant tumors or benign diseases that significantly affect the quality of life, e.g. uterine submucous leiomyomas causing severe anemia, bulky pelvic tumors pressing the bladder or rectum, etc. Although there are recommendations on gynecological surgery and chemotherapy amid COVID-19 pandemic and debates about the COVID-19-related safety of open versus minimally invasive surgery [12-14], we do not change our surgery modalities or chemotherapy regimens because we havesufficient medical resources to provide standard care for patients and the evidence on the risk of SARS-CoV-2 transmission associated with surgery modalities is absent.Given that postponing chemotherapy may increase the risk of cancer progression, chemotherapies are administrated as scheduled as possible. Moreover, adverse effects of chemotherapy such as myelosuppression and hepatic dysfunction are prevented as far as possible to decrease the possibility of additional hospital visits for diagnosis and treatment of such severe side effects.
Triage and treatment of emergency patients
For emergency gynecologic patients, by whom a waiting time of 4 hours or longer for intervention is allowed, a COVID-19 triple-test screening program is also required before surgery; for those who need extremely urgent surgery or have positive results of COVID-19 screening tests, emergency surgery should be conducted in specific negative-pressure surgery rooms.After finishing surgery, patients are sent to thequarantine wards set up by the hospital with "three areas and two passages", i.e. clean, semi-clean, and contaminated zones, and separated patient passage and medical staff passage, where they are treated as suspected COVID-19 patients. In the quarantine wards, a COVID-19 triple-test screening should be completed and patients by whom COVID-19 is excluded aretransferred to the buffering rooms in the gynecologicwards(Figure 1).In case of confirmed infection, patients are transferred to designated hospitals for further treatment and the surgeons who performed the emergency surgery and the medical staff in operation rooms are informed.
Personal protection of medical staffs
It is mandatory for all medical staff to receive COVID-19 screening tests before coming back to work and report personal health status regarding fever and respiratory symptoms daily per a mobile phone app. The use of personal protective equipment is summarized in Table 1. Briefly, defense level I is recommended for low risk of exposure (gynecologic normal wards), and defense level II for moderate and high risk of exposure (outpatient department and gynecologic buffering rooms). The medical staffs who have contacted with confirmed or suspected individuals or COVID-19 symptoms are subjected to screening tests and required to undergo a 14-day medical surveillance.
Under the triage framework described above, we received19298patient visits, admitted 326 patients, and performed 223 operations in the first two months after the lockdown is lifted (April and May 2020), less than 40% of that in the two months before the lockdown (October and November 2020) and the same period 2019 (April and May 2019, Table 2).Among them, 20121 patients received ambulatory COVID-19 screening, 95 underwent emergency surgery before completing screening, and 46 were transferred to designated hospitals because of confirmed or suspected infection. No single COVID-19 case occurred in the gynecologic department since reopening.
In the early phase of the resumption, cancer patients called for more efforts, especially those suffering from cancers that progress rapidly, such as ovarian cancers. The proportion of cancer patients in April and May 2020 (58.6%) was increased compared to the pre-lockdown period (October and November 2020, 50.0%) and the same period in 2019(April and May 2019, 44.1%).Also, the percentage of cancer surgery was increased. Among the cancer patients, ovarian cancer became the most frequent disease, while the proportions of cervical cancer and endometrial cancer were decreased compared to the pre-COVID-19 periods (Table 2). The ovarian cancer patients with chemotherapy showed less myelosuppression (neutrophil count less than 1.5 G/L) in the post-lockdown cohort (16/47, 34.0%) compared to the pre-lockdown cohort (52/102, 51.0%) and the 2019 cohort (41/95, 43.2%), which may be due to the more frequent use of long-effective colony stimulating factor (PEG-rhG-CSF).However, there were more patients with leiomyoma or adenomyosis suffering from severe anemia in the post-lockdown cohort, that may be due to the postponed diagnosis and surgery and inadequate iron supplementation during the COVID-19 lockdown (Table 2).