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:
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.