DAY CASE SURGERY
unless outweighed by the risk of deferring the procedure – such as disease progression or clinical priority. If patients have ongoing and persistent symptoms, surgery should be delayed even further. “These seven weeks should be used to optimise patients. It is not a waiting list; it is an activity period,” commented Prof. Cook. The time should be used for functional assessment, rehabilitation, prehabilitation, and multidisciplinary optimisation. National bodies should also decide whether such patients can be prioritised for vaccination.
Restarting surgery Prof. Cook highlighted the challenges caused by the pandemic – not only has the elective surgery backlog increased, but a fifth of hip fracture patients caught COVID-19 while in hospital (based on evidence from the Scottish IMPACT data, March to April 2020).2
If we reach the top decile for one-year readmissions, 30-day readmissions, day case rates and length of stay, we can free up 83 beds, allowing us to perform an extra 7,279 THR/TKR procedures, improving
productivity and efficiency. Professor Tim Briggs
Keeping patients safe, while tackling the backlog, will be crucial as hospitals resume elective surgery. So, what exactly is the scale of the challenge? Prof. Cook highlighted figures from the Anaesthesia and Critical Care COVID Activity Survey, which compared surgical activity in December 2020 and December 2019, indicating that one-third of non-cancer elective surgeries, a quarter of cancer surgeries, one-third of paediatric surgery, and 10% of emergency surgeries had not been performed. This represents around a 28% loss of surgery compared to December 2019, with an estimated loss of 5,503 operations per day in all UK hospitals. He added these figures were recorded before the second wave hit and the UK went into lockdown once again. Prof. Cook pointed out that safe surgery requires the ‘four Ss’: “space, staff, systems and stuff” (equipment), but the impact of COVID-19 on these areas will be felt for
some time to come. In December 2020, 1 in 5 theatres were closed. Those theatres that remained open were operating at 50-75% of their normal activity, compared to 2019. Prof. Cook said this reduced productivity is likely to continue for many months. In December 2020, 1 in 5 anaesthetists were not available to perform anaesthesia because they were working in intensive care. So, what is the solution? Prof. Cook commented that innovation and strategic thinking will be required, adding: “To clear the backlog, we could double our normal activity and clear it in a year, increase activity by almost 50% and clear it in three years, or increase activity by 10% and clear it in around 10 years. Currently, there aren’t any additional operating theatres; there aren’t any additional staff; and there isn’t any additional money. It won’t be a sprint to the finish; we should be preparing for a marathon.” Prof. Cook co-authored a report titled
‘Towards safe, stable and sustainable resumption of planned surgery after COVID-19’. Supported by the Royal College of Anaesthetists, Association of Anaesthetists and The Faculty of Intensive Care Medicine, the document was published in Anaesthesia in February 2021.3
The key points highlighted in the report included:
l The need to pause the majority of planned surgery for almost a year is unique in the history of the NHS. Resuming planned surgery also presents enormous challenges. To make this resumption safe, stable and sustainable will require planning, patience, understanding and novel ways of working.
l Planned surgery may restart only when the necessary minimum four Ss (space, staff, systems and ‘stuff’ (equipment) are in place to support this in a safe, stable and sustainable manner.
l Surgical activity will resume in a setting in which COVID-19 is an endemic disease requiring additional precautions compared to pre-pandemic care. This will impact capacity and capability. Flexibility will also be needed to enable re-expansion of critical care services and reduced planned activity if future pandemic surges occur, particularly in Winter 2021.
He pointed out that there have been 2,251 more ICU beds compared to January 2020, the equivalent to 140-200 additional ICUs, without any increase in substantive staffing numbers. This has been reliant upon increased hours worked, redeployment of staff and decreased patient-to-staff ratios, thereby increasing work intensity posing challenges to the delivery of optimal care. Prof. Cook reported that the system is “extraordinarily stressed”. “We are only just managing to cope…Staff have been sick and staff have been stressed… Staff are not ‘tired’ – they have been depleted and damaged,” commented Prof. Cook. A study by Greenberg et al revealed very high rates of psychological harm among healthcare workers, during the first wave, comparable or exceeding that reported by troops returning from active military deployment.4
“While the rates of significant psychological harm were reported to be 45% in the first wave, we know that this has increased even further with the second wave,” said Prof. Cook. Around 40% reported post-traumatic stress disorder, 6% had severe depression, 11% experienced severe anxiety and 13% reported frequent thoughts of being better
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