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Perioperative surgical patient care during COVID- 19

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Introduction

The coronavirus disease 2019 (COVID-19) pandemic has caused tragic events by disrupting people’s lives, social welfare and the global economy.1,2 The burden of COVID-19 is critical and devastating in healthcare institutions, and carries a significant risk of disease transmission to the healthcare team and cross-contamination to patients.3–9

In general, the pandemic has overwhelmed health systems and presented unprecedented challenges to medical staff globally. Surgical departments are the cornerstone of every health system, contributing to public health in both elective and emergency situations. They are very vulnerable to the spread of the disease and the main source of viral transmission to individuals, both surgical staff and patients, and likely to their attendants, and of contamination of the community at large.10–12

The nature of COVID-19 transmission creates significant risks in surgical departments, including obstetric care, owing to the close contact of medical staff with patients, the limited physical environment of the operating theatre and recovery room, and the possibility of shared surgical equipment, especially aerosol-generating equipment/procedures such as surgical sets, airway devices and electrosurgery equipment. The pandemic also presents challenges to the practices in the surgical department, especially to ENT surgery, maxillofacial surgery and anesthesia care providers, as they share a high viral load.13–17

Epidemic statistics from Wuhan, China, and Italy revealed that the disease infected about 3.8–20% of health workers, with an overall mortality rate of 0.6%.18–20

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Globally, studies have reported that the effects of the pandemic on surgical departments have been profound, potentially long-lasting and extensive, and have had a collateral health effect on the delivery of surgical care to millions of patients as a result of the near-universal disruption and cancellation of surgical services.21–28

To manage these effects, different local guidelines and recommendations have been developed to control the disease, which may create differences in the local conditions relating to the extent of COVID-19 infections within the type of practice/hospital system, the availability of effective personal protective equipment (PPE) and other supplies, the physical configuration of workspaces, practice economics, local rules and regulations, and other constraints (eg, economic).

Thus, harmonized and effective national/international guidelines for specific surgical streams during perioperative periods are pertinent to curtail the infection, and will inevitably need to be adapted for consistent and sustainable implementation by all medical staff. The ultimate goal of the adapted guidelines and recommendations is to provide the right and optimal decisions, to maximize the benefits to both medical staff and patients, as well as to improve patient outcomes and minimize the burden of the disease on the healthcare systems through the wise use of resources, routine screening for the disease prior to surgical intervention, and focusing on emergency treatment while postponing non-priority treatments, especially in resource-constrained countries.

The standard guidelines and recommendations for perioperative surgical patient care during a pandemic equivocally enable and alert medical staff and health institutions to prepare for a pandemic and familiarize themselves with standard guidelines to manage the surgical space/environment, staff and supplies, so that optimum care is provided to patients through the domains of infection prevention measures, equipment handling, use of PPE and patient preparation, which can be implemented to reduce disease transmission in the hospital and in the community at large. The extent of surgical patient care during the COVID-19 pandemic at Jimma Medical Center (JMC) has not been explored yet. Therefore, the present study aimed to describe the extent of perioperative surgical patient care, equipment handling and operating room (OR) management during the COVID-19 pandemic at JMC, compared with standard guidelines, and to suggest adaptations for implemention.

Materials and Methods

An institution-based cross-sectional study was conducted at JMC, located in Jimma zone, Oromia region, southwest Ethiopia, at a distance of 350 km from the capital of the country, Addis Ababa. The hospital provides health services to millions of people living in the catchment area.

The pattern of current hospital practice in perioperative (preoperative, intraoperative and postoperative) surgical patient care was assessed using five-point Likert scales (0, not at all; 1, rarely; 2, sometimes; 3, most of the time; 4, frequently) in terms of seven domains (A, infection prevention and PPE;29 B, patient preparation/preoperative phase;30,31 C, intraoperative phase;32 D, equipment handling process and status of CSR;33 E, operating room management;34 F, anesthesia care;35 and G, recovery room/ICU care in the postoperative phase36) at JMC in seven surgical departments (A, ophthalmology; B, ENT/maxillofacial surgery; C, orthopedics; D, general surgery; E, gynecology/obstetrics; F, pediatrics; and G, neurosurgery). A total of 90 respondents [35 patients (five patients from each of the seven surgical departments) and 55 healthcare providers (six professionals from each of the nine units, including the center of sterility room and anesthesia)] who were available during the study period, selected by a convenience sampling technique with multistage clustering, participated in the study. Data were collected using a structured questionnaire (Supplementary Annex 1) via direct observation and a face-to-face interview approach (with patients undergoing surgery, healthcare providers and hospital administrators), against the developed checklists for the standard surgical patient care guidelines/recommendations set by different organizations.11,37–48

A letter of ethical clearance was obtained from the research ethical committee/institutional review board of Jimma University (IHRPGR/152/2021). Letters of support were also collected from JMC. Oral and written consent was obtained from all participants and their information was handled confidentially (Supplementary Annex 2). All protocols for COVID-19-preventive measures were maintained during data collection. The participants were informed about the purpose of the study, in accordance with the Declaration of Helsinki. The collected data were manually checked for missing values and outliers, cleared, entered into EpiData version 4.3.1 and finally exported to SPSS version 22 for further analysis. The findings of the study were reported using tables and narration. The mean score of surgical care practice was compared among different disciplines by applying the unpaired t-test. A p-value of less than 0.05 was declared as statistically significant.

Results

Extent of Surgical Care Practice in the Domain of Infection Prevention and Personal Protective Equipment Use Status During COVID-19 Pandemic in JMC

The implementation of COVID-19-preventive measures was higher among surgical staff compared to patients undergoing surgery, as detailed in Table 1 for different surgical departments.

Table 1 Extent of Surgical Care Practice in the Domain of Infection Prevention and Personal Protective Equipment Use (Implementation Level of COVID-19 Preventive Measures) During COVID-19 Pandemic in JMC

Status of Surgical Care Practice in the Patient Preparation/Preoperative Phase During COVID-19 Pandemic in JMC

Even though the extent of preoperative patient care differed before and during the COVID-19 pandemic, there was variation among surgical disciplines. The preoperative care implemented during the pandemic included the application of telemedicine to reduce physical contacts, screening for COVID-19 by different methods, isolation of high-risk patients in the ward and the use of PPE according to the patient status during preoperative evaluations. The practice of following preoperative guidelines (especially isolation of risky patients on the ward and screening for COVID-19) was satisfactory in the general surgery and gynecology/obstetrics departments, with mean scores of 3.6 for each (where they performed most of the time), as seen in Table 2.

Table 2 Status of Surgical Care Practice During the Patient Preparation/Preoperative Phase in JMC

Level of Surgical Care Practice in the Intraoperative Phase During COVID-19 Pandemic in JMC

Different preoperative patient care guidelines/recommendations were implemented during the COVID-19 pandemic. For instance, patients wore a face mask when they were transferred to the OR, and differences were observed in the techniques of donning/doffing, scrubbing, disinfecting, cautery usage and PPE use, according to patient status, etc (Table 3).

Table 3 Level of Surgical Care Practice During the Intraoperative Phase in JMC

Status of Equipment Handling in the Center of Sterility Room During COVID-19 Pandemic in JMC

The extent of implementation of equipment handling guidelines/recommendations was very low (not at all practiced or rarely practiced) in the center of sterility room of JMC, as the staff working in the area raised multiple barriers (especially claiming that there was no up-to-date information/training on the guidelines), as detailed in Table 4.

Table 4 Status of Equipment Handling in the Center of Sterility Room During COVID-19 Pandemic in JMC

Status of Operating Room Management Practice During COVID-19 Pandemic in JMC

Different OR management guidelines/recommendations were implemented during the COVID-19 pandemic, for instance, limiting the number of OR attendees and differences in OR cleaning patterns after the patient had been transferred. The level of implementation of the guideline that recommends having separate OR entry and exit showed statistically significant differences among surgical departments, and was lacking in the ophthalmology OR (Table 5).

Table 5 Status of Operating Room Management Practice During COVID-19 Pandemic in JMC

Status of Anesthesia Care Practice During COVID-19 Pandemic in JMC

Different anesthesia care practice guidelines/recommendations were implemented during the COVID-19 pandemic at different levels of practice, as shown in Table 6.

Table 6 Status of Anesthesia Care Practice During COVID-19 Pandemic in JMC

Extent of Postoperative Care Practice in the Recovery Room During COVID-19 Pandemic in JMC

Different postoperative safe practice guidelines/recommendations were implemented during the COVID-19 pandemic, for instance, limiting the number of OR attendees and differences in the OR cleaning patterns after the patient had been transferred (Table 7).

Table 7 Extent of Postoperative Care Practice in the Recovery Room During COVID-19 Pandemic in JMC

Discussion

The COVID-19 pandemic has led to an unprecedented number of infections and deaths in recent years and continues to present a colossal challenge to healthcare systems. The situation is especially bad in surgical departments, where there is a higher risk of transmission owing to the close contact with patients and the use of procedures that generate aerosols.22,49,50

Therefore, it is important to triage patients effectively, using preferred practices and recommendations set by expert panels, so that genuine emergencies can be tackled effectively and efficiently without facilitating disease transmission.32,34

The current study revealed that the majority of surgical staff were implementing preventive measures against COVID-19 most of the time, while they were less well practiced among patients. The guidelines for surgical practice during the preoperative phase were well applied, especially screening patients by different methods and the application of telemedicine to reduce physical contacts. But, against the guidelines, elective patients were planned and underwent surgery, especially in the general surgery department.

The implementation of recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic. The extent of practice for anesthesia care, operating room management and postoperative care in the recovery room had changed, and the guidelines were sometimes applied.

Limitation of the Study

The study lacks a comparison of the extent of perioperative surgical care practice during the pandemic among healthcare professionals. It simply describes the extent of perioperative surgical care practice among different surgical departments by taking a convenience sample of patients and professionals. The provided responses thus relate to the pattern of practice in the specific surgical departments, not that of the individual respondents.

Conclusion and Recommendations

Despite the differences in perioperative surgical care practice before and during the pandemic, the standard guidelines/recommendations were inconsistently implemented among the surgical departments. The safe surgical guidelines were not strictly developed and implemented in the hospital and the level of the practice varied for different domains among the surgical departments. The implementation of the recommended guidelines in the center of sterility room in handling surgical equipment was not very different before and during the pandemic.

Therefore, the authors developed safe surgical care guidelines throughout different domains (infection prevention and PPE use; preoperative care, intraoperative care, operating room management, anesthesia care, equipment handling process and postoperative care) for all disciplines and shared them with all staff. Thus, we recommend that all surgical staff should access these guidelines/recommendations and strictly adhere to them during surgical service.

It is also recommended that awareness of the disease and its preventive measures should be raised in patients, and that such information should be communicated frequently.

Data Sharing Statement

The authors confirm that the data used for the study are available within the article, and any other required data and materials will be provided by the corresponding author of the study.

Ethics Approval and Consent to Participate

A letter of ethical clearance was obtained from the research ethical committee/institutional review board of Jimma University (IHRPGR/152/2021). The participants were informed about the purpose of the study, in accordance with the Declaration of Helsinki. Letters of support were also collected from JMC. Oral and written consent was obtained from all participants and their information was handled confidentially. All protocols of COVID-19 preventive measures were maintained during data collection. The procedures in this study were conducted in accordance with the ethical standards of the committee responsible for human experimentation in accordance with the Declaration of Helsinki.

Acknowledgment

The authors would like to thank Jimma University for providing funding, and all data collectors and study participants.

Funding

Jimma University provided funding for data collectors through the postgraduate mega research program in 2021 (IHRPGR/152/2021).

Disclosure

The authors report no conflicts of interest in relation to this work.

References

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39. Zimmermann M, Nkenke E. Approaches to the management of patients in oral and maxillofacial surgery during COVID-19 pandemic. J Cranio-Maxillofac Surg. 2020;48(5):521–526. doi:10.1016/j.jcms.2020.03.011

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Young and old more likely to face severe flu. Here’s why doctors think it happens

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Canadians have been getting sick enough with seasonal flu to land in hospital, say doctors with suggestions on who is most at risk and what it could mean for festive gatherings.

“We’re starting to now see the effect of flu on certain populations, particularly very young children and very older people, in making them sick enough that they need to come into hospital,” said Dr. Gerald Evans, chair of the division of infectious diseases at Queen’s University and Kingston Health Sciences Centre.

During the depths of the COVID-19 pandemic, air travel declined. It’s one of the suspected reasons that influenza all but disappeared, Evans said.

Flu viruses need human hosts travelling between the southern and northern hemispheres to gain a foothold during winter on both ends of the planet, according to influenza experts.

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Dr. Upton Allen, head of infectious diseases at Sick Kids Hospital, said the H3N2 strain of influenza might be associated with more severe disease than other strains. (SickKids)

For about 100 years, doctors have known that the youngest and oldest are most at risk for serious flu. Why hasn’t been nailed down, but there are a few possible reasons — including what strains were circulating when you were first exposed.

Generational effects explored

Canadian and international research on humans as well as in animal models suggest that the first strain of flu virus you’re infected with tends to prime or shape the immune system. The result is that our immune system responds best to the original type of flu infection it faced.

“That’s why we believe that older people who are mostly primed with H1N1 don’t do very well during an H3N2 year like we’re having this year,” Evans said.

Staff at pediatric hospitals like Sick Kids continue to face pressures from pandemic backlogs of surgeries. (Michael Wilson/CBC)

The 2009 H1N1 pandemic also continues to affect how younger ones do with flu.

Those aged 13 and under were probably primed to H1N1 after 2009, just as their grandparents were in their childhoods, Evans said.

If so, today’s kids could be more vulnerable to severe disease from flu now than their parents’ generation who first encountered an H3N2 strain.

Evans added it’s also thought that older people may have more severe outcomes from flu because of underlying problems such as heart disease, lung disease or treatments for cancer.

Youngest hadn’t been exposed

Another reason why young children are being hit hard by flu and RSV this year: recent pandemic public health measures meant those under two haven’t seen flu at all and preschoolers haven’t experienced it or another respiratory virus known as respiratory syncytial virus, or RSV, for a couple seasons.

“The boost of immunity they get from having had some prior exposures in the year before are missing and so they’re tending to get infected more,” Evans said.

Dr. Upton Allen, chief of infectious diseases at the Hospital for Sick Children in Toronto, pointed to a few other possibilities.

One is the strain of flu virus that’s mainly circulating. It’s officially called Influenza A H3N2, which Allen said might be associated with more severe disease.

Also, our immune system is considered weakest at the extremes of life.

“The overwhelming majority of kids who get the flu will get it mild, but some people can get it severe,” Allen said.

 

 

Health experts in Canada and the U.S. are recommending people start wearing masks again with a ‘perfect storm’ of respiratory diseases on the rise, a strain on our hospital systems and a shortage of medication. But is that enough to get us to wear masks again? Dr. Susy Hota joins About That with Andrew Chang to take us through it all.

If a child is breathing very quickly, having trouble breathing, weak, doesn’t wake up or respond then those might indicate a more severe bout. “Call 911 or go to the nearest emergency department,” Allen said.

The Public Health Agency of Canada reports fewer than five influenza-associated deaths among those aged 16 and younger for the week ending Nov. 19.

“Each year the number of deaths generally are in single digits,” for that age group in Canada, Allen said.

Doctor’s holiday flu forecast

Marie Tarrant, a professor in the nursing school at the University of British Columbia Okanagan, is concerned about the uptick in hospitalizations from flu for patients and health-care systems.

“The other side of that is just the burden that is putting on a healthcare system that has been maximally strained for the last 2 ½ years.”

A lab technician at work.
A lab technician works in the H1N1 laboratory at the British Columbia Centre for Disease Control in Vancouver in 2009. This year’s flu season started earlier than the norm. (Darryl Dyck/The Canadian Press)

People with flu, RSV and other infections have a “compounding effect” of burdening hospitals, she said. Like Canada’s National Advisory Committee on Immunization, Tarrant recommends those aged six months and older who are eligible get a flu shot.

“Flu vaccines prevent about 40 to 60 per cent of serious illness and hospitalization,” she said. “They do work.”

Evans has similar advice.

“Get your flu shot,” he said. “It’s not going to be for everybody, but it’s going to prevent a lot of people getting infected and that’s going to help of course alleviate the stresses that we’re seeing in trying to provide care to everybody.”

It’s also not too late to get a flu shot, clinicians say.

Plus, flu season started earlier than it typically does this year, which could (eventually) offer a yuletide bright spot. Evans said seasonal flu usually disappears after a period of about six weeks. Canada is now about two weeks into a surge.

“By the time the holidays come around, we should be seeing a waning down of numbers of influenza infections, if it follows the pattern that we have seen now literally for decades.”

The good news? “As long as you’re feeling OK and you don’t have signs and symptoms of a cold, I think gathering together is fine.”

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St. Joe's opens Hamilton Mountain flu, COVID and cold clinic – Hamilton Spectator

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St. Joseph's West 5th Campus has opened a flu, COVID and cold clinic.

With the cold and flu season now in full swing, St. Joseph’s Healthcare Hamilton has opened a flu, COVID and cold clinic at their West 5th (and Fennell) campus.

St. Joe’s officials say the goal of the dedicated clinic is to provide both adults and children with timely care, while reducing the number of patients visiting emergency departments for respiratory illnesses commonly seen throughout the fall and winter.

Clinic visits are by appointment only.

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See stjoes.ca/FluCOVIDCold to book an appointment.

Clinic hours are Monday to Friday 4:30 p.m. to 9 p.m., Saturday/Sunday 8 a.m. to 4 p.m.

The clinic is a collaborative effort between St. Joseph’s Healthcare Hamilton, Hamilton Health Sciences (HHS) and primary care doctors

St Joe’s official say adults and children experiencing flu, COVID or cold symptoms, who are unable to seek timely care from their family doctor or do not have a family doctor, should book an appointment if their symptoms are not improving after a few days, despite using common over-the-counter medications as indicated on the label, such as ibuprofen (Advil), acetaminophen (Tylenol), nasal rinses and cold/flu medications or if they are particularly worried about any of their symptoms.

Common symptoms include fever, cough, sore throat, runny or stuffy nose, chills, loss of taste or smell, headache, and muscle aches.

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World AIDS Day: HIV activists hopeful for end to backsliding on infections, stigma

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HIV activists are marking World AIDS Day by urging Ottawa to help stop a global backslide in progress on stemming infections and stigma.

“It’s clear to us that this government is seized of the issue, but the truth of the matter is, no movement is happening quickly enough for people with HIV living in Canada,” says Janet Butler-McPhee, who co-leads the HIV Legal Network in Toronto.

The Public Health Agency of Canada estimated that 62,790 people in Canada were living with HIV in 2020, and that 10 per cent of them didn’t know they had the virus.

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That represented a slight drop in overall cases from 2018, but an increase among the most vulnerable.

Indigenous people accounted for nearly one-fifth of new HIV infections in Canada in 2020, the data say. That year, women and people who inject drugs made up an increasing share of infections, while men who have sex with men made up a smaller share.

Advocates argue that the numbers reflect the uneven effects of the COVID-19 pandemic.

Butler-McPhee noted that the Harper and Trudeau governments both pledged funding for grassroots groups that serve people with HIV that hasn’t fully materialized, despite the added factors of a toxic drug crisis and the COVID-19 pandemic.

“You’re talking about organizations who have had to pivot pretty significantly and take on new work without funding that has been long-promised,” she said.

Meanwhile, Canada continues to trail its peers in criminalizing HIV non-disclosure. Canadians living with the virus can be prosecuted for not disclosing their status to sexual partners, even when prescription drugs make it impossible to transmit the virus.

“Criminalization can lead to the stigmatization of people living with HIV, which can often discourage individuals from being tested or seeking treatment,” the Department of Justice noted in October.

The Liberals have been promising to fix the issue since 2016, but only launched a national consultation in October. They have also asked prosecutors to avoid criminalizing people with HIV in the territories, while suggesting provinces follow suit, with mixed success.

“For the last six years, there has been a recognition by this federal government that HIV criminalization is an issue in Canada, but there has been not as much movement as we’d like to see,” said India Annamanthadoo, a lawyer with the HIV Legal Network.

Abroad, the World Health Organization reported disruptions in HIV patients accessing treatments that suppress symptoms and stop the virus from progressing to AIDS, as countries targeted their health care systems at stemming COVID-19 infections.

That’s put a dent in progress toward the United Nations sustainable development goal of ending the epidemic of HIV-AIDS by 2030.

Before the pandemic, the UN’s joint program on AIDS reported that AIDS-related deaths had gone down by 68 per cent since the peak in 2004, and by 52 per cent since 2010.

Thursday marks World AIDS Day, which the United Nations has marked every year since 1988. The disease has killed roughly 40 million people, including 650,000 in 2021.

In a report this week, the agency said inequalities will make it impossible to reach global targets, whether it’s the presence of girls and women in school or continued stigma against men who have sex with men.

Girls and women in sub-Saharan Africa aged 15 to 24 are acquiring HIV at rates three times that of males in the same age group, the agency reported.

 

Gay men and people engaged in sex work are more likely to avoid HIV testing when the country they live in criminalizes their behaviour, the agency says.

In September, Canada was praised for pledging $1.2 billion to the Global Fund to Fight AIDS, Tuberculosis and Malaria, after months of concern that Ottawa would pull back its funding.

The move came after the Liberals cancelled a ministerial address to the International AIDS Conference in Montreal this summer, a summit clouded by controversy after African delegates were refused visas.

Back home, the Canadian Aboriginal AIDS Network argues that mainstream public-awareness campaigns and access to HIV-preventing drugs are not reaching Indigenous communities, particularly women.

Trevor Stratton, an Ojibwa activist with the group, told an online panel on Wednesday that Ottawa ought to launch an inquiry into the disproportionate rates of HIV among Indigenous peoples.

“It’s a national embarrassment; when I travel internationally I am actually embarrassed to be a citizen of Canada,” he said.

&copy 2022 The Canadian Press

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