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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.

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37. Kozin ED, Remenschneider AK, Blevins NH, et al. American Neurotology Society, American Otological Society, and American Academy of otolaryngology–head and Neck Foundation guide to enhance Otologic and Neurotologic care during the COVID-19 pandemic. OtolNeurotol. 2020;41(9):1163–1174.

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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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Kevin Neil Friesen Obituary 2024 – Crossings Funeral Care

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It is with heavy hearts that we announce the peaceful passing of Kevin Neil Friesen age 53 on Thursday, March 28, 2024 at the Bethesda Regional Health Centre.

A funeral service will be held at 2:00 pm on Thursday, April 4, 2024 at the Bothwell Christian Fellowship Church, with viewing one hour prior to the service.

A longer notice to follow.  

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Spring allergies: Where is it worse in Canada? – CTV News

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The spring allergy season has started early in many parts of Canada, with high levels of pollen in some cities such as Toronto, Ottawa and Montreal.

Daniel Coates, director of Aerobiology Research Laboratories in Ottawa, expects the elevated amounts to continue next week for places, such as most of Ontario, if the temperature continues to rise. Aerobiology creates allergen forecasts based on data it collects from the air on various pollens and mould spores.

Pollens are fertilizing fine powder from certain plants such as trees, grass and weeds. They contain a protein that irritates allergy sufferers.

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Although pollen levels declined after a cold spell in some places, he said they are soaring again across parts of Canada.

“So the worst is definitely British Columbia right now, followed by Ontario and Quebec and then the Prairies and Atlantic Canada for the upcoming weeks,” said Coates in a video interview with CTVNews.ca. “We are seeing pollen pretty much everywhere, including the Maritimes.”

He said pollen has increased over the past 20 years largely due to longer periods of warm weather in Canada.

Meanwhile, the Maritimes is one of the best places to live in Canada if you have seasonal allergies, in part because of its rocky territory, Coates said.

With high levels of cedar and birch pollen, British Columbia is the worst place for allergy sufferers in Canada, he added.

“British Columbia is going strong,” Coates explained, noting the allergy season started “very early” in the province in late January. “It has been going strong since late January, early February and it’s progressing with high levels of pollen, mostly cedar, but birch as well, and birch is highly allergenic.”

Causes of high pollen levels

Coates expects a longer allergy season if the warm weather persists. He notes pollen is increasing in Canada and worldwide, adding that in some cases the allergy season is starting earlier and lasting longer than 15 years ago.

He says tree pollen produced last year is now being released into the air because of warmer weather.

“Mother nature acts like a business,” he said. “So you have cyclical periods where things go up and down. … So when it cooled down a little bit, we saw (pollen) reduce in its levels, but now it’s going to start spiking.”

Along with warmer weather, another factor in higher pollen levels is people planting more male trees in urban areas because they don’t produce flowers and fruits and are less messy as a result, he said. But male trees produce pollen while female ones mostly do not.

Moulds

Coates said moulds aren’t as much of a problem.

“They’ve been mainly at lower levels so far this season,” he explained. “Moulds aren’t as bad in many areas of Canada, but they’re really, really bad in British Columbia.”

In B.C., moulds are worse because of its wet climate and many forested areas, he said.

Coping with allergies

Dr. Blossom Bitting, a naturopathic doctor and herbal medicine expert who works for St. Francis Herb Farm, says a healthy immune system is important to deal with seasonal allergies.

“More from a holistic point of view, we want to keep our immune system strong,” she said in a video interview with CTVNews.ca from Shediac, N.B. “Some would argue allergies are an overactive immune system.”

Bitting said ways to balance and strengthen the immune system include managing stress levels and getting seven to nine hours of restful sleep. “There is some research that shows that higher amounts of emotional stress can also contribute to how much your allergies react to the pollen triggers,” Bitting said.

Eating well by eating more whole foods and less processed foods along with exercising are also important, she added. She recommends foods high in Omega-3 Fatty Acids such as flaxseeds, flaxseed oil, walnuts and fish. Fermented foods with probiotics such as yogurt, kimchi and miso, rather than pasteurized ones, can keep the gut healthy, she added. Plant medicines or herbs such as astragalus, reishi mushrooms, stinging nettle and schisandra can help bodies adapt to stressors, help balance immune systems or stabilize allergic reactions, she said.

To cope with allergies, she recommends doing the following to reduce exposure to pollen:

  • Wear sunglasses to get less pollen into the eyes;
  • Wash outdoor clothes frequently, use outer layers for outside and remove them when you go inside the house;
  • Use air purifiers such as with HEPA (high efficiency particulate air) filters;
  • Wash pets and children after they go outside;
  • Keep the window closed on days with high pollen counts.

Mariam Hanna, a pediatric allergist, clinical immunologist and associate professor with McMaster University in Hamilton, Ont., says immunotherapy can help patients retrain their bodies by working with an allergist so they become more tolerant to pollens and have fewer symptoms.

“Some patients will need medications like over-the-counter antihistamines or speaking with their doctor about the right types of medications to help with symptom control,” she said in a video interview with CTVNews.ca.

Coates recommends people check pollen forecasts and decrease their exposure to pollen since no cure exists for allergies. “The best is knowing what’s in the air so that you can adjust your schedules, or whatever you’re doing, around the pollen levels.”

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Do you need a spring COVID-19 vaccine? Research backs extra round for high-risk groups

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Recent studies suggest staying up-to-date on COVID shots helps protect high-risk groups from severe illness

New guidelines suggest certain high-risk groups could benefit from having another dose of a COVID-19 vaccine this spring — and more frequent shots in general — while the broader population could be entering once-a-year territory, much like an annual flu shot.

Medical experts told CBC News that falling behind on the latest shots can come with health risks, particularly for individuals who are older or immunocompromised.

Even when the risk of infection starts to increase, the vaccines still do a really good job at decreasing risk of severe disease, said McMaster University researcher and immunologist Matthew Miller.

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Who needs another COVID shot?

Back in January, Canada’s national vaccine advisory body set the stage for another round of spring vaccinations. In a statement (new window), the National Advisory Committee on Immunization (NACI) stated that starting in spring 2024, individuals at an increased risk of severe COVID may get an extra dose of the latest XBB.1.5-based vaccines, which better protect against circulating virus variants.

That means:

  • Adults aged 65 and up.
  • Adult residents of long-term care homes and other congregate living settings for seniors.
  • Anyone six months of age or older who is moderately to severely immunocompromised.

The various spring recommendations don’t focus on pregnancy, despite research (new window) showing clear links between a COVID infection while pregnant, and increased health risks. However, federal guidance does note that getting vaccinated during pregnancy can protect against serious outcomes.

Vaccinated people can also pass antibodies to their baby through the placenta and through breastmilk, that guidance states (new window).

What do the provinces now recommend?

Multiple provinces have started rolling out their own regional guidance based on those early recommendations — with a focus on allowing similar high-risk groups to get another round of vaccinations.

B.C. is set to announce guidance on spring COVID vaccines in early April, officials told CBC News, and those recommendations are expected to align with NACI’s guidance.

In Manitoba (new window), high-risk individuals are already eligible for another dose, provided it’s been at least three months since their latest COVID vaccine.

Meanwhile Ontario’s latest guidance (new window), released on March 21, stresses that high-risk individuals may get an extra dose during a vaccine campaign set to run between April and June. Eligibility will involve waiting six months after someone’s last dose or COVID infection.

Having a spring dose is particularly important for individuals at increased risk of severe illness from COVID-19 who did not receive a dose during the Fall 2023 program, the guidance notes.

And in Nova Scotia (new window), the spring campaign will run from March 25 to May 31, also allowing high-risk individuals to get another dose.

Specific eligibility criteria vary slightly from province-to-province, so Canadians should check with their primary care provider, pharmacist or local public health team for exact guidelines in each area.

WATCH: Age still best determines when to get next COVID vaccine dose, research suggests:

 

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Age still best determines when to get COVID vaccines, new research suggests

It’s been four years since COVID-19 was declared a pandemic, and new research suggests your age may determine how often you should get a booster shot.

Why do the guidelines focus so much on age?

The rationale behind the latest spring guidelines, Miller said, is that someone’s age remains one of the greatest risk factors associated with severe COVID outcomes, including hospitalization, intensive care admission and death.

So that risk starts to shoot up at about 50, but really takes off in individuals over the age of 75, he noted.

Canadian data (new window) suggests the overwhelming majority of COVID deaths have been among older adults, with nearly 60 per cent of deaths among those aged 80 or older, and roughly 20 per cent among those aged 70 to 79.

People with compromised immune systems or serious medical conditions are also more vulnerable, Miller added.

Will people always need regular COVID shots?

While the general population may not require shots as frequently as higher-risk groups, Miller said it’s unlikely there will be recommendations any time soon to have a COVID shot less than once a year, given ongoing uncertainty about COVID’s trajectory.

Going forward, I suspect for pragmatic reasons, [COVID vaccinations] will dovetail with seasonal flu vaccine campaigns, just because it makes the implementation much more straightforward, Miller said.

And although we haven’t seen really strong seasonal trends with SARS-CoV-2 now, I suspect we’ll get to a place where it’s more seasonal than it has been.

In the meantime, the guidance around COVID shots remains simple at its core: Whenever you’re eligible to get another dose — whether that’s once or twice a year — you might as well do it.

What does research say?

One analysis, published in early March in the medical journal Lancet Infectious Diseases (new window), studied more than 27,000 U.S. patients who tested positive for SARS-CoV-2, the virus behind COVID, between September and December 2023.

The team found individuals who had an updated vaccine reduced their risk of severe illness by close to a third — and the difference was more noticeable in older and immunocompromised individuals.

Another American research team from Stanford University recently shared the results from a modelling simulation looking at the ideal frequency for COVID vaccines.

The study in Nature Communications (new window) suggests that for individuals aged 75 and up, having an annual COVID shot could reduce severe infections from an estimated 1,400 cases per 100,000 people to around 1,200 cases — while bumping to twice a year could cut those cases even further, down to 1,000.

For younger, healthier populations, however, the benefit of regular shots against severe illness was more modest.

The outcome wasn’t a surprise to Stanford researcher Dr. Nathan Lo, an infectious diseases specialist, since old age has consistently been a risk factor for severe COVID.

It’s almost the same pattern that’s been present the entire pandemic, he said. And I think that’s quite striking.

More frequent vaccination won’t prevent all serious infections, he added, or perhaps even a majority of those infections, which highlights the need for ongoing mitigation efforts.

Lauren Pelley (new window) · CBC News

 

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