Surgical Providers Research Articles

Patient prioritisation methods to shorten waiting times for elective surgery: A systematic review of how to improve access to surgery.

BackgroundConcern about long waiting times for elective surgeries is not a recent phenomenon, but it has been heightened by the impact of the COVID-19 pandemic and its associated measures. One way to alleviate the problem might be to use prioritisation methods for patients on the waiting list and a wide range of research is available on such methods. However, significant variations and inconsistencies have been reported in prioritisation protocols from various specialties, institutions, and health systems. To bridge the evidence gap in existing literature, this comprehensive systematic review will synthesise global evidence on policy strategies with a unique insight to patient prioritisation methods to reduce waiting times for elective surgeries. This will provide evidence that might help with the tremendous burden of surgical disease that is now apparent in many countries because of operations that were delayed or cancelled due to the COVID-19 pandemic and inform policy for sustainable healthcare management systems.MethodsWe searched PubMed, EMBASE, SCOPUS, Web of Science, and the Cochrane Library, with our most recent searches in January 2020. Articles published after 2013 on major elective surgery lists of adult patients were eligible, but cancer and cancer-related surgeries were excluded. Both randomised and non-randomised studies were eligible and the quality of studies was assessed with ROBINS-I and CASP tools. We registered the review in PROSPERO (CRD42019158455) and reported it in accordance with the PRISMA statement.ResultsThe electronic search in five bibliographic databases yielded 7543 records (PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane) and 17 eligible articles were identified in the screening. There were four quasi-experimental studies, 11 observational studies and two systematic reviews. These demonstrated moderate to low risk of bias in their research methods. Three studies tested generic approaches using common prioritisation systems for all elective surgeries in common. The other studies assessed specific prioritisation approaches for re-ordering the waiting list for a particular surgical specialty.ConclusionsExplicit prioritisation tools with a standardised scoring system based on clear evidence-based criteria are likely to reduce waiting times and improve equitable access to health care. Multiple attributes need to be considered in defining a fair prioritisation system to overcome limitations with local variations and discriminations. Collating evidence from a diverse body of research provides a single framework to improve the quality and efficiency of elective surgical care provision in a variety of health settings. Universal prioritisation tools with vertical and horizontal equity would help with re-ordering patients on waiting lists for elective surgery and reduce waiting times.

Health facilities\u2019 readiness for safe surgical care provision in Uganda and the Eastern Democratic Republic of Congo during Ebola and COVID-19 era

ObjectiveThis study aimed to assess health facilities’ readiness to provide safe surgical care during Ebola and COVID-19 era in Uganda and in the Eastern DR Congo.Methods A cross-sectional study was conducted in selected national, regional referral and general hospital facilities in Uganda and in the eastern part of DR Congo from 1st August 2020 to 30th October 2020. Data was analysed using Stata version 15.ResultsThe participation rate was of 37.5 % (72/192) for both countries. None of the hospitals fulfilled the readiness criteria for safe surgical care provision in both countries. The mean bed capacity of participating health facilities (HF) was 184 in Eastern DR Congo and 274 in Uganda with an average surgical ward bed capacity of 22.3 % (41/184) and 20.4 % (56/274) respectively. The mean number of operating rooms was 2 and 3 in Eastern DR Congo and Uganda respectively. Nine hospitals (12.5 %) reported being able to test for Ebola and 25 (34.7 %) being able to test for COVID-19. Postponing of elective surgeries was reported by 10 (13.9) participating hospitals. Only 7 (9.7 %) hospitals reported having a specific operating room for suspect or confirmed cases of Ebola or COVID-19. Appropriate Personal Protection Equipment (PPE) was reported to be available in 60 (83.3 %) hospitals. Most of the staff had appropriate training on donning and doffing of PPE 40 (55.6 %). Specific teams and protocols for safe surgical care provision were reported to be present in 61 (84.7 %) and 56 (77.8 %) respectively in Uganda and Eastern DR Congo participating hospitals.ConclusionsThe lack of readiness to provide safe surgical care during Ebola and COVID-19 era across the participating hospitals in both countries indicate a need for strategies to enhance health facility supplies and readiness for safe surgical provision in resource-limited settings.

A Tale of Two Cities: Residents’ Operative Experience in the United Kingdom and Germany During the Coronavirus Disease 2019 Pandemic

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic has had a detrimental effect on residents’ operative training. Our aim was to identify the proportion of procedures performed by residents across 2 neurosurgical centers (1 in the United Kingdom and 1 in Germany) during the pandemic-affected months of March 2020–May 2020, inclusive, compared with March 2019–May 2019, inclusive.MethodsAll neurosurgical procedures performed at the United Kingdom and German institutions, between March 1, 2019 and May 31, 2019 (pre-COVID months) and March 1, 2020 and May 31, 2020 (COVID months), were extracted and operative notes evaluated. Statistical analysis was performed on SPSS version 22.ResultsThere was a statistically significant reduction in operative volume in the United Kingdom center from the pre-COVID months to the COVID months (χ2(5) = 84.917; P < 0.001) but no significant difference in the operative volume in the German center (P = 0.61). A Mann-Whitney U test showed a statistically significant difference in the volume of residents operating in the COVID months compared with pre-COVID months in both United Kingdom and German centers (P < 0.001). The average number of procedures performed by residents in the United Kingdom center as the primary surgeon decreased from 82 to 72 per month (pre-COVID vs. COVID months), whereas German residents’ operating volume increased from 68 to 89 per month (pre-COVID vs. COVID months).ConclusionsThe COVID-19 pandemic has significantly reduced the volume of operating by neurosurgical residents in the United Kingdom center, whereas residents in the German center performed more procedures compared with 2019. This finding may reflect variations in national practice on maintaining surgical activities and provision of critical care beds during the first wave of the pandemic.

Segmentation of specialised and non-specialised work as a model for dealing with rising demand for paediatric surgical services

Introduction Shifts in the landscape of surgical care provision have resulted in a rise in demand for specialist paediatric surgery services. Here we describe a model of a single paediatric surgery service delivering elective surgery across two sites, a specialist children’s hospital and an inner-city district general hospital. This model has allowed for a management of increased demand while maintaining key quality indicators within national standards. Materials and methods In a single specialist paediatric surgical service working at two sites (specialist and non-specialist), service demand was evaluated by number of referrals and waiting list additions and removals over an eight-year period (2011–2018). Daycase rate, 30-day readmission, and 12-month reoperation for three commonly performed general surgery of childhood procedures (umbilical hernia repair, Inguinal herniotomy, orchidopexy) are reported. NHS Getting it Right First Time data are used to allow comparison with national standards. Results Referrals to the service increased 2.5-fold (955 in 2011/12 compared with 2,419 in 2017/18) and waiting list additions increased 1.4-fold (585 compared with 840), net additions to the waiting list indicate that demand was met. Readmission and reoperation rates met or exceeded national standards. Discussion This model allows for a high quality of care to be provided with acceptable daycase rates and low readmission and reoperation rates. We commend this model to other specialist paediatric surgical centres experiencing increasing demand on their services

94 An Observational Cohort Study to Evaluate Volume and Severity of Emergency General Surgery Admissions During The COVID-19 Pandemic: Is There A “Lockdown” Effect?

IntroductionThe COVID-19 pandemic has led to changes in NHS surgical service provision. This, combined with the government-imposed lockdown, may have impacted on patient attendance, severity of surgical disease, and outcomes. This study aimed to investigate a possible ‘lockdown’ effect on the volume and severity of surgical admissions and outcomes.MethodTwo cohorts of adult emergency general surgery admissions 30 days immediately before (16/2/2020 to 15/3/2020), and after UK government advice (16/3/2020 to 15/4/2020). Data were collected relating to patient characteristics, disease severity, clinical outcomes, and compared between these groups.ResultsFollowing lockdown, a significant reduction in median daily admissions from 7 to 3 (p < 0.001) was observed. Post-lockdown patients were significantly older, frailer with higher inflammatory indices and rates of AKI, and more likely to present with gastrointestinal cancer, obstruction, and perforation. Patients had significantly higher rates of Clavien-Dindo Grade ≥3 complications (p = 0.001), all-cause 30-day mortality (8.5% vs. 2.9%, p = 0.028), but no significant difference was observed in operative 30-day mortality.ConclusionsThere appears to be a “lockdown” effect on general surgical admissions with fewer admissions, more acutely unwell patients, and an increase in all-cause 30-day mortality. Patients should be advised to present promptly, and this should be reinforced for future lockdowns during the pandemic.

AB036. SOH21AS225. The impact of COVID on surgical provision in Ireland: lessons learned and new possibilities

Background: The unprecedented burden of the COVID pandemic has brought with it many challenges including economic, social, infrastructural, and crucially significant disruptions in healthcare provision. Consequently, certain aspects of elective care have been deprioritised to enable health systems to respond resulting in growing waiting lists, delayed and in some cases suboptimal care. The purpose of the current study is to evaluate the impact of COVID on elective scheduled care nationally.

EVALUATION OF THE SHORT-TERM IMPACT OF COVID-19 IN A LARGE DISTRICT GENERAL HOSPITAL

Intro: Since December 2019, SARS-CoV-2 has had a dramatic impact on the global landscape. One of the biggest challenges has been the additional strain that the virus has put on healthcare systems. Although there has been much data on the direct affects of COVID-19 on intensive care beds and ventilator availability, there has been little exploration into the wider impacts that the restrictions brought about by COVID-19 have had on the provision of other healthcare services. We designed this study to explore how Aim: COVID-19 has impacted surgical service provision at a tertiary centre. We Methods: compared the number and types of general surgeries carried out at a single hospital in the six months prior to the initial UK COVID-19 outbreak (September 2019 - February 2020) and the six months after (March 2020 - August 2020). We found that since March 2020 there has been a 70% decrease i Results: n the number of operations being carried out, with numbers dropping from a pre-COVID surgery number of 1761 to a post-COVID number of 529. This mainly affected elective procedures however, with emergency surgeries remaining relatively constant (48 pre-COVID vs 44 post-COVID). COVID-19 has Conclusion: caused a signicant decrease in the number of surgeries being undertaken. This is due to a combination of factors including stafng issues, reduced investigation, and national mandates requesting the cessation of non-urgent procedures. Although this has mainly affected elective operations, it is likely to have a larger impact in the future as surgical waiting lists continue to grow

Effect of the COVID-19 pandemic first wave and public policy on elective and emergency surgery provision in Southern Queensland.

BackgroundSeveral public health initiatives in Australia were implemented in March 2020 to contain the spread of COVID‐19. The effect of these initiatives on surgical provision is unknown. The primary objective was to determine the effect of public health policies and surgical society guidelines implemented during the pandemic on elective and emergency caseload of surgical specialities operating within South East Queensland.MethodsThis observational study utilized non re‐identifiable electronic data to quantify the caseload of surgical specialities across five secondary and tertiary referral hospitals in South East Queensland prior to and during the implementation of such initiatives. All patients undergoing a surgical procedure between 1 March and 24 April 2019 and the same period in 2020 were included. Participants' demographic and clinical information, such as age, the American Society of Anesthesiologists score, surgical date and location, surgical subspecialty and procedure name, was included.ResultsDuring the 2020 time period, there were 2991 elective cases compared to 4422 surgeries occurring in the same period in 2019 (32.4% reduction). Meanwhile, 2082 emergency surgeries were performed in the 2020 period compared to 2362 in 2019 (12.0% decrease). Ophthalmology and dental/ear, nose and throat/maxillofacial surgery experienced the largest reduction in elective surgeries, whereas emergency caseload increased for vascular and cardiothoracic services, and only slightly decreased for plastics and urology.ConclusionThe public health initiatives and guidance implemented during the COVID‐19 pandemic reduced surgical specialties' elective caseload. However, emergency caseload was not affected to the same extent. This insight helps to guide resource allocation in future waves of the pandemic.

Collateral Damage or Benefit? The Impacts of COVID-19 Induced Lockdown and Mandatory Screening Policy on Lung Surgery: Evidence from Wuhan

Background: The COVID-19 pandemic, accompanied by governments' regulatory restrictions to contain it, interfered with surgical services provision. We aimed to evaluate the impact of a 76-day city-wide lockdown in Wuhan, China, on the provision of four types of surgery and investigate the association between COVID-19 screening measures and the post-lockdown surge in lung surgery. Methods: We collected data of four types of surgery: lung, esophagus, liver, and stomach, conducted between October 1, 2019, to July 31, 2020, from three major hospitals in Wuhan. We compared the demographic information of patients before and after the COVID-19 induced lockdown by surgery types. We then used difference-in-differences analysis to compare the volumes of lung surgery with three other types of surgery. We estimated the abnormal post-lockdown surge in lung surgery, accounting for scheduling delay. Next, we probed into the association between such abnormal increase in lung surgery and the mandatory chest CT scans required by the government as a COVID-19 screening measure using linear regression. Finally, we analyzed the proportion of lung cancer surgery and its demographic characteristics before and after the lockdown.Findings: After the lockdown started, all four types of surgery quickly dropped to a very low level and stayed at that minimum level throughout the lockdown period. Within 12 weeks after the lockdown was lifted, all three surgery types returned to and stayed at the pre-lockdown period except lung surgery, which surged to 150% of the pre-lockdown level. Specifically, the weekly volume of lung surgery in the post-lockdown period was 60% higher than that of esophagus surgery (95% CI, 0·31-0·90), 39% higher than that of liver surgery (95% CI, 0·17-0·63), and 24% higher than that of stomach surgery (95% CI, 0·01-0·47). Moreover, for every 1,000 chest CT scans conducted in week t-1, on average 3·5 (95% CI, 0·56-6·49) lung surgery were expected to occur in the week that followed. Besides, more young female patients received lung surgery after the lockdown [82 (58%) vs. 57 (45%)]. Finally, the fractions of post-lockdown lung cancer surgery were significantly greater than those in the pre-lockdown period (73% vs. 66%).Interpretation: The lockdown severely affected surgical services in Wuhan. Amid the recovery, the surge in lung surgery was associated with the large-scale chest CT screening policy implemented during and after the lockdown. Such a large-scale chest CT screening could be a blessing as it advanced the diagnosis window of lung diseases for young females.Funding: No funding is declared for this study.Declaration of Interests: None reported.Ethics Approval Statement: The authors have used data with the approval from the healthcare information system of three Triple-A accredited hospitals.

Results from ACROCOVID: an international survey on the care of acromegaly during the COVID-19 era.

With most global healthcare resources focused on COVID-19, altered resource allocation is disrupting the continuum of care for chronic endocrine conditions, including acromegaly. In order to assess the effects of COVID-19 on care of patients with acromegaly, we conducted an international online survey of endocrinologists. The questionnaire was drafted by a Steering Committee of acromegaly experts and covered both respondent demographics, contact and communication with patients, and patient care. Respondent awareness was generated through social media campaigns and the survey completed online using Google forms. The majority of endocrinologists who responded (N = 84) were based in Europe (67.9%) and were female (58.3%). Slightly more than half of respondents worked in a specialized pituitary center (52.4%) and a large minority cared for more than 50 acromegaly patients (47.6%). Most respondents (85.7%) indicated surgery was their first-line treatment, with only 14.3% indicating medical therapy as a first-choice treatment option. One-third (33.3%) of respondents reported having delayed a planned surgery due to a lack of COVID-19 testing provision and 54.8% due to a lack of surgical provision; 19.1% indicated that a lack of personal protective equipment had reduced their ability to treat patients with acromegaly. Just 21.4% of respondents reported no negative effects from the pandemic on diagnostic practice patterns, and just 19.1% reported no negative effect on patient follow-up practices. Many respondents (55.9%) indicated that remote methods had improved their ability to communicate with their patients and 69.0% indicated that they would continue to use methods of consultation necessitated by the COVID-19 pandemic. Our data suggest the COVID-19 pandemic is substantially affecting the care of acromegaly. However, these results also suggest that endocrinologists are embracing aspects of the ‘new normal’ to create a novel continuum of care better suited to the presumed post-COVID-19 environment. The goal of these changes must be both to improve care while shielding patients from more severe involvement in concomitant acute illnesses such COVID-19.

Interpersonal Challenges in Surgical Care Provision in Rural Mexico: A Qualitative Study

Background: Chiapas is among the states with lowest access to health care, like surgical services, in Mexico. A better understanding of the role of interpersonal relationships in referral systems could improve access to care in the region. The purpose of this study was to analyze the underlying barriers and facilitators to accessing surgical care at public hospitals run by the Ministry of Health in Chiapas. Methods: In this qualitative study based in grounded theory, we performed semi-structured interviews with 19 surgical patients and 18 health care workers at three public hospitals in the Fraylesca Region of Chiapas to explore barriers and facilitators to successfully accessing surgical treatment. Transcripts were coded and analyzed using an inductive, thematic approach to data analysis. Findings: The five major themes identified as barriers to surgical care were dehumanization of patients, the toll of rehumanizing patients, animosity in the system, the refraction of violence onto patients, and poor resource coordination. Three themes identified as facilitators to receiving care were teamwork, social capital, and accompaniment. Interpretation: Health care workers described a culture of demoralization and mistrust within the health system that is worsened by a scarcity of resources. As a result, patient care is hampered by conflict, miscommunication, and feelings of dehumanization. Efforts to improve access to surgical care in the region should consider strategies to improve teamwork and expand patient accompaniment. Funding Information: The Harvard Mexico Foundation, the David Rockefeller Center for Latin American Studies, the Abundance Foundation, and the National Council of Science and Technology of Mexico provided funding for this project Declaration of Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Ethics Approval Statement: Researchers read and obtained verbal consent from patient participants. This study was approved by Harvard IRB, the Instituto Tecnologico y Estudios Superiores de Monterrey (ITESM) ethics committee, and the Chiapas MOH ethics review board.

Suspected appendicitis and COVID-19, a change in investigation and management-a multicentre cohort study.

PurposeThe COVID-19 pandemic has reformed global healthcare delivery. On 25 March 2020, Intercollegiate guidelines were published in the UK to promote safe surgical provision during the COVID-19 outbreak advocating non-operative management or avoidance of laparoscopy when surgery is essential. The effects of this on the investigation and management of appendicitis remain unknown.MethodsWe performed a multicentre, prospective, observational study from the start of the new guidelines to the 6th of May 2020. We included all patients referred to surgical teams with suspected appendicitis. A recent historical cohort was identified for comparison. The primary outcome was the impact of the COVID-19 pandemic on the use of non-operative management in appendicitis. Secondary outcomes included imaging, negative appendicectomy rate (NAR), length of stay (LOS) and 30-day complications.ResultsA total of 63/164 (38%) patients compared to 79/191 (41%) were diagnosed with appendicitis before and after the guidelines were introduced (p = 0.589). CT scanning increased (71/164 vs 105/191; p = 0.033) while ultrasound scanning decreased (71/164 vs 62/191; p = 0.037). Appendicitis was more likely to be managed non-operatively (11/63 vs 51/79; p < 0.001) and, of those managed surgically, with an open approach (3/52 vs 26/28 p < 0.001). The NAR also reduced (5/52 vs 0/28; p = 0.157). LOS was shorter in non-operatively managed patients (1 day vs 3 days; p < 0.001) without a difference in complications (10/51 vs 4/28; p = 0.760).ConclusionIntroduction of the guidelines was associated with changes in practice. Despite these changes, short-term complications did not increase and LOS decreased. Questions remain on the longer-term complication rates in non-operatively managed patients.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00423-020-02023-6.

The effect of the COVID-19 lockdown on hand trauma surgery utilization.

AimsThe aim of this study was to evaluate the need for hand trauma services during the COVID-19 pandemic lockdown, specifically related to surgical requirements. This will provide useful information for planning and resource allocation in the event of any further lockdown.MethodsA prospective analsysis of all patients attending our hand trauma unit throughout the UK COVID-19 lockdown period (24 March to 10 May 2020) was carried out. Prospectively collected departmental data from the same period in 2019 was obtained and reviewed for comparison. The number of patients attending clinic, undergoing surgery, the type of surgical procedure, and rate of surgery was compared.ResultsIn all, 463 patients attended hand trauma services during the lockdown period compared to 793 in 2019 (32% reduction); 190 surgical procedures were carried out during lockdown compared to 236 in 2019 (20% reduction). Intervention rate was higher during the lockdown period (41% compared to 30%). There was no difference in the type of cases. In the first half of lockdown, 47% fewer procedures were performed than in 2019, but in the second half of lockdown 13% more procedures were carried out than the same period in 2019.ConclusionRequirements for hand trauma surgery remain high during a pandemic lockdown. Attendances and surgical requirements can be expected to steadily return to normal levels during a prolonged lockdown period. Throughout any future lockdown period adequate surgical provision must be maintained for patients with hand injuries.Cite this article: Bone Joint Open 2020;1-10:639–643.

Maintaining a safe uro-oncological surgical service in the face of the COVID-19 pandemic

Objective: The COVID-19 pandemic has had a profound impact on the provision of surgery across the NHS. Despite the challenges, the uro-oncology surgical provision at our centre in the northwest of England, a COVID-19 hotspot, has continued throughout. Patients and methods: We report a 26-patient case series performed following national lockdown. Patients were initially screened for COVID-19 symptoms and later all patients required a negative swab pre-operatively. Personal protective equipment using aerosol precautions was used for all cases. A post-operative ‘cold’ COVID-19 critical-care ward was created. Patients who developed possible symptoms of COVID-19 were isolated and swabbed. A telephone questionnaire was completed two weeks following discharge. Results: Three out of 26 patients developed post-operative pyrexia, but all tested negative for COVID-19. Non-COVID-19-related complication rates were consistent with our previous results. Telephone follow-up confirmed that none had experienced symptoms suggestive of COVID-19 infection. Overall, patient satisfaction with hospital COVID-19 precautions was high. All patients were satisfied with their decision to undergo surgery during the pandemic. Conclusions: Our results indicate that during the peak of the COVID-19 pandemic, with appropriate precautions, a safe surgical service can be continued. Level of evidence Level 3

A single-centre observational cohort study to evaluate volume and severity of emergency general surgery admissions during the COVID-19 pandemic: Is there a "lockdown" effect?

IntroductionThe COVID-19 pandemic has led to changes in NHS surgical service provision, including reduced elective surgical and endoscopic activity, with only essential emergency surgery being undertaken. This, combined with the government-imposed lockdown, may have impacted on patient attendance, severity of surgical disease, and outcomes. The aim of this study was to investigate a possible ‘lockdown’ effect on the volume and severity of surgical admissions and their outcomes.MethodsTwo separate cohorts of adult emergency general surgery inpatient admissions 30 days immediately before (February 16, 2020 to March 15, 2020), and after UK government advice (March 16, 2020 to April 15, 2020). Data were collected relating to patient characteristics, severity of disease, clinical outcomes, and compared between these groups.ResultsFollowing lockdown, a significant reduction in median daily admissions from 7 to 3 per day (p < 0.001) was observed. Post-lockdown patients were significantly older, frailer with higher inflammatory indices and rates of acute kidney injury, and also were significantly more likely to present with gastrointestinal cancer, obstruction, and perforation. Patients had significantly higher rates of Clavien-Dindo Grade ≥3 complications (p = 0.001), all cause 30-day mortality (8.5% vs. 2.9%, p = 0.028), but no significant difference was observed in operative 30-day mortality.ConclusionThere appears to be a “lockdown” effect on general surgical admissions with a profound impact; fewer surgical admissions, more acutely unwell surgical patients, and an increase in all cause 30-day mortality. Patients should be advised to present promptly with gastrointestinal symptoms, and this should be reinforced for future lockdowns during the pandemic.

Identifying essential components of surgical care delivery through quality improvement: An updated surgical assessment tool.

Surgical care is a cost-effective intervention with major public health impact. Yet, five billion people do not have access to surgical and anesthesia care. This overwhelming unmet need has generated a rising interest in scale-up of these services globally. The purpose of this research was to aggregate available guidelines and create a synthesized tool that could provide valuable information at the local, national, and international health system levels. A systematic review identified current documents cataloging elements for surgical care provision. Items with a reported frequency of >30% were included in the initial draft of the Surgical Assessment Tool. This underwent two cycles of Delphi-method expert opinion elicitation from providers working in low- and middle-income settings. Finally, the tool underwent vetting by the World Health Organization to create an expert-endorsed survey. Fifteen surgical tools were identified, containing a total of 216 unique elements in the following domains: infrastructure (n=152), service delivery (n=49), and workforce (n=15). The final tool consisted of 169 items in the following domains: infrastructure (n=35), service delivery (n=92), workforce (n=20), information management (n=10), and financing (n=12). Informed planning is critical to ensure successful expansion of surgical services. Our analysis of current tools shows varying agreement on the essential components of surgical care delivery. This updated tool serves as a crucial method to systematically assess surgical systems as well as monitor, modify, and strengthen in a scalable fashion. Importantly, it has the potential to be used in all settings after adaptation to local context.

SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic.

The unprecedented pandemic of COVID-19 has impacted many lives and affects the whole healthcare systems globally. In addition to the considerable workload challenges, surgeons are faced with a number of uncertainties regarding their own safety, practice, and overall patient care. This guide has been drafted at short notice to advise on specific issues related to surgical service provision and the safety of minimally invasive surgery during the COVID-19 pandemic. Although laparoscopy can theoretically lead to aerosolization of blood borne viruses, there is no evidence available to confirm this is the case with COVID-19. The ultimate decision on the approach should be made after considering the proven benefits of laparoscopic techniques versus the potential theoretical risks of aerosolization. Nevertheless, erring on the side of safety would warrant treating the coronavirus as exhibiting similar aerosolization properties and all members of the OR staff should use personal protective equipment (PPE) in all surgical procedures during the pandemic regardless of known or suspected COVID status. Pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open. All emergent endoscopic procedures performed during the pandemic should be considered as high risk and PPE must be used by all endoscopy staff.

Slow implementation of mifepristone medical termination of pregnancy in Quebec, Canada: a qualitative investigation

Objectives: Mifepristone for first-trimester medical termination of pregnancy (MTOP) became available in Quebec in 2018, one year after the rest of Canada. Using the theory of the Diffusion of Innovation (DOI) and the transtheoretical model of change (TTM), we investigated factors influencing the implementation of mifepristone MTOP in Quebec.Material and Methods: Semi-structured interviews were conducted with 37 Quebec physicians in early 2018. Deductive thematic analysis guided by the theory of DOI explored facilitators and barriers to physicians’ adoption of mifepristone MTOP. We then classified participants into five stages of mifepristone adoption based on the TTM. Follow-up data collection one year later assessed further adoption.Results: At baseline, three physicians provided mifepristone MTOP (Maintenance) and two were about to start (Action). Thirteen physicians at Preparation and Advanced Contemplation stages intended to start while, within the Slow Contemplation, two intended to start and ten were unsure. Seven had no intention to provide mifepristone MTOP (Pre-Contemplation). Major reported barriers were: complexity of local health care organisations, medical policy restrictions, lack of support, and general uncertainty. One year later, ten physicians provided mifepristone MTOP (including three at baseline) and nine still intended to, while seventeen did not intend to start provision. Seven of sixteen participants (44%) who worked in TOP clinics at baseline were still not providing MTOP with mifepristone one year later.Conclusion: Despite ideological support, mifepristone MTOP uptake in Quebec is slow and laborious, mainly due to restrictive medical policies, vested interests in surgical provision and administrative inertia.

The Surgical and Anesthesia Workforce and Provision of Surgical Services in Rural Communities: A Mixed-Methods Examination.

Rural-urban disparities in the surgical and anesthesia workforce exist. This mixed-methods study describes the distribution of the surgical and anesthesia workforce and qualitatively explores how such workforce and other factors influence rural hospitals' provision of surgical services. We calculated provider counts by county from the Area Health Resource File. Using American Hospital Association survey data, we sampled rural hospitals, stratified by critical access status and state policies. We conducted qualitative semistructured interviews with administrators at 16 hospitals and performed directed content analysis of factors influencing surgical services provision at rural hospitals. Within rural counties, 55.1% of counties had no surgeon, 81.2% had no anesthesiologist, and 58.1% had no Certified Registered Nurse Anesthetist (CRNA). Administrators reported that rural hospitals struggled to provide many surgical services given lack of subspecialty surgeons and adequate postsurgical care. Rural hospitals likely struggle to generate volumes necessary to support safe and profitable subspecialty surgery programs. Anesthesia services were not reported as a current limitation given that CRNAs in particular had strong, diverse skills sets and many hospitals allowed high CRNA autonomy. However, meeting anesthesia needs for emergency surgeries and 24-hour obstetrics posed significant challenges. While rural hospitals reported meeting community needs for elective and noncomplex surgeries, rural hospitals continued to face significant challenges providing subspecialty surgeries, emergency surgeries, and 24-hour obstetrical services.

Организация хирургической помощи в многопрофильном стационаре в условиях пандемии COVID-19

The spread of caused by SARS-CoV2 acute respiratory infection associated with severe life-threatening complications has necessitated transformation of most general hospitals into infectious diseases hospitals in order to provide specialized care to infected patients, as well as the change of surgical care provision strategy. The example of surgical service reorganization has been reported for the general clinic transformed into the infectious diseases hospital capable of providing care both during the COVID-19 pandemic and after the outbreak has abated.