key: cord-273303-g86w0xt5
authors: Latz, Christopher A.; Boitano, Laura T.; Png, C. Y. Maximilian; Tanious, Adam; Kibrik, Pavel; Conrad, Mark; Eagleton, Matthew; Dua, Anahita
title: Early Vascular Surgery Response to the COVID-19 Pandemic: Results of a Nationwide Survey
date: 2020-05-23
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.05.032
sha: 
doc_id: 273303
cord_uid: g86w0xt5

OBJECTIVES: The COVID-19 pandemic has had major implications for the United States healthcare system. This survey study sought to identify practice changes, understand current personal protection equipment (PPE) use, and determine how caring for patients with COVID-19 differs for vascular surgeons practicing in states with high COVID-19 case numbers versus low case numbers. METHODS: A fourteen-question online survey regarding the effect of the COVID-19 pandemic on vascular surgeons’ current practice was sent to 365 vascular surgeons across the country via REDCap from 4/14/2020 to 4/21/2020 with responses closed on 4/23/2020. The survey response was analyzed with descriptive statistics. Further analyses were performed to evaluate whether responses from states with the highest number of COVID-19 cases (New York, New Jersey, Massachusetts, Pennsylvania and California) differed from those with lower case numbers (all other states). RESULTS: A total of 121 vascular surgeon responded (30.6%) to the survey. All high-volume states were represented. The majority of vascular surgeons are reusing PPE The majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. This did not differ between high case and low COVID case states (p=0.285). High case states were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs. 77.5%, p=0.046), but otherwise case types did not differ. Most attendings work with residents (90.8%) and limited their exposure to procedures on suspected/confirmed COVID-19 cases (56.0%). Thirty-eight percent of attendings have been redeployed within the hospital to a vascular access service, and/or other service outside of vascular surgery. This was more frequent in high case volume states compared to low case volume states (p=0.039). The majority of vascular surgeons are reusing PPE (71.4%) and N95 masks (86.4%), and 21% of vascular surgeons feel that they do not have adequate PPE to perform clinical their duties. CONCLUSION: The initial response to the COVID-19 pandemic has resulted in reduced elective cases with primarily only urgent and emergent cases being performed. A minority of vascular surgeons have been redeployed outside of their specialty, however, this is more common among states with high case numbers. Adequate PPE remains an issue for almost a quarter of vascular surgeons who responded to this survey.

involvement in COVID-19 positive cases, 38% of attendings have been redeployed to services 1 other than traditional vascular surgery, such as the ICU and vascular access service, and 71% are 2 reusing personal protective equipment (PPE). Twenty-one percent of vascular surgeons do not 3 feel they have adequate access to PPE. Twenty-one percent did not feel they have adequate access to PPE. responses from states with the highest number of COVID-19 cases (New York, New Jersey, 1 Massachusetts, Pennsylvania and California) differed from those with lower case numbers (all 2 other states).

3 Results: A total of 121 vascular surgeon responded (30.6%) to the survey. All high-volume 4 states were represented. The majority of vascular surgeons are reusing PPE The majority of 5 respondents worked in an academic setting (81.5%) and were performing only urgent and 6 emergent cases (80.5%) during preparation for the surge. This did not differ between high case 7 and low COVID case states (p=0.285). High case states were less likely to perform a lower 8 extremity intervention for critical limb ischemia (60.8% vs. 77.5%, p=0.046), but otherwise case 9 types did not differ. Most attendings work with residents (90.8%) and limited their exposure to 10 procedures on suspected/confirmed COVID-19 cases (56.0%). Thirty-eight percent of attendings 11 have been redeployed within the hospital to a vascular access service, and/or other service 12 outside of vascular surgery. This was more frequent in high case volume states compared to low 13 case volume states (p=0.039). The COVID-19 pandemic is impacting the entire United States in unprecedented ways.

This is especially true of the healthcare system as certain hospitals are amid an overwhelming 4 surge of patients, while other hospitals are actively preparing for predicted surges. Issues for 5 surgeons are wide-reaching as practices are shut down and patient care is delayed. In addition, 6 there are increased levels of stress and anxiety amongst surgical staff as a significant portion of 7 the worldwide cases have involved healthcare workers. 1-4 8 There have been major changes to most surgical practices in preparation for the pandemic. 5 As 9 operative caseloads dwindle, and new consults are deferred indefinitely, new issues arise. These 10 include the possibility of redeployment from traditional roles, threats of decreased 11 reimbursement, and a potential decrease in case volume and learning opportunities for trainees. Of the 365 physicians contacted to complete this survey 121 replied for a 30.6% response rate. Thirty-three states were represented including all high volume COVID-19 states (figure 2). The 7 majority of respondents were from California (13.2%), Massachusetts (9.9%), and New York 8 (11.6%) but these states still represented less than 50% of respondents (n=51, 42.1%). Seventy 9 respondents (57.9%) were from low volume COVID-19 states.

The majority of physicians who answered this survey practice in an academic setting (81.5%), 11 followed by a large community practice (14.3%). Small community practices were not well 12 represented in this survey, comprising only 4.2% of respondents (figure 3). 13 Practice changes have been instituted with 80.5% of vascular surgeon respondents limiting their survey are modifying their practice to limit trainee exposure. This practice may also be partially 20 driven by PPE shortages, but likely also reflects a desire to protect our trainees from 21 unnecessarily exposure. The majority of vascular surgeon respondents were also being asked to 22 reuse PPE, a common practice throughout the United States during the pandemic. 18 It is unclear how many institutions have instituted re-sterilization protocols. 19 Resources should be directed at 1 improving access to PPE for all healthcare providers to ensure those providing essential duties 2 are not at an increased risk of contracting Delay in cases seems common, whether it is occurring while waiting for a COVID-19 4 rule out test or waiting to enter the operating room until a sufficient amount of time has passed 5 after intubation on COVID-19 positive or suspected cases. The impact this has on outcomes is 6 currently unknown but given the many time-sensitive interventions that vascular surgeons 7 provide, this may be problematic. Even in negative pressure rooms, it takes 30 minutes for 8 99.99% of the aerosolized particles to be removed; waiting for these rooms to clear of 9 aerosolized particles can cause fatal delays in treating ruptured aneurysms or cause undue 10 ischemia time in cases where tourniquets are applied for extremity hemorrhage. It was outside 11 the scope of this project to determine the impact this operative delay may have on patient 12 outcomes.

An even greater impact than the delay in cases is the transition of cases from all elective, 14 urgent and emergent operations to primarily only vascular urgencies and emergencies which are 15 life and limb saving. These include symptomatic/ruptured AAA, type B dissection with 16 malperfusion, wet gangrene, acute limb ischemia, acute mesenteric ischemia, symptomatic 17 carotid artery disease, and revision/removal of nonfunctional or infected dialysis access. It is 18 likely that the centers not performing the above cases are transferring patients with these 19 diagnoses to higher levels of care as opposed to opting for non-operative management. The fact 20 that less than 5% of respondents are still performing elective cases shows the far-reaching 21 implications of the pandemic on vascular surgery daily practice, as well and adherence to 22 recommended protocols from both the surgeon general and vascular surgery specific 23 recommendations. 20 Furthermore, the downstream effects of not treating vascular disease that is 1 considered elective has yet to be determined. It will be important to understand how the health of 2 the vascular surgery patient population is affected by this shift toward urgent and emergent 3 cases.

At our large, tertiary institution, which is both a high-volume vascular center and within a 5 high volume COVID-19 state, we have altered practice to manage our vascular services 6 optimally. In our initial response (early March 2020), vascular trainees were not involved in 7 COVID-19 cases and attendings saw these patients alone (both to protect our trainees and to 8 limit use of PPE). All elective surgeries and clinics were canceled, and patients were tracked on a 9 master list managed by the division chief to ensure appropriate follow up. Patients admitted to 10 the hospital were not allowed to have visitors. The division created a combined list of surgical 11 cases, and each attending determined individually if their patient could be rescheduled or 12 required an urgent procedure.

As the pandemic evolved, so did the response from our division; by the end of March into 14 mid-April the vascular service had been restructured such that teams of two attendings were 15 covering call week to week and served as each other's back up. The rationale was to limit 16 exposure, and in the event that one team contracted COVID-19, a back-up team would be readily 17 available. The team that was "on call" for the week also would see any clinic patients of their 18 partners that were deemed necessary for an in-patient visit. Once our hospital established an 19 appropriate supply of PPE, our vascular trainees were involved in cases and patient care once 20 again. Over the last month, our group has evolved further; hospital-wide initiatives included 

1 Strengths inherent to this study include the novel data provided regarding attending vascular 2 surgeon sentiment and practice patterns during the COVID-19 pandemic and the reasonably high 3 response rate obtained over a short period of time. These data can be used to inform other crises 4 by highlighting trends in practice and surgeon sentiment, and hopefully this will inform 5 expectations and lead to a more streamlined response during the next crisis. Because there was 6 only a one-week period over which responses were collected, there was unlikely to be much 7 evolution and the practice and systems issues addressed in the survey. The COVID-19 pandemic has resulted in practice changes for the survey respondents including a 2 shift to only operating for urgent and emergent indications. This has led many untreated vascular 3 patients, the effect of which has yet to be determined. A minority of vascular surgeons have 4 been redeployed outside their specialty, however, this is more frequent among states with high 5 COVID-19 case numbers. Reuse of PPE and N95 masks are common. However, adequate PPE 6 remains an issue for 21% of vascular surgeons who responded to this survey. pandemic-time-to-act-is-long-past-due/. 

Rapid 17 Response of an Academic Surgical Department to the COVID-19 Pandemic: Implications for 18

The 20 Importance of the Minimum Dosage Necessary for UVC Decontamination of N95 Respirators COVID-19 Survey 1