key: cord-0740481-xoeblh80
authors: Shaw, Abigail V; Reed, Alistair JM; Ryan, Daisy; Nijjher, Jagdeesh; Critchley, Paul; Ramsden, Alex; Furniss, Dominic
title: Coming out of the crisis: restarting services after the coronavirus pandemic
date: 2020-08-25
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.08.067
sha: 727b520739d54c3b03bd6afb593eb286d8d7926b
doc_id: 740481
cord_uid: xoeblh80

nan

The first wave of the coronavirus (COVID-19) pandemic was considered to peak in the United Kingdom on 8 th April 2020. NHS England guidance advised on the 29 th April that within six weeks, all urgent surgery should be provided at pre-pandemic capacity 1 .

The plastic surgery service at Oxford University Hospitals made significant changes to the structure and delivery of services at the start of the pandemic 2 . Hand trauma referrals have been triaged by consultants via telemedicine, in-house patients reviewed by the most senior clinician available and patients requiring surgical intervention allocated directly to a theatre list for a 'see and treat' approach. All elective surgeries were paused, with cancer services continuing on 'clean' sites, using stringent protocols involving pre-operative isolation and swab testing. As of the 25 th June, Oxfordshire had 2,125 confirmed cases of COVID-19 in a population of 691,000 3 .

There have been limited reports on the outcomes of plastic surgery patients operated on during the pandemic. The COVIDSurg collaborative published its first cohort of 1128 patients, diagnosed with COVID-19 in the perioperative period, reporting a 30-day mortality of 23.8% and 51.2% suffering pulmonary complications 4 . However, only three patients were operated on by plastic surgery services.

A retrospective service evaluation in a single tertiary trauma centre reviewed all patients operated on by our plastic surgery department between the 9 th March (two weeks prior to lockdown) and 28 th April, covering the peak of the outbreak. The intention was to advise our unit Telephone calls identified one paediatric patient who had suspected symptoms three days following an elective GA procedure but did not undergo testing or require medical attention. Review of records identified two further patients who had died within 30 days of a LA day case procedure. One presented to another hospital with respiratory symptoms, but had a negative COVID-19 PCR test three days post-procedure. The other did not present to hospital or undergo testing but suspected COVID-19 was recorded as a cause of death. Both were elderly with a Clinical Frailty Scale score over six.

To our knowledge, 2.6% (9/349) patients developed possible coronavirus symptoms or abnormal radiology following procedures in our department during the COVID-19 pandemic with 0.9% (3/349) having a positive test (two patients with symptoms were not tested). Those with positive tests all underwent GA procedures and were inpatients for over ten days. Overall 30day mortality of the patient group was 1.1% (4/349), with two of these deaths confirmed as COVID-19 related and one suspected. Following significant departmental discussion and government guidance, electives have cautiously restarted utilising clear protocols, initially focussing on LA procedures. Elective patient must isolate for 14 days and have negative PCR testing 72 hours before their procedure.

We will continue to monitor if patients develop symptoms of COVID-19 post-operatively.

Our study provides some evidence to suggest that plastic surgery procedures, especially under LA as a day case, carry limited risk of patients developing symptoms of COVID-19, as long as stringent guidelines are followed. Rarely patients may contract COVID-19, and if vulnerable, are likely to have a high mortality rate from the infection, similar to frail elderly patients who develop COVID-19 infection without undergoing surgery 5 . Therefore, we advise caution in elderly patients and those with underlying health conditions.

Funding statement: None for completion of submission.

Second phase of NHS response to COVID-19

A plastic surgery service response to COVID-19 in one of the largest teaching hospitals in Europe

Coronavirus (COVID-19) cases in the UK

Mortality and pulmonary complications in patients undergoing surgery with peri-operative SARS-CoV-2 infection: an international cohort study

Centre for Evidence-Based Medicine Research. Global COVID-19 case fatality rates