key: cord-0827022-hvp12oxg authors: Joseph, Anokha Oomman; Joseph, Janso Padickakudi; Nageswaran, Haritharan; Rajalingam, Viswa Retnasingam; Sharma, Amit; Pereira, Bernadette; Gahir, Jasdeep title: A multi‐centre insight into general surgical care during the coronavirus outbreak in the United Kingdom date: 2020-08-05 journal: Br J Surg DOI: 10.1002/bjs.11885 sha: 5549860fbad4cc5df039155ebe38e51c733bbaa6 doc_id: 827022 cord_uid: hvp12oxg We confirm that this manuscript has not been previously published, and that it is not under consideration with a different journal All authors have reviewed and approved this manuscript in the current form We declare no conflict of interest We have not received financial support for this manuscript We submit his article after discussion with Mr. Des Winter as a special research letter to the Editor. The day-to-day staffing arrangements were predicated by re-deployment of junior staff. At NMUH the department was staffed by registrars and consultants with the support of generic ward-based junior doctors. At BH and HH a cadre of all grades remained on surgery. At WHH surgical registrars contributed to both surgical and intensive care rotas. Resident medical officers, physician associates and advanced nurse practitioners continued to contribute to the surgical workforce. Rearrangement of shifts meant new working patterns, creation of novel shifts, and minimisation of doctors on site. At HH reorganisation was multidisciplinary, with the creation of mixed medical and surgical "interventional teams", which were also responsible for COVID-19 patients on their ward. Universally a second tier "back-up" rota accommodated staff illness and periods of self-isolation. WhatsApp groups and handover between shifts were used to fill known staffing gaps internally. There was an extension of existing ambulatory surgical units (ASUs), staffed by senior decision makers, and attended only by symptom-screened low-risk for COVID-19 patients. All sites had direct access to some diagnostic and therapeutic modalities (e.g. ultrasound, MRCP, ERCP, CT and interventional radiology). At NMUH and BH patients were streamed directly from A&E to speciality. At POW patients were referred directly to consultants. There was a trend towards seven-day working and maturation of ASU pathways. Departments and multidisciplinary teams have attempted to safeguard urgent cancer surgery (UCS). Some new diagnostic and treatment algorithms were created (e.g. using CT instead of endoscopy for gastrointestinal cancer diagnosis at WHH). At BH and POW, limited UCS has continued throughout the pandemic. Collaboration between the public and private sectors has allowed UCS to be provided at "cold" private sites. At HH and WHH, UCS is consultant-delivered. At BH surgeons continue to offer laparoscopic UCS; in contrast, all colorectal cancer surgery is now performed by open technique by WHH surgeons. The limitation of the partnership with the private sector has been a lack of staffing for inpatient care, and limited ITU resources. Major operations requiring Level 3 care (e.g. oesophagectomy or pelvic exenteration) have not been performed at any of our sites during the pandemic. Telephonic and virtual patient consultation have been used ubiquitously to provide outpatient clinic services. At NMUH, BH, POW and HH only suspected cancer referrals are accepted. WHH continues to accept benign referrals. The coronavirus pandemic has had a profound impact on all aspects of working in general surgery. It has necessitated new and flexible work patterns, maximisation of ambulatory care units, prioritisation of urgent cancer cases and the use of telemedicine. The challenges faced during this unprecedented time have forced us to evolve and innovate new ways of delivering care in surgery. We must identify the positive changes that have occurred as a result of this pandemic and implement these into a new form of surgical working. COVID-19 and emergency surgery Elective Surgeries During the COVID-19 COVID-19 Pandemic: Perspectives on an Unfolding Crisis Immediate and Long-Term Impact of the COVID-19 Pandemic on Delivery of Surgical Services Intercollegiate General Surgery Guidance on COVID-19 We would like to thank Miss Gemma Conn, Mr. Mark Dilworth, Mr.