key: cord-0879174-82yqoza6 authors: Chor Lip, Henry Tan; Huei, Tan Jih; Mohamad, Yuzaidi; Alwi, Rizal Imran; Azmah Tuan Mat, Tuan Nur' title: Critical adjustments and trauma surgery trends in adaptation to COVID-19 pandemic in Malaysia date: 2020-05-22 journal: Chin J Traumatol DOI: 10.1016/j.cjtee.2020.05.007 sha: 3d48de07707f908131ef466d9ddd4a631fd6b224 doc_id: 879174 cord_uid: 82yqoza6 Malaysia has one of the highest numbers of COVID-19 infections within the Southeast Asian nations, which led to enforcements of drastic measures of Malaysian Movement Control Order” to curb disease transmission. The overwhelming increasing amount of infections has led to a major strain on healthcare services. This causes shortages in hospital beds, ventilators and various critical personnel protective equipment. This article focuses on the critical adaptations from a general surgery department in Malaysia which is part of a Malaysia tertiary centre that treats COVID-19 patients. The core highlights of these strategies during this pandemic are: (1) surgery ward and clinic decongestions; (2) deferment of elective surgeries; (3) restructuring of medical personnel; (4) utilization of online applications for tele-communication; (5) operating room adjustments and patient screening; and (6) continuing learning and updating practices in context to COVID-19. These adaptations are important for the continuation of emergency surgery services, preventing transmission of COVID-19 amongst healthcare workers and optimization of medical personnel work force in times of a global pandemic. In addition, an early analysis on the impact of COVID-19 pandemic and lockdown measures in Malaysia towards the reduction in total number of elective/emergent/trauma surgeries performed is described in this article. From the first ever recorded case on 25 th January 2020, the number of COVID-19 patients in Malaysia has risen exponentially. This led to more than 6071 perpetuating infections, placing Malaysia as one of the highest numbers of positive cases within the Southeast Asian nations. 1 These high number of infected patients has led to a significant strain on healthcare systems in Malaysia. With the "Movement Control Order" (MCO) being implemented in Malaysia starting 18th March 2020, major changes and adaptations were required for all major medical disciplines to overcome hospital bed occupancy shortages, continuing emergency medical or surgical services and strict control measures to prevent disease transmission amongst healthcare workers. The general surgery department of Hospital Sultanah Aminah, Malaysia is an umbrella for multiple subspeciality surgical units (trauma and acute care surgery unit 2 , colorectal surgery unit 3 , upper gastrointestinal surgery unit 4 , hepatobiliary surgery unit and paediatric surgery unit 5 ). The substantial amount and variety of cases managed by the general surgery department is reflected by the trauma and acute care surgery unit which provides treatment for no less than 500 patients per year. 6, 7 With the anticipation of increasing bed occupancy for COVID-19 patients and protection of medical personnel from transmission of disease, major adjustments are required. These adjustments can be categorized into the sub headings: (1) surgery ward and clinic decongestions; (2) deferment of elective surgeries; (3) restructuring of medical personnel; (4) utilization of online applications for tele-communication; (5) operating room (OR) adjustments and patient screening; and (6) continuing learning and updating practices in context to COVID-19. With these measures implemented, there is an expectation of significant reduction of surgeries performed during this period. This is due to the lockdown measures which allow citizens to continue duties in essential departments only and stay home preventive strategies that led to a reduction in road traffic accidents and industrial related trauma. A brief analysis of the general surgery operative records to estimate the impact of COVID-19 pandemic and lockdown measures towards the number of elective/emergent/trauma surgeries were performed 4 weeks before and after the implementation of Malaysian MCO. As part of strategies to reduce transmission of COVID-19 which is via air-borne and droplets, decongestion of the closely bedded surgery ward and clinics is required. 8 Steps taken to decongest the wards is by delaying all elective surgeries. 9 This reduces the daily ward admissions for elective surgeries and its postoperative care significantly. Priority is given to patients who require emergent surgery for life-threatening conditions and cancer cases. Another strategy to minimize transmission is by dividing the daily ward rounds according to ward cubicles. Doctors and nurses assigned to the designated cubicles is advised against attending to patient in other cubicles unless under life threatening conditions. The daily surgery clinic (which averages from 120 to 160 patients per day) is reduced to a minimum and screening of cases is performed daily to ensure quality and timely delivery of treatment prior deferral of clinic appointment. During the clinic visit, an additional measure implemented is to record the contact details of patients, attending nurses and medical officers. This is to facilitate accurate tracing in case of a positive COVID-19 contact. To further minimize the risk of disease transmission, all patients is required to declare any travelling history to high risk nations of COVID-19 within the last 14 days, contact with COVID-19 patients or with symptoms within the last 14 days. Failure to declare these pertinent histories may lead to legal action being taken as it poses a risk not only to the medical personnel but to the public which is being exposed concomitantly. Medical personnel which includes consultant surgeons, general surgeons, surgical registrars, medical officers and house officers is segregated into 2 teams to prevent a total collapse of workforce in the event of co-infection or exposure to a positive COVID-19 patient (Fig. 1A ). In Malaysia, healthcare workers with history of positive contact or is suspected to have COVID-19 is required to take a 14 days home quarantine or to be admitted if the nasal swab tests returns positive. By segregating the work force into 2 teams with alternate working days for each team, it minimizes contact between the entire department (Fig. 1B) . Other strategies implemented are to reduce movement between work stations. Medical personnel being stationed in the surgery ward, operating theatres, endoscopy suite and clinics will remain at their work place and is advised against going to other work stations. This approach minimizes the number of quarantined personnels and makes contact tracing procedures easier in an event of positive COVID-19 exposure. OR adaptation is important and tedious to implement. One of the major features of COVID-19 OR is a separate, standalone location which does not mixed with other operating facilities. Basic negative pressure environment (which allows inflow of air into the OR and outflow of air via specialized outlet with filter) is a compulsory requirement to reduce dissemination of the virus past the OR. The OR must be equipped with its individual ventilation system with an integrated high-efficiency particulate air (HEPA) filter with at least 25 air changes per hour. Restriction of movement and minimizing personnel during surgery is required at all times. Situation which requires emergency surgery for patients with COVID-19, maximum personnel protective equipment (PPE) is mandatory which consist of powered air-purifying respirator, N95 respirators and a sterile gown. 10 All trauma patients with suspicious history of COVID-19 requiring surgery will be treated as patient under investigation and surgery is performed with precaution as per positive COVID-19 until a confirmatory swab postoperatively. The surrounding equipment (anaesthetic monitors, laptop computers and ultrasound machine) will be covered with plastic wrap to decrease the risk of contamination. Intraoperatively, laparoscopic surgery is avoided due to the risk of aerosolizing particles during insufflation of gas. 11 Single use drapes and equipment is advocated. Postoperatively, the patient should be extubated and reviewed in the OR. Following extubation, prompt transfer directly to a designated COVID-19 surgery ward following a special designated route and lift is important. All the involved staffs are required to shower and change into a clean set of scrubs for the subsequent case. During the preliminary 2 weeks of the lockdown in Malaysia, the criteria for screening with nucleic acid nasal swab test was performed only in patients with symptoms and with the risk of contact with COVID-19 patients. For patients who required emergent surgery but swab test was not performed due to the nature of exsanguinating traumatic injuries, surgeons and nurses wore full PPE as aforementioned and surgery was performed in a standalone OR with its individual ventilating system. However, as the test kits became more readily available and more guidelines were implemented in the subsequent 2 weeks of MCO, all patients (elective and emergent) undergoing surgery had mandatory nucleic acid nasal swab test preoperatively. In addition to the mandatory nucleic acid test, all patients that had suspicious chest radiograph had a contrast enhanced computed tomography of the thorax prior surgery (elective or emergent surgeries). 12 The antecedent implementations have led to a restriction in continuous medical learning via the traditional classroom teachings. 13 This shortcoming is overcome by using online applications installed on mobile devices. WhatsApp messenger and Microsoft Teams webinar became more pertinent in daily telecommunications and patient case discussions within the general surgery department. 8 From dissemination of departmental information to continuous medical learning, the application of WhatsApp and Microsoft Teams has demonstrated their reliability and importance during this period. This maintains a continuous two-way communication and allows the department to run smoothly despite the new restrictive implementations. Early analysis 4 weeks before and after the implementation of MCO in Malaysia on 18 March 2020 showed a 55% reduction in total surgeries (4 weeks prior MCO: 348 surgeries and 4 weeks after MCO: 156 surgeries) as illustrated in Table 1 . Elective operations were reduced by over 80% with only 37 surgeries performed in comparison to 187 elective surgeries which was performed 4 weeks prior to the implementation of MCO. During the initial 2 weeks, there were no elective surgeries performed with gradual recommencement and priority given to cancer patients. Emergent surgeries remained as the majority (124 surgeries) of operations performed after the implementation of MCO. Throughout the MCO implementation, there were no patients with COVID-19 that required surgery in our institution. These critical adjustments were effective as till date, there were no reports of COVID-19 transmission within medical personnel or patients treated at the general surgery department. There was also no recorded COVID-19 infection to any post-elective or emergent surgery patients which was treated and warded within the general surgery department. From the early analysis of surgery records, there was a 23% reduction of emergent operations performed after the start of MCO (161 vs. 124). Prior MCO, 10.6% emergent surgeries were comprised of traumarelated injuries. This number was further reduced to only 4.8% after implementation of MCO for 4 weeks. Due to a reduction in trauma patients, the amount of minor/major trauma surgeries and number of injured organ/multiple organs were also reduced after the implementation of MCO. Detailed information is shown in Tables 1-3. From our past experiences, the majority of patients treated by the trauma team were 90% from blunt traumatic injuries. 2 In addition, motorcyclist makes up 60% of the traumatic patients involved in road traffic accidents. 7 With the commencement of MCO which restricts the citizens to stay in bound with only workers in the essential services (healthcare, finance, essential food supplies and government services) to continue duties led to a drastic reduction in road traffic accidents and industrial occupation related trauma. The overall impact is a positive reduction in trauma cases which is attributed to reduce in activity and movement from the restriction order to prevent disease transmission. The challenges faced to execute these necessary changes within a short period of time are gruelling. However, the key to success in striking a balance in maintaining a continuous quality surgery service to the community and safeguarding the safety of the medical health care workers is by a strong team foundation coupled with compromise and sacrifice of all personnel. The COVID-19 pandemic has led to a restriction in movement which overall led to a reduction in traumatic cases. We hope this article may shed a light on the optimal management of general surgery services in this difficult time of Covid-19 pandemic to all affected nations. Nil. This study is registered under the National Medical Research Register of Malaysia (ID: NMRR-20-815-54725). Liver resection 1 (5.9) 0 (0) Splenectomy 2 (11.8) 0 (0) Nephrectomy 1 (5.9) 0 (0) Relaparotomy -liver pack removal/washout/closure 4 (23.5) 1 (16.7) Brachial artery repair 1 (5.9) 0 (0) Diagnostic angiogram 1 (5.9) 0 (0) Official Portal Ministry of Health Malaysia. 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Malaysia Ministry of Health UNESCO: COVID-19 Educational disruption and response We would like to thank the Director General of Health Malaysia for his permission to publish this article (NIH.800-4/4/1Jld.80 (31). All the authors have declared no competing conflict of interest.