key: cord-0890917-pivbgzot authors: Okonkwo, I.N.C.; Howie, A.; Parry, C.; Shelton, C.L.; Cobley, S.; Craig, R.; Permall, N.; El‐Sheikha, S.H.; Herbert, N.; Arnold, P. title: The safety of paediatric surgery between COVID‐19 surges: an observational study date: 2020-09-21 journal: Anaesthesia DOI: 10.1111/anae.15264 sha: 7ec04f44df56bf599408ca054019d39ddef76c7a doc_id: 890917 cord_uid: pivbgzot Despite the ongoing coronavirus disease 2019 (COVID‐19) pandemic, elective paediatric surgery must continue safely through the first, second and subsequent waves of disease. This study presents outcome data from a children’s hospital in north‐west England, the region with the highest prevalence of COVID‐19 in England. Children and young people undergoing elective surgery isolated within their household for 14 days, then presented for real‐time reverse transcriptase polymerase chain reaction testing for severe acute respirator syndrome coronavirus disease‐2 (SARS‐CoV‐2) within 72 hours of their procedure (or rapid testing within 24 hours in high‐risk cases), and a screening questionnaire on admission. Planned surgery resumed on 26 May 2020; in the four subsequent weeks there were 197 patients for emergency and 501 for elective procedures. A total of 488 out of 501 (97.4%) elective admissions proceeded, representing a 2.6% COVID‐19‐related cancellation rate. There was no difference in the incidence of SARS‐CoV‐2 amongst children and young people who had or hadn’t isolated for 14 days (p > 0.99). One out of 685 (0.1%) children who had surgery re‐presented to hospital with symptoms potentially consistent with SARS‐CoV‐2 within 14 days of surgery. Outcomes were similar to those in the same time period in 2019 for length of stay (p = 1.0); unplanned critical care admissions (p = 0.59); and 14‐day hospital readmission (p = 0.17). However, the current cohort were younger (p = 0.037); of increased complexity (p < 0.001) and underwent more complex surgery (p < 0.001). The combined use of household self‐isolation, testing and screening questionnaires has allowed the re‐initiation of elective paediatric surgery at high volume whilst maintaining pre‐COVID‐19 outcomes in children and young people undergoing surgery. This may provide a model for addressing the ongoing challenges posed by COVID‐19, as well as future pandemics. The scale of the challenge facing the NHS after the first wave of coronavirus disease 2019 is only just coming to light. Estimates suggest NHS waiting lists in England could reach 10 million patients, generating a backlog of work predicted to take up to 2 years to overcome [1, 2] . The considerations for re-initiating and continuing elective surgery in paediatric practice are different to those faced within adult services [3] . The impact on the whole family must be considered, including the child's return to education; the parents return to work; as well as the potential for wider social and economic consequences. Many children present for straightforward day case procedures where there is limited exposure to the wider hospital environment and staff [4] , and given what is now understood about the prevalence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in the general paediatric population [5] [6] [7] , hospital attendance for surgery may represent a child's highest risk of SARS-CoV-2 infection. There is therefore a need to demonstrate outcomes and develop the evidence-base for guidance on the re-initiation and continuation of elective surgery for children and young people through what is likely to be a protracted pandemic. Paediatric anaesthesia in the context of an ongoing respiratory viral infection is associated with an increased incidence of peri-operative complications which vary in severity from minor respiratory symptoms to unexplained death [8] [9] [10] [11] . It is therefore likely that the This article is protected by copyright. All rights reserved to understand whether it differs in children compared with adults. Additionally, during periods of low disease prevalence (e.g. < 1% community prevalence), the positive predictive value of the test becomes poor as the pre-test probability of actually having the virus is very low. Despite the high analytical sensitivity of RT-PCR, studies demonstrate false negatives of 20-40% from upper airway swabs in adults with confirmed disease [33-34, Yang et al., unpublished observations, https://doi.org/10.1101/2020.02. 11.20021493 ]. This may be higher in children due to the technical challenges of obtaining upper respiratory tract swabs from patients who are unable to fully cooperate with the procedure. Furthermore, given the incubation period and pathogenesis of SARS-CoV-2 a negative test one day does not guarantee the absence of infection the next [35] . COVID-19 has highlighted the impact of health inequality, with higher death rates seen in the most deprived communities [36] . It is therefore paramount that the delivery of surgery within children's specialist services during the endemic phase of COVID-19 minimises the impact of these existing health inequalities. The north-west of England has seen the highest infection rate for SARS-CoV-2 in England with continued surges in disease prevalence [32] . Catchments in the Merseyside area, where our institution is located, report some of the highest population cumulative incidences in the region. In addition, Liverpool and Knowsley, local communities served by our hospital, are two of the most deprived local authorities in This article is protected by copyright. All rights reserved the UK [37] . We therefore aimed to report our outcomes and experiences in re-initiating and continuing elective paediatric surgical services at a specialist children's hospital at a time of global and national uncertainty. This observational cohort study was conducted between 23 March and 5 July 2020 in accordance with the strengthening the reporting of observational studies in epidemiology (STROBE) statement utilising routinely collected institutional data to prospectively evaluate the impact of pre-operative household isolation and SARS-CoV-2 screening on children presenting for surgery at a specialist paediatric centre. The UK Health Research Authority's research decision tool (hra-decisiontools.org.uk/research) was consulted to determine that this project was considered to be a service evaluation by the NHS. Approval was therefore not sought from a research ethics committee, but this was registered prospectively with our institutional clinical governance board (ID 6093) and the principles of Good Clinical Practice were adhered-to throughout the study. Data were collected in two phases. Phase 1 was a retrospective analysis of urgent and emergency paediatric surgical cases presenting between 23 March 2020 (the start of the UK lockdown and cessation of all elective non-cardiac surgery at our institution) and 25 May 2020 . Following the re-initiation of elective surgery, phase 2 commenced with prospective This article is protected by copyright. All rights reserved data analysis of all children and young people undergoing elective surgery between 26 May 2020 and 21 June 2020. Within phases 1 and 2 we evaluated patient, surgical and hospital demographic data alongside SARS-CoV-2 RT-PCR testing outcomes utilising electronic case notes. In phase 2, unplanned admissions to critical care, 14-day re-admission rates and length of stay were also evaluated. All patients scheduled for elective surgery at Alder Hey Children's Hospital after 26 May 2020 received instructions to self-isolate with their families as a household for 14 days before surgery. Patients then underwent SARS-CoV-2 testing by trained staff using RT-PCR from a combined nose and throat swab 72 h before surgery, either in clinic, at the hospital drive-in testing facility or at a community pop-up station (in the case of families residing a This article is protected by copyright. All rights reserved considerable distance from our hospital). Parents and carers of patients who tested negative for SARS-CoV-2 were informed of the test result and asked to attend the hospital as planned. Patients who tested positive were offered appropriate medical treatment and advice and had their procedures postponed for 4 weeks, with the requirement of two negative tests before being allowed to proceed to surgery. On both the day of swabbing and procedure, clinical screening paired with a three-question screening questionnaire (online Supporting Information Appendices S1 and S2) was conducted by nursing staff as part of the hospital admissions procedure to identify whether the patients or any member of their household had experienced symptoms of COVID-19 or been in contact with anyone who had, within the preceding 14 days. Patients undergoing elective surgery who fell into the category of being high-risk (undergoing cardiac surgery; requiring planned postoperative admission to intensive care; or at the specific consultant request for reasons otherwise undefined) also underwent a rapid (result available within 2 h) SARS-CoV-2 RT-PCR test, taken by a combined nose and throat swab on admission within 24 h of surgery. Patients who were deemed low risk on the screening questionnaire, and who had a negative rapid test (if conducted) then proceeded to elective surgery. This article is protected by copyright. All rights reserved In addition to appropriate medical care or advice, the households of patients deemed high risk for SARS-CoV-2 or who had a positive rapid RT-PCR test completed a survey to identify how well they had been able to self-isolate as a household and any barriers faced. testing were processed at the Alder Hey microbiology laboratory using the Cepheid assay with a turnaround time of within 2 h from receipt of the swab in the laboratory [38] . Due to the unplanned nature of admission and presentation, children and young people presenting for emergency surgery at Alder Hey Children's Hospital received no instructions to self-isolate with their families as a household prior to presentation to hospital. Patients underwent SARS-CoV-2 testing by trained staff utilising RT-PCR from a combined nose and This article is protected by copyright. All rights reserved pyrexial with a suspected diagnosis of appendicitis and another with respiratory symptoms requiring an emergency gastrointestinal procedure. Phase 2: elective surgery Table 1 for a 41% reduction in total theatre throughput (Fig. 1) . In the third and fourth weeks since resuming elective surgery, our centre is operating at 72% of historical capacity (Fig. 1) . There was no difference in the incidence of SARS-CoV-2 amongst children and young people who had or hadn't isolated for 14 days: 1/496 (0.2%) in the planned elective surgery population compared with 0/ 197 (0.0%) in the unplanned emergency surgical population (p > 0.99). This article is protected by copyright. All rights reserved To date, within the planned elective surgery group 13/501 (2.6%) children and young people had their surgery postponed as they were either confirmed or suspected high-risk of SARS-CoV-2. This represents a 2.6% SARS-CoV-2-related cancellation rate (Table 1) . Five out of 501 (1.0%) children and young people had surgery postponed without testing for SARS-CoV-2. Three of the 501 (0.6%) patients did not get tested because their families refused to attend the hospital citing a fear of the hospital swabbing process and potentially acquiring nosocomial COVID-19. One child had an autistic spectrum disorder and the family felt they would not tolerate swabbing and declined to trial the process. The other 2/501 (0.4%) patients did not attend hospital for swabbing due to confirmed SAR-CoV-2 within members of their household, though these patients were not known to be symptomatic for disease. Two out of 501 (0.4%) patients had procedures cancelled due to failure of members of their household to isolate for 14 days: one child, scheduled to undergo major cardiac surgery, was from a household where a parent cared for both the partner and siblings. Three out of 501 (0.6%) children and young people had procedures cancelled due to symptoms of SARS-CoV-2 or symptomatic members of the household, in all of these patients test results were negative. Three out of 501 (0.6%) patients had their surgery cancelled due to test results outside the 72 h window of safety. This article is protected by copyright. All rights reserved Compared with those undergoing surgery in a similar time period in 2019, patients having elective surgery during the re-initiation phase were younger (p = 0.037); had higher ASA physical statuses (p < 0.001); a lower proportion of day-case procedures and increased proportion of emergency and other elective surgeries (p < 0.001); and were from a wider spectrum of surgical specialities (p < 0.001; Table 2 ). There was no difference in length of stay; unplanned critical care admissions and 14-day readmissions to hospital. No patients have been diagnosed with SARS-CoV-2 on repeat postoperative tests, and none failed testing utilising a combined nose and throat swab administered by staff. This study presents peri-operative outcomes from children and young people undergoing surgery during the endemic phase COVID-19. At present few data exist regarding peri-operative outcomes of SARS-CoV-2 in the paediatric population. It is however understood that the challenges of re-initiating and continuing elective surgery in children during the COVID-19 pandemic are different to those faced by adult services. Our data suggest that in children and young people undergoing surgery during the endemic phase of COVID-19, a combined approach of 14-day household isolation, pre-operative testing and clinical screening confers comparable levels of safety and peri-operative outcomes to surgery during before the COVID-19 pandemic. Within our institution, a This article is protected by copyright. All rights reserved younger cohort of patients with greater co-morbid burden underwent more complex surgery but had similar outcomes to pre-COVID-19 patients. We found the risk of peri-operative infection of SARS-CoV-2 in children and young people presenting for elective surgery to be low, which is reassuring given that a visit to hospital for surgery has been hypothesised to represent a child's highest risk of contracting SARS-CoV-2 Our observational cohort study indicates that now that the UK is past the initial surge of disease, during the endemic phase of COVID-19 the risk of peri-operative SARS-CoV-2 in our paediatric population is not significantly different amongst groups of children and young people that have isolated for 14 days compared with those who have not. We observed the same incidence of disease in children and young people undergoing elective surgery who had received instructions to isolate as household for 14-days compared with those This article is protected by copyright. All rights reserved presenting for emergency surgery who had not. This is despite the location of our institution in a region with the highest population cumulative incidence of SARS-CoV-2 in England [32]. The reasons behind this are likely multi-factorial. At the time of this study community prevalence of SARS-CoV-2 is low (< 1%) and the prevalence and disease burden of SARS-CoV-2 is lower still within the paediatric population when compared with adults [13] [14] . Anecdotal data also suggest that adherence to recommended isolation within populations is generally poor even for short periods of time (< 72 h), so it is possible that the data from defined isolated patient groups may not be from a truly isolated population [3] . To date, households admitting to failing to self-isolate have had surgery at our institution postponed, but in light of our findings and new national guidance it would be beneficial for paediatric institutions to adopt a pragmatic approach involving risk assessment of patient co-morbidities against surgical factors such as type and severity of surgery. Further studies and wider publication of national paediatric datasets are still required to determine the optimal duration of household isolation. Moving forward our institution is routinely isolating households following swab testing for < 72 h before surgery. The variability of symptomatology seen in the children and young people presenting for elective surgery at our institution supports the peri-operative use of hybrid approaches that combine pre-operative testing and clinical screening in the paediatric population. Given that This article is protected by copyright. All rights reserved The generalisability of our data is limited by its observational nature, recording a unique and fluctuant disease phenomenon in the context of a rapidly evolving evidence base. It also has the additional limitation of being from a single UK centre. We also acknowledge that patients in standalone children's hospitals may be subject to different risks of peri-operative infection compared with children's services co-located within adult trusts. Alder Hey Children's NHS Foundation trust is busy specialist centre delivering a range of quaternary and tertiary surgeries to children and young people from a wide geographical region encompassing north-west England, Ireland and Wales. However, given our location within the region of highest SARS-CoV-2 disease prevalence in England, with associated high levels of social deprivation, which is acknowledged as a risk factor for high disease prevalence and poor disease outcomes in SARS-CoV-2 [32,36], our data is relevant to both specialist and non-specialist centres providing paediatric surgery throughout the UK. This article is protected by copyright. All rights reserved adds to the evidence base upon which future guidelines will be built. Furthermore, there is potential to utilise similar principles paired with ongoing study to maintain elective paediatric surgical services during any future outbreaks of communicable disease. This article is protected by copyright. All rights reserved COVID-19) in China Severe outcomes among patients with coronavirus disease 2019 (COVID-19)-United States Coronavirus disease 2019 (COVID-19) in Italy Should you cancel the operation when a child has an upper respiratory tract infection? Anesthesia for the child with an upper respiratory tract infection: still a dilemma? Pulmonary collapse during anaesthesia in children with respiratory tract symptoms Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study Accepted Article This article is protected by copyright. All rights reserved SARS-CoV-2 testing and outcomes in the first 30 days after the first case of covid-19 at an Australian children's hospital Neonatal early-onset infection with SARS-CoV-2 in 33 neonates born to mothers with COVID-19 in Wuhan A typical case of critically ill infant of coronavirus disease 2019 with persistent reduction of T lymphocytes Novel coronavirus in a 15-day-old neonate with clinical signs of sepsis, a case report Clinical characteristics of 58 children with a pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 Hyperinflammatory shock in children during COVID-19 pandemic Severe COVID-19 in children and young adults in the Washington, DC metropolitan region Positive rate of RT-PCR detection of SARS-CoV-2 infection in 4880 cases from one hospital in Asymptomatic transmission during the COVID-19 pandemic and implications for public health strategies Disparities in the risk and outcomes of COVID-19 Ministry of Housing, Communities and Local Government. The English Indices of Deprivation 2019: research report Comparison of Cepheid Xpert Xprss and Abbott ID Now to Roche cobas for the rapid detection of SARS-CoV-2 The authors would like to thank J. Jensen This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved This article is protected by copyright. All rights reserved Accepted Article