key: cord-0930616-rmdyr68h
authors: Shannon, Adrienne B.; Roberson, Jeffrey L.; Clapp, Justin T.; Vaughan, Casey; Kleid, Melanie; Song, Yun; Miura, John T.; Dempsey, Daniel T.; DeMatteo, Ronald P.; Fleisher, Lee A.; Karakousis, Giorgos C.
title: What is the Patient Experience of Surgical Care During the COVID-19 Pandemic? A Mixed-Methods Study at a Single Institution
date: 2020-12-29
journal: Surgery
DOI: 10.1016/j.surg.2020.12.031
sha: c42a5f21f31d2c8ff6f3fda63075e8889f2da02f
doc_id: 930616
cord_uid: rmdyr68h

BACKGROUND: The COVID-19 outbreak has spread worldwide and has resulted in hospital restrictions. The perceived impact of these practices on patients undergoing essential surgeries is less understood. METHODS: Adult (≥18 years) patients who underwent medically-necessary surgical procedures spanning multiple surgical specialties from March 23, 2020 to April 24, 2020 during the COVID-19 pandemic were identified as eligible for a phone survey. Survey responses were analyzed using a mixed-methods approach involving descriptive statistics and thematic analysis of coded and annotated survey results. RESULTS: Of the 212 patients who underwent medically-necessary surgical procedures during the COVID-19 pandemic, the majority of these patients were male (61.3%), White (83.5%), married or with a domestic partner (68.9%), and underwent oncologic procedures (69.3%). Of the 46 (21.7%) patients who completed the survey, the majority of these patients indicated that COVID-19 pandemic restrictions had no impact on their inpatient hospital stay and were satisfied with their decision to proceed with surgery. Severity of patient condition (44.4%), the risk/benefit discussion with the surgeon (24.4%), and COVID-19 education and testing (19.5%) were the most important factors in proceeding with surgery during the pandemic; 34.4% of patients felt their inpatient postoperative course was negatively impacted by the lack of visitors. CONCLUSION: Medically-necessary, time-sensitive surgical procedures, as determined by the surgeon, can be performed during a pandemic with good patient satisfaction provided there is an appropriate discussion between the surgeon and patient about the risks and benefits.

During December 2019, an outbreak of pneumonia and respiratory syndromes in Wuhan, Hubei Province, China resulted in the identification of a novel coronavirus, Severe Acute Respiratory Syndrome (SARS)-CoV-2 or COVID-19. 1 Since December, there has been rapid expansion of the COVID-19 outbreak worldwide. The outbreak emerged in the United States (US) on January 20, 2020, and the swift spread of the virus prompted the World Health Organization (WHO) to declare it to be a global pandemic on March 11, 2020. [2] [3] [4] Given the necessity to minimize infection risk and to preserve resources for COVID-19 patients, US hospital systems resorted to cancelling elective surgeries, mirroring surgical urgency schemas developed in other regions, including Lyon, France and the Lombardy region of Italy. 5, 6 On March 18, 2020, the Center for Medicare and Medicaid Services (CMS) announced that all elective and non-essential procedures should be delayed, resulting in 33 states (66%) issuing individual guidance (i.e. mandates or recommendations) regarding how to determine which procedures are considered essential. 7 While indications for emergency surgery during the pandemic have remained unchanged, there has been a question of how to define "elective" surgeries, as many of these procedures are necessary and time-sensitive without being urgent. [8] [9] [10] Many surgical societies, principally the American College of Surgeons (ACS), have issued recommendations regarding prioritization of surgical procedures during the pandemic. [11] [12] [13] While providers have assumed the responsibility of decision-making for scheduling surgeries, some have questioned the psychologic impact that this may have on patients should their surgery be postponed. 14 Some patients, particularly those with malignancies, may be more willing to pursue surgical procedures during a pandemic despite having up to a five-fold increased risk of COVID-19 infection as compared to patients without malignanices. 15 Even so, a recent study of patients scheduled for endoscopic procedures in Italy found that a quarter of patients did not show up for their procedures, suggesting that the fear of COVID-19 infection J o u r n a l P r e -p r o o f Surgical Patients' Experiences During COVID-19 4 outweighed the fear of undiagnosed or untreated disease. 16 On the other hand, a recent study out of Chicago noted that one out of five patients, particularly those with more comorbidities, believed that the COVID-19 outbreak had little or no effect on their life. 17 This suggests that healthcare providers may have a poor sense of patients' experiences of the pandemic as the impact of the pandemic on patients undergoing surgical procedures is not defined. This study seeks to identify patients undergoing essential surgical procedures during the pandemic and to investigate how these patients perceived their surgical experience as a result of the pandemic.

Adult (≥18 years) patients were included in the study following a retrospective analysis of all medically-necessary surgical procedures performed at the Hospital of the University of Pennsylvania between March 23, 2020 and April 24, 2020. This time period was determined based on restriction start time and surgical resurgence time put in place by our institution.

Included procedures were defined as procedures which were deemed medically-necessary, despite being scheduled as "elective" within our institution's internal scheduling system, and where patients arrived in the pre-operative area directly from home on the morning of surgery.

The formal medically-necessary, time-sensitive surgery (MeNTS) scoring system was not implemented at our institution until May 4, 2020, beyond the time period of this study; all patients within the study were classified as medically-necessary at the discretion of the surgeon with oversight by Department and Division Chairs.

Patients who underwent a procedure in which Urology, Obstetrics and Gynecology, or Breast Oncology was the primary surgical service were excluded from inclusion in the study due to potential bias of patient sex. Additionally, patients who underwent minor procedures with nonsurgical specialties, including bronchoscopy, endoscopy, colonoscopy, laryngoscopy, and gastrostomy tube placement, were excluded from the study. Patients who were admitted directly from the emergency department prior to surgery were excluded from the study, as these J o u r n a l P r e -p r o o f Surgical Patients' Experiences During COVID-19 5 patients indicated emergent or urgent procedures. Patients who expired during their admission period were excluded from the study (N=2) due to inability to survey these patients. Of note, neither of these patients expired due to reasons related to COVID-19 infection.

Of those patients who were eligible for inclusion in the study, we retrospectively collected detailed data regarding patient demographics, pre-operative information, operative characteristics, and postoperative characteristics from the medical records. Patient data were maintained in accordance with the Health Insurance Portability and Accountability Act. The study was deemed exempt from continuing review by the Institutional Review Board of the University of Pennsylvania (protocol #842962). Descriptive analyses were performed to demonstrate the patient, pre-operative, admission, and postoperative characteristics of the patients. Quantitative statistical analyses were conducted with Stata for Windows version 13.1. 18

We developed a survey to address patient perceptions of the impact of the COVID-19

pandemic on their experience undergoing surgical procedures during a time period in which institution restrictions were in place. Specifically, we investigated patients' perceptions regarding their pre-operative, day of surgery, and postoperative experiences with their healthcare team.

We additionally inquired as to whether patients had been tested for COVID-19 or had developed symptoms of COVID-19 at any point during their admission or postoperative period. Beginning on April 14, 2020, the Hospital of the University of Pennsylvania began a pilot periprocedural testing program in which all elective surgeries required testing for COVID-19 within 48 hours prior to proceeding; this resulted in some patients within our population being tested prior to their surgical procedure. administered within a minimum of 2 weeks following the date of the surgical procedure to patients who were deemed eligible, and two attempts were made to contact patients for survey completion.

Using a cross-sectional study design, we developed a survey that was based on published recommendations for survey design and was delivered by phone. The survey were included as part of the surgical consent and were left to the discretion of the surgical team.

Qualitative analysis for the study was managed with NVivo 12 (QSR International) and used a content analysis approach. 19 Responses to open-ended survey questions were annotated individually by authors ABS, JTC, and CV to derive thematic categories. Themes were compiled and used to develop a codebook-a formal thematic taxonomy-comprised of a combination of categories derived from the structure of the questionnaire and categories emergent in respondents' discourse. This codebook was used by authors CV and MK to double code a randomly selected subset of responses (40% of the data). The codebook was refined by revising vague categories, introducing new ones to characterize previously missing themes, and eliminating classifications that were shown to lack utility. Coding was compared between coders to reconcile discrepancies through discussion and consensus. The remaining data were double coded by CV and MK using the second iteration of the codebook. Following this second round of coding it was determined that the codebook needed no further adjustments. Coding was again compared to reconcile any discrepancies between coders.

The final study population included 212 patients with a median age of 61 (interquartile range [IQR] 42.5-79.5) years and 38.7% female patients ( Table 1 ). The majority of all patients who underwent surgery during the study period were White race (83.5%), were married or with a domestic partner (68.9%), and had private insurance (62.7%). Additionally, when examining the comorbidities of this population, the majority of patients had an American Society of Anesthesiology (ASA) classification of 3 (54.7%). The majority of the procedures performed during the study period were oncologic (69.3%), distributed among the gastrointestinal (13.7%), colorectal (13.7%), oncologic (18.4%), thoracic (16.5%), and otolaryngology (11.3%) services (Table 2 ). Almost all patients were discharged to home or home with home health services; 1 patient required discharge to acute rehabilitation. While almost all patients were seen in the clinic for their pre-operative history and physical visit, 24.1% of patients had no postoperative follow-up (i.e. in-person, telemedicine, and telephone) with their surgical team.

Out of 212 eligible patients, 46 patients (21.7%) completed the phone survey. Patient characteristics in the survey group were similar to those within the overall study population based on descriptive analyses. Of the 46 patients, 2 (4.3%) patients indicated their surgical date had been rescheduled due to the implementation of COVID-19 pandemic restrictions. All patients indicated being asked about COVID-19 signs and symptoms on the day of surgery.

During the pre-operative period, 41 (89.1%) patients indicated that the risks and benefits of proceeding with their medically-necessary procedure during a pandemic were explained to them by someone from their surgical team (i.e. the surgeon or another outpatient provider). Following this discussion, 6 (13%) patients considered not proceeding with their procedure, despite ultimately proceeding. Overall, the majority of patients (N=44, 95.7%) were satisfied or very satisfied with their decision to proceed with surgery based on mean and median Likert scores (mean 4.6, SD 0.9; median 5, IQR 1). 

The six open-ended survey questions included in the phone survey were subjected to content analysis and are presented in Table 3 . Regarding satisfaction with the risk/benefit J o u r n a l P r e -p r o o f Surgical Patients' Experiences During COVID-19 9 discussion with the surgical team, 17 (41.5%) patients expressed a degree of expectation that this conversation should occur given the risks of COVID-19 and 15 (36.6%) patients felt that the discussion assuaged their anxieties. Despite this, many participants expressed that this conversation would have not changed their decision to proceed with surgery due to the severity of the problem for which they underwent the surgical procedure (N=8, 19.5%). The importance of balancing the need for surgical intervention and the risk of COVID-19 (N=14, 34.1%) and

providing COVID-19 education to patients (N=8, 19.5%) were additional relevant themes. A large portion of patients indicated that the severity of their condition (N=20, 44.4%) and the importance of the risk/benefit discussion that they had with their provider (N=11, 24.4%) were the reasons that they decided to proceed with surgery. Of note, a minority of patients (N=7, 15 .6%) indicated that they were not concerned about COVID-19, so the risk of infection did not impact their decision.

When patients were asked about how comfortable they were with not being able to have visitors accompany them during their perioperative stay, 7 (15.2%) patients expressed negative feelings, including loneliness and fear and that they would miss instructions regarding their care.

Even so, a portion of patients expressed their understanding for the restrictions (N=4, 8.7%) and the majority of patients (25, 54 .3%) said that the absence of visitors had no impact on their overall experience. Regarding both the recovery and inpatient experience, the majority of patients expressed that they were either content with their care or felt that the care they received was normal despite the pandemic restrictions.

Patients were asked about their overall satisfaction level with the decision to proceed with surgery, and the majority of patients (N=24, 52.2%) indicated that they were satisfied because they were able to get the surgery done. Additionally, 10 patients (21.7%) indicated their satisfaction to "fix-it" and return to the normalcy of their lives. A cohort of surveyed patients indicated a sense of gratitude (N=16, 34.8%) in having the opportunity to receive their surgeries J o u r n a l P r e -p r o o f given the restrictions at our institution and the cancellations of medically-necessary surgeries at institutions elsewhere in the country.

Following the initial identification of the COVID-19 outbreak in December 2019, medical providers observed a worldwide spread of the virus that has led to significant changes in daily operations. Implementation of protocols to identify medically-necessary procedures have been widely put into place in order to prioritize surgeries, balance the risk of infection to the provider and patient, and to preserve scarce resources necessary for hospital surges of infected patients. [5] [6] [7] [8] [9] [10] [11] [12] [13] While studies to date have investigated patients that contracted COVID-19 after undergoing surgery and have examined the impact of the pandemic's response and restrictions on healthcare providers, none, to the knowledge of the authors, have examined the perceived impact of the pandemic's restrictions on patients undergoing essential, elective surgical procedures. 20 Within a five-week period in which our institution had restrictions in place regarding surgical procedures, we identified patients who underwent medically-necessary procedures and surveyed them regarding the perceived impact of these restrictions on their surgical experience.

In this study, we identified that most patients who underwent surgical intervention had an in-person, pre-operative clinic visit 30 days prior to the date of surgery, despite clinical restrictions, but this was not mirrored in postoperative follow-up. A sizeable proportion (16.5%) of patients received follow-up by telemedicine methods after surgery. This transition toward telemedicine is in accordance with recommendations that healthcare providers and global health organizations should adopt telemedicine communication services in place of in-person visits during pandemic restrictions, particularly among high-risk patients, including surgical patients. [22] [23] [24] [25] As the Centers of Medicaid and Medicare services have expanded coverage for telehealth coverage during the pandemic, this aspect of healthcare access will likely become a more permanent fixture in healthcare. 25 J o u r n a l P r e -p r o o f Overall, the majority of patients were satisfied with their decision to proceed with surgery during the pandemic and its associated restrictions. Even those with dissatisfied comments during the survey still felt overall satisfied, and some even expressed gratitude due to the ability to get the procedure done at our institution despite larger scale elective surgery cancellations elsewhere. Dissatisfaction among patients was highest in regard to the inability to be allowed family or friends in the hospital at the time of surgery; patients who expressed dissatisfaction with their hospital stay cited this as the most important factor. A large portion of the patients surveyed indicated that their decision to proceed with the surgery was due to the severity of their condition, which is expected given that the COVID-19 restrictions emphasized medicallynecessary procedures. Overall, patients primarily expressed satisfaction with their care and the decision to proceed with surgery.

While, to the author's knowledge, none of the patients within this study had COVID-19, three weeks into the study period, our institution implemented pre-operative COVID-19 testing for all scheduled surgical procedures, similar to practices put in place for labor and delivery units in New York City. 26 Patients expressed reassurance during the survey regarding the ability to be tested pre-operatively, despite none testing positive for COVID-19. Recent studies suggest that patients who believe that they are at risk of developing COVID-19 have lower emotional wellbeing and sense of control, resulting in a worse patient experience. 27 Additionally, it is important to note that surgical patients with perioperative COVID-19 had increased 30-day mortality and morbidity rates, highest among men, patients age 70 or older, and those undergoing emergent or major surgeries. 28 These findings reinforce the importance of pre-operative testing of patients for COVID-19 undergoing medically-necessary surgical procedures to optimize patient outcomes and wellbeing. Our survey findings suggest that pre-operative testing of patients for COVID-19 both allows providers to control transmission of the virus but also positively impacts patient surgical experience and recovery due to perceived peace of mind.

This study has notable limitations; the study occurred at a single institution within a metropolitan city with a large surgical census so the patient census during this time period and patient perceptions' may not be generalizable to other institutions or regional centers. The survey methodology was inherently biased due to response bias and recall bias. We surveyed patients 2-4 weeks following their procedures to attempted to mitigate the impact of recall bias.

We had an adequate response rate in this survey with >20% of the patient census during this time period responding to the survey. The individuals who responded to this survey may have particular experiences (either favorable or unfavorable) that differ from the greater population, potentially limiting their representativeness. Additionally, our survey respondents, though their descriptive profile appears representative of greater surgical patient populations, may have representative bias when compared to our larger study population and a larger overall surgical patient population. Finally, this study only represented the perspectives of patients who elected to undergo medically-necessary surgical procedures during the COVID-19 pandemic; we did not utilize a referent group from outside of the pandemic due to inability to properly survey such a group similarly to a COVID-19 cohort. Utilization of a referent surveyed group could have allowed comparison of patient reports during the pandemic restrictions to baseline perceptions at a single institution.

Despite these limitations, our study offers important insight into patient perceptions of their surgical experience during the COVID-19 pandemic. Of note, as our institutional census of COVID-19 has decreased, our hospital policy has permitted restricted visitation for patients undergoing surgical procedures, a factor which was deemed particularly important for patients with their decision to proceed with surgery, but clinicians should recognize the importance of COVID-19 education and testing and appropriate risk/benefit discussions for their patients.

Continued reassessment of patients' experiences will be important moving forward to ensure continued safety for patients while optimizing the surgical and recovery process.

We have no relevant disclosures.

We received no funding to conduct this study "We discussed how my heart condition increases my risk for infections but also that benefits of my surgery likely were more than the COVID risk."

3.12 Expectation of conversation N=17 (41.5%)

"I expected the conversation but it wasn't going to change anything anyway so it felt unnecessary you know?" 3.13 COVID-19 education N=8 (19.5%)

Patients noted the conversation helped them understand COVID-19's risks and/or helped them understand the way the hospital planned to take precautions.

"I think it was helpful to get a realistic idea of the risk COVID posed to me." 3.14 Providers reduced concerns N=15 (36.6%)

Patients mentioned the conversation with the surgeon helped reduce anxieties regarding their condition or the pandemic.

"I was really nervous because if I had a sick lung I didn't know if I should get a lung surgery during a lung disease but the staff really helped calm me down."

Patients noted their specific health condition as playing a role in their desire to have the surgical procedure.

"We discussed that I needed this done sooner rather than later." "My surgery was explained as essential so I was nervous that you all like other places would stop surgeries so I wanted to get it done ASAP before you did that." 3.22 Lack of COVID-19 concern N=7 (15.6%)

Patients did not believe the virus posed a significant threat either due to their personal health status or a lack of overall concern about the disease.

"I needed the heart surgery, there wasn't a doubt in my mind. The virus doesn't scare me."

3.23 Severity of condition N=20 (44.4%) Patient's current condition was too pressing to wait on a procedure.

"I heard in the news about places pausing cancer surgeries and I wasn't going to let that happen to me."

Patients placed heavy weight on the opinion of their surgeon and acted in accordance with his or her recommendation.

"My main concern was that it was a lung surgery and COVID is a lung disease but I figured that my doctor felt this was necessary. Patient was unhappy with some aspect of the care they received at the hospital.

"I mean I guess I'm very satisfied because I got the surgery done but seriously these restrictions are absurd. COVID isn't a real issue." 3.63 Facilities N=12 (26.1%) Patients had a positive or negative opinion regarding the organization and preparedness of the hospital and staff.

"I was impressed with how you all were able to make huge changes to a system in such short time." 3.64 Fix-It Mentality N=10 (21.7%)

Patients mentioned being satisfied they went through with the surgery because it restored a sense of normalcy to them or surgery was a long-awaited fix.

"Finally getting the treatment I needed, get the cancer behind me, I can get back to work." 3.65 Gratitude N=16 (34.8%)

Patients were thankful that their surgery was not delayed, and thankful for the precautions taken and level of care provided to them.

"It was just something that was so unknown and concerning but it was so impressive to see how organized you all were/I am so thankful my treatment wasn't delayed, and I felt that you all cared about me. I am so grateful." 3.66 No concern for COVID-19 N=3 (6.5%)

Patients mentioned their lack of concern regarding COVID-19, or felt the restrictions and changes to care were unnecessary.

"I really did not understand the gravity of COVID. I was so concerned about my disease so COVID was just background stuff." Table 3 . Coded themes and illustrative interviewee quotes from a survey administered to patients who underwent elective surgical procedures at the Hospital of the University of Pennsylvania during the 2020 COVID-19 pandemic restrictions period. Forty-six patients participated in the phone survey. a 41 out of 46 patients answered this question. b 45 out of 46 patients answered this question. c 32 out of 46 patients were admitted to the hospital and were eligible to answer this question. The COVID-19 outbreak has resulted in hospital restrictions that have decreased operative censuses and altered the surgical experience, but the perceived impact of these practices on patients undergoing medically-necessary surgeries is less understood. The importance of this study was to portray patients' perceptions of their perioperative experience given the pandemic restrictions by administering a phone survey to those patients undergoing medically-necessary surgical procedures during the pandemic

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