Safe surgery during the coronavirus disease 2019 crisis

Surgery's Rosetta Stone: Natural language processing to predict discharge and readmission after general surgery

BACKGROUND

This study aimed to examine the accuracy with which multiple natural language processing artificial intelligence models could predict discharge and readmissions after general surgery.

METHODS

Natural language processing models were derived and validated to predict discharge within the next 48 hours and 7 days and readmission within 30 days (based on daily ward round notes and discharge summaries, respectively) for general surgery inpatients at 2 South Australian hospitals. Natural language processing models included logistic regression, artificial neural networks, and Bidirectional Encoder Representations from Transformers.

RESULTS

For discharge prediction analyses, 14,690 admissions were included. For readmission prediction analyses, 12,457 patients were included. For prediction of discharge within 48 hours, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.86 and 0.86 for Bidirectional Encoder Representations from Transformers, 0.82 and 0.81 for logistic regression, and 0.82 and 0.81 for artificial neural networks. For prediction of discharge within 7 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.82 and 0.81 for Bidirectional Encoder Representations from Transformers, 0.75 and 0.72 for logistic regression, and 0.68 and 0.67 for artificial neural networks. For readmission prediction within 30 days, derivation and validation data set area under the receiver operator characteristic curves were, respectively: 0.55 and 0.59 for Bidirectional Encoder Representations from Transformers and 0.77 and 0.62 for logistic regression.

CONCLUSION

Modern natural language processing models, particularly Bidirectional Encoder Representations from Transformers, can effectively and accurately identify general surgery patients who will be discharged in the next 48 hours. However, these approaches are less capable of identifying general surgery patients who will be discharged within the next 7 days or who will experience readmission within 30 days of discharge.

Vital signs and medical emergency response (MER) activation predict in-hospital mortality in general surgery patients: a study of 15 969 admissions

BACKGROUND

The applicability of the vital signs prompting medical emergency response (MER) activation has not previously been examined specifically in a large general surgical cohort. This study aimed to characterize the distribution, and predictive performance, of four vital signs selected based on Australian guidelines (oxygen saturation, respiratory rate, systolic blood pressure and heart rate); with those of the MER activation criteria.

METHODS

A retrospective cohort study was conducted including patients admitted under general surgical services of two hospitals in South Australia over 2 years. Likelihood ratios for patients meeting MER activation criteria, or a vital sign in the most extreme 1% for general surgery inpatients (<0.5th percentile or > 99.5th percentile), were calculated to predict in-hospital mortality.

RESULTS

15 969 inpatient admissions were included comprising 2 254 617 total vital sign observations. The 0.5th and 99.5th centile for heart rate was 48 and 133, systolic blood pressure 85 and 184, respiratory rate 10 and 31, and oxygen saturations 89% and 100%, respectively. MER activation criteria with the highest positive likelihood ratio for in-hospital mortality were heart rate ≤ 39 (37.65, 95% CI 27.71-49.51), respiratory rate ≥ 31 (15.79, 95% CI 12.82-19.07), and respiratory rate ≤ 7 (10.53, 95% CI 6.79-14.84). These MER activation criteria likelihood ratios were similar to those derived when applying a threshold of the most extreme 1% of vital signs.

CONCLUSIONS

This study demonstrated that vital signs within Australian guidelines, and escalation to MER activation, appropriately predict in-hospital mortality in a large cohort of patients admitted to general surgical services in South Australia.

Potentially avoidable mortality after endoscopic retrograde cholangiopancreatography in Australia: an 8-year qualitative analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure worldwide. The aim of this study was to examine cases of mortality after ERCP to identify clinical incidents that are potentially preventable, to improve patient safety.

METHODS

The Australian and New Zealand Audit of Surgical Mortality provides an independent and externally peer-reviewed audit of surgical mortality pertaining to potentially avoidable issues. A retrospective review of prospectively collected data within this database was performed for the 8-year audit period from 1 January 2009 to 31 December 2016. Clinical incidents were identified by assessors through first- or second-line review, and thematically coded into periprocedural stages. These themes were then qualitatively analysed.

RESULTS

There were 58 potentially avoidable deaths following ERCP, with 85 clinical incidents. Preprocedural incidents were most common (n = 37), followed by postprocedural (n = 32) and then intraprocedural (n = 8). Communication issues occurred across the periprocedural period (n = 8). Preprocedural incidents included delay to procedure, inadequate resuscitative management, decision to perform procedure and inadequate assessment. Intraprocedural incidents comprised technical factors and inadequate support. Postprocedural incidents involved inappropriate treatment, delay in definitive surgical treatment or in recognizing complications, inappropriate second-line intervention and inadequate assessment. Communication incidents comprised inadequate documentation, failure to escalate care and poor inter-clinician communication.

CONCLUSION

Causes of mortality following ERCP are wide-ranging, and reviewing clinical incidents associated with potentially avoidable mortality can serve to inform and educate practitioners. In collating a subset of cases in which procedure-related mortality was deemed avoidable, a series of cautionary tales about ERCP is presented that may provide cues to practitioners on improving patient safety and inform future surgical practice.

Routine pre-operative Covid testing in elective surgeries: Is it worth it?

BACKGROUND

Pre-procedural COVID-19 testing in patients scheduled for elective cases have become routine to reduce the risk of COVID-19 exposure and pulmonary complications related to perioperative COVID-19 infection, and to reduce the use of specific hospital resources among other reasons. This study evaluates the efficacy of universal COVID-19 testing for elective procedures.

METHODS

Single institution retrospective observational study from July 2020 through August 2021.

RESULTS

There were a total of 499 unique patients who were scheduled for 581 surgeries or procedures. A total of 569 anterior nares reverse transcriptase polymerase chain reaction (RT-PCR) tests were completed before scheduled procedure. There were 2 (0.35%) positive COVID tests, both of whom were asymptomatic and unvaccinated at time of testing, and 13 (2.2%) cancelled cases overall. The total cost for labor and materials during this period was $19,738, with each RT-PCR test costing $34.69 and each true positive test costing $9,869.

CONCLUSIONS

Given the low COVID-19 positivity in the elective procedural patient population, testing protocols for elective procedures should be re-evaluated as the pandemic evolves.

Safety of Three-Dimensional versus Two-Dimensional Laparoscopic Hysterectomy during the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has resulted in a significant decrease in the number of surgical procedures performed. Therefore, it is important to use surgical methods that carry the lowest possible risk of virus transmission between the patient and the operating theater staff.

AIM

Safety evaluation of three-dimensional (3D) versus two-dimensional (2D) laparoscopic hysterectomy during the COVID-19 pandemic.

METHODS

44 patients were assigned to a prospective case-control study. They were divided either to 3D (n = 22) or 2D laparoscopic hysterectomy (n = 22). Fourteen laparoscopic supracervical hysterectomies (LASH) and eight total laparoscopic hysterectomies (TLH) were performed in every group. The demographic data, operating time, change in patients' hemoglobin level and other surgical outcomes were evaluated.

RESULTS

3D laparoscopy was associated with a significantly shorter operating time than 2D. (3D vs. 2D LASH 70 ± 23 min vs. 90 ± 20 min, p = 0.0086; 3D vs. 2D TLH 72 ± 9 min vs. 85 ± 9 min, p = 0.0089). The 3D and 2D groups were not significantly different in terms of change in serum hemoglobin level and other surgical outcomes.

CONCLUSIONS

Due to a shorter operating time, 3D laparoscopic hysterectomy seems to be a safer method both for both the surgeon and the patient. Regarding terms of possible virus transmission, it may be particularly considered the first-choice method during the COVID-19 pandemic.

Paradigm shift: Beyond the COVID-19 era, is YouTube the future of education for CABG patients?

INTRODUCTION

Patients commonly use YouTube for education, and this may have increased due to COVID-19 related restrictions on access to healthcare professionals. However, YouTube videos lack peer review and regulation. To assess patient education in the COVID-19 era, we analyzed the quality of YouTube videos on coronary artery bypass graft (CABG) surgery.

METHODS

We searched YouTube using the phrase "coronary artery bypass graft." Two authors individually used the Journal of the American Medical Association (JAMA), DISCERN, and Health on the Net (HON) systems, to rate the first 50 videos retrieved. Data collected for each video included; number of views, duration since upload, percentage positivity (proportion of likes relative to total likes plus dislikes), number of comments, and video author. Interobserver reliability was assessed using an intraclass correlation coefficient (ICC). Associations between video characteristics and quality were tested using linear regression or t-tests.

RESULTS

The average number of views was 575,571. Average quality was poor, with mean scores of 1.93/4 (ICC 0.54) for JAMA criteria, 2.52/5 (ICC 0.78) for DISCERN criteria, and 4.04/8 (ICC 0.66) for HON criteria. Videos uploaded by surgeons scored highest overall (p < .05). No other factors demonstrated significant association with video quality.

CONCLUSION

YouTube videos on CABG surgery are of poor quality and may be inadequate for patient education. Given the complexity of the procedure and that beyond the COVID-19 era, patients are more likely to seek education from digital sources, treating surgeons should advise of YouTube's limitations and direct patients to reliable sources of information.

Evidence, not eminence, for surgical management during COVID-19: a multifaceted systematic review and a model for rapid clinical change

BACKGROUND

Coronavirus (COVID-19) forced surgical evolution worldwide. The extent to which national evidence-based recommendations, produced by the current authors early in 2020, remain valid, is unclear. To inform global surgical management and a model for rapid clinical change, this study aimed to characterize surgical evolution following COVID-19 through a multifaceted systematic review.

METHODS

Rapid reviews were conducted targeting intraoperative safety, personal protective equipment and triage, alongside a conventional systematic review identifying evidence-based guidance for surgical management. Targeted searches of PubMed and Embase from 31 December 2019 were repeated weekly until 7 August 2020, and systematic searches repeated monthly until 30 June 2020. Literature was stratified using Evans' hierarchy of evidence. Narrative data were analysed for consistency with earlier recommendations. The systematic review rated quality using the AGREE II and AMSTAR tools, was registered with PROSPERO, CRD42020205845. Meta-analysis was not conducted.

RESULTS

From 174 targeted searches and six systematic searches, 1256 studies were identified for the rapid reviews and 21 for the conventional systematic review. Of studies within the rapid reviews, 903 (71.9 per cent) had lower-quality design, with 402 (32.0 per cent) being opinion-based. Quality of studies in the systematic review ranged from low to moderate. Consistency with recommendations made previously by the present authors was observed despite 1017 relevant subsequent publications.

CONCLUSION

The evidence-based recommendations produced early in 2020 remained valid despite many subsequent publications. Weaker studies predominated and few guidelines were evidence-based. Extracted clinical solutions were globally implementable. An evidence-based model for rapid clinical change is provided that may benefit surgical management during this pandemic and future times of urgency.

Proposed delay for safe surgery after COVID-19

BACKGROUND

Long-term effects after COVID-19 may affect surgical safety. This study aimed to evaluate the literature and produce evidence-based guidance regarding the period of delay necessary for adequate recovery of patients following COVID-19 infection before undergoing surgery.

METHODS

A rapid review was combined with advice from a working group of 10 clinical experts across Australia and New Zealand. MEDLINE, medRxiv and grey literature were searched to 4 October 2020. The level of evidence was stratified according to the National Health and Medical Research Council evidence hierarchy.

RESULTS

A total of 1020 records were identified, from which 20 studies (12 peer-reviewed) were included. None were randomized trials. The studies comprised one case-control study (level III-2 evidence), one prospective cohort study (level III-2) and 18 case-series studies (level IV). Follow-up periods containing observable clinical characteristics ranged from 3 to 16 weeks. New or excessive fatigue and breathlessness were the most frequently reported symptoms. SARS-CoV-2 may impact the immune system for multiple months after laboratory confirmation of infection. For patients with past COVID-19 undergoing elective curative surgery for cancer, risks of pulmonary complications and mortality may be lowest at 4 weeks or later after a positive swab.

CONCLUSION

After laboratory confirmation of SARS-CoV-2 infection, minor surgery should be delayed for at least 4 weeks and major surgery for 8-12 weeks, if patient outcome is not compromised. Comprehensive preoperative and ongoing assessment must be carried out to ensure optimal clinical decision-making.

Consistency of global recommendations regarding open versus laparoscopic surgery during the COVID-19 pandemic: a systematic review

Background

Throughout the COVID‐19 pandemic, there has been worldwide debate regarding whether open surgery should be performed in preference to laparoscopic surgery due to the theoretical higher risk of viral aerosolization by the release of pneumoperitoneum. We aimed to assess the consistency of national and international surgical society recommendations regarding the choice of surgical approach; assess the quality of evidence of viral emission in surgical aerosol; and assess the quality of evidence comparing aerosol generation by different surgical energy devices.

Methods

A systematic review of PubMed, Medline, Embase and Cochrane databases was performed. Three search strategies were employed. Twenty‐eight studies were included in the final analysis and quality appraised. Confidence in review findings was assessed using the GRADE‐CERQual (Confidence in Evidence from Reviews of Qualitative research) tool.

Results

Worldwide recommendations regarding open versus laparoscopic surgery are consistent, with a majority recommending that surgical approach is decided on a case‐by‐case, risk minimization approach. There is limited, low‐quality evidence that viral particles can be emitted in surgical aerosol. There is a paucity of literature on the quantity of aerosol produced by different surgical energy devices, and no evidence to support the use of certain surgical instruments to minimize aerosol production.

Conclusions

There is considerable consistency among worldwide recommendations regarding the choice of surgical approach, although the evidence base is lacking. To inform clinical recommendations, further research examining viral emission, transmission, infectivity and amount of surgical aerosol produced is required.

Paediatric surgery and COVID-19: urgent lessons to be learned

Background

The dissemination of scientific data on coronavirus disease 2019 (COVID-19) continually builds but, in April 2020, could not keep up with the spread of the disease. Through technology, surgeons in Italy and the UK, representing both peak and pre-peak infective time zones, were able to communicate so that the urgent lessons on the huge expected demands of care learned in Italy could be brought to the UK in advance. This paper specifically discusses the issues related to paediatric surgery, currently under-reported in the literature.

Methods

The aim of this paper is to conjoin experience from the field to provide a framework for a safe assessment and treatment of paediatric patients by adopting a systemic approach aimed at reducing the risk of contamination. We reviewed the processes and good practices that were undertaken in contexts of emergency such as in Italy and the UK and then adapted them within the Systems Engineering Initiative for Patient Safety (SEIPS) framework to provide an assessment of how to reorganize the services in order to cope with an unexpected situation. The SEIPS model is the adopted theoretical framework, which allows to analyse the system in its main components with a human factors and ergonomics (HFE) perspective.

Results

The results introduce some of the good practices and recommendations developed during the emergency in the surgical scenario with a focus on the paediatric patients. They represent the lessons learned from the combination of the little existing evidence of literature and the experience from surgical teams who responded in an impromptu and unrehearsed way.

Conclusions

Lessons learned from the frontline ‘on the fly’ during COVID-19 emergency should be consolidated and taken into the future. In order to prepare proactively for the next phases and get ahead of the curve of these hospital accesses, there is a need for a risk assessment of the new clinical pathways with a multidisciplinary approach centred on HFE with the adoption of the SEIPS model and an involvement of all the surgical teams.

Impact of the COVID-19 Pandemic on the Education of Plastic Surgery Trainees in the United States

The current COVID-19 pandemic has vastly impacted the health care system in the United States, and it is continuing to dictate its unprecedented influence on the education systems, especially the residency and fellowship training programs. The impact of COVID-19 on these training programs has not been uniform across the board, with plastic surgery residency and fellowship programs among the hardest hit specialties. Implementation of social distancing regulations has affected departmental educational activities, including preoperative, morbidity and mortality conferences and journal clubs; operating room educational activities; as well as the overall education of plastic surgery trainees in the United States. Almost all elective and semielective surgeries across the United States were suspended for a few months during the COVID-19 pandemic; this constitutes a significant portion of plastic surgery cases. Considering the current staged reopening policies, it may be a long time, if ever, before restrictions are completely lifted. In this paper, we review the multidimensional impact of the current COVID-19 pandemic on the training programs of plastic surgery residents and fellows in the United States and worldwide, along with some potential solutions on how to address existing challenges.

Screening and testing for COVID-19 before surgery

Background

Preoperative screening for coronavirus disease 2019 (COVID‐19) aims to preserve surgical safety for both patients and surgical teams. This rapid review provides an evaluation of current evidence with input from clinical experts to produce guidance for screening for active COVID‐19 in a low prevalence setting.

Methods

An initial search of PubMed (until 6 May 2020) was combined with targeted searches of both PubMed and Google Scholar until 1 July 2020. Findings were streamlined for clinical relevance through the advice of an expert working group that included seven senior surgeons and a senior medical virologist.

Results

Patient history should be examined for potential exposure to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Hyposmia and hypogeusia may present as early symptoms of COVID‐19, and can potentially discriminate from other influenza‐like illnesses. Reverse transcription‐polymerase chain reaction is the gold standard diagnostic test to confirm SARS‐CoV‐2 infection, and although sensitivity can be improved with repeated testing, the decision to retest should incorporate clinical history and the local supply of diagnostic resources. At present, routine serological testing has little utility for diagnosing acute infection. To appropriately conduct preoperative testing, the temporal dynamics of SARS‐CoV‐2 must be considered. Relative to other thoracic imaging modalities, computed tomography has the greatest utility for characterizing pulmonary involvement in COVID‐19 patients who have been diagnosed by reverse transcription‐polymerase chain reaction.

Conclusion

Through a rapid review of the literature and advice from a clinical expert working group, evidence‐based recommendations have been produced for the preoperative screening of surgical patients with suspected COVID‐19.

Laparoscopic Surgery in COVID-19 Era-Safety and Ethical Issues

(1) Background: The paper aims to review the available evidence regarding the health risk of the aerosolization induced by laparoscopy induced and impact of the COVID-19 pandemic upon minimally invasive surgery. (2) Materials and methods: A systematic review of the literature was performed on PubMed, Medline and Scopus until 10 July. (3) Results: Chemicals, carcinogens and biologically active materials, such as bacteria and viruses, have been isolated in surgical smoke. However, the only evidence of viral transmission through surgical smoke to medical staff is post-laser ablation of HPV-positive genital warts. The reports of SARS-CoV-2 infected patients who underwent laparoscopic surgery revealed the presence of the virus, when tested, in digestive wall and stools in 50% of cases but not in bile or peritoneal fluid. All surgeries did not result in contamination of the personnel, when protective measures were applied, including personal protective equipment (PPE) and filtration of the pneumoperitoneum. There are no comparative studies between classical and laparoscopic surgery. (4) Conclusions: Previously published data showed there is a possible infectious and toxic risk related to surgical smoke but not particularly proven for SARS-CoV-2. Implementing standardized filtration systems for smoke evacuation during laparoscopy, although increases costs, is necessary to increase the safety and it will probably remain a routine also in the future.

Surgery triage during the COVID-19 pandemic

BACKGROUND

The novel coronavirus, SARS-CoV-2, caused the COVID-19 global pandemic. In response, the Australian and New Zealand governments activated their respective emergency plans and hospital frameworks to deal with the potential increased demand on scarce resources. Surgical triage formed an important part of this response to protect the healthcare system's capacity to respond to COVID-19.

METHOD

A rapid review methodology was adapted to search for all levels of evidence on triaging surgery during the current COVID-19 outbreak. Searches were limited to PubMed (inception to 10 April 2020) and supplemented with grey literature searches using the Google search engine. Further, relevant articles were also sourced through the Royal Australasian College of Surgeons COVID-19 Working Group. Recent government advice (May 2020) is also included.

RESULTS

This rapid review is a summary of advice from Australian, New Zealand and international speciality groups regarding triaging of surgical cases, as well as the peer-reviewed literature. The key theme across all jurisdictions was to not compromise clinical judgement and to enable individualized, ethical and patient-centred care. The topics reported on include implications of COVID-19 on surgical triage, competing demands on healthcare resources (surgery versus COVID-19 cases), and the low incidence of COVID-19 resulting in a possibility to increase surgical caseloads over time.

CONCLUSION

During the COVID-19 pandemic, urgent and emergency surgery must continue. A carefully staged return of elective surgery should align with a decrease in COVID-19 caseload. Combining evidence and expert opinion, schemas and recommendations have been proposed to guide this process in Australia and New Zealand.