International Journal of Human and Health Sciences Vol. 05 No. 02 April’21 154 Review Article: Acute Care Surgery Preparedness for COVID-19 Pandemic: An Experience from Qatar Ahmad Abutaka1, Omar Aboumarzouk1, Nizar Bouchiba1, Sherif Abdelaziem1, Hesham El Gohary1, Hijran Mahdi1, Shameel Musthafa1, and Ahmad Zarour1 Abstract: Most cases of COVID-19 pandemic are now being reported outside Wuhan, China where the first case was detected. It is highly contagious and has engulfed the world in a short span of time. The burden on healthcare resources to care for the public has mounted multifold due to its fast transmission. Non-operative management of COVID-19 positive or the clinical suspicious cases is preferred. Personal protective equipment (PPE) should be utilized to protect the healthcare professionals’ safety. The Ministry of Public Health, Qatar has launched a series of virtual health care facilities to manage patient appointments, medical consultation, sick leave and drug distribution to avoid hospitalization and to minimize the spread of COVID-19 infection to non-emergency patients by dialing hotline number to provide appropriate services. We would like to share and disseminate the experiences at the Acute Care Surgery (ACS) section, Hamad Medical Corporation (HMC). Ethical considerations, social distancing and optimum utilization of the available resources are essential to overcome the pandemic situation. Keywords: COVID-19, emergency surgery, SARS-Cov-2. Correspondence to: Ahmad Zarour, MD, FACS. Head, Acute Care Surgery Division Hamad Medical Corporation. E-mail: azarour@hamad.qa 1. Acute Care Surgery Division, Hamad Medical Corporation, Doha, Qatar. International Journal of Human and Health Sciences Vol. 05 No. 02 April’21 Page : 154-158 DOI: http://dx.doi.org/10.31344/ijhhs.v5i2.252 Introduction On February 29, 2020, our country announced the recording of its first COVID-19 case1, since then the number of confirmed cases has risen to 117,226 cases after running 594,215 tests, at the time of this written article. As part of the response to the pandemic, a protocol was devised by our team at Hamad Medical Corporation (HMC), Doha, Qatar. The disease causes a respiratory illness with symptoms such as cough, fever, and difficulty in breathing. It spreads mainly through contact with the diseased person when he/she coughs or sneeze and can be prevented taking precautions like washing hands frequently, avoiding touching the face and avoiding close contact with people suffering from it2. The novel coronavirus (SARS-CoV-2) also shows evidence of causing gastrointestinal symptoms such as diarrhea, nausea, vomiting, and abdominal discomfort and has the potential to be transmitted by the fecal- oral route. The SARS coronavirus showed up in the stool specimens, after the patients have been discharged from the hospital3. We would like to share our experience in the Acute Care Surgery Section in dealing with the surgical services during COVID-19 as an example of a Middle-Eastern experience, in managing this pandemic. Our strategy is anticipatory and preemptive. In addition to the general strategies implemented during this pandemic crisis, we undertook additional strategies, with the aim of limiting cross contamination between COVID-19 positive and negative cases, utilizing a well- established protocol and pathway for managing surgical emergencies during this crisis. The Acute Care Surgery division at Hamad Medical Corporation provides emergency tertiary general surgical services. To ensure the safety of the staff and to allow for continual care for patients we have reduced the number of staff to try and mitigate the risk of exposure. We have restructured the manpower and staggered the staff into four teams (On-call, Post-call, Pre-call and Standby 155 International Journal of Human and Health Sciences Vol. 05 No. 02 April’21 teams). This reduces the number of staff who are present in the hospital simultaneously. Each team is composed of the attending consultants, fellows and residents carrying out the day to day patient care activities. This structure allows a backup coverage in case of illness or exposure to COVID-19 to the onboard team and restricts the non-essential personnel from the operating rooms and the emergency department. Furthermore, the minimum number of medical personnel are allowed at the bedside during the ward rounds and in the operating rooms. We supported physical distancing practices by allowing physicians and team members with no direct contact with the patients to work from home, where they carried out administrative duties and virtual clinics. Regular staff meetings were all cancelled and were converted into virtual meetings. Morbidity, mortality and business meetings have been reduced to four attending physicians, to ensure patient safety and continuity of safe surgical practice of these vital meetings. Vital to the success of these major changes were continued education of staff, patients, and visitors. These included education on physical distancing, self-isolation in case of mild symptoms, and protective measures ranging from hand washing to mask wearing. We have revised the recommendations of best practices during the pandemic issued by the major surgical societies, namely, the American College of Surgeons, SAGES, and the Intercollegiate Royal College of Surgeons4-6. Our consultants, fellows and residents discussed the emerging guidelines to make sure we continue to update our protocols and practices to conform with the global surgical community. Four days a week, our patients are followed up in our tele-clinic. The patients are contacted by phone, all clinical issues are addressed over the phone wherever possible. The patient is only brought to the clinic if a physical examination is considered to be crucial. Refill medications are also ordered for the patient to be picked up from the nearest pharmacy. COVID-19 positive patients who require admission for emergency surgical care are referred to the general hospital which has been designated as the COVID-19 positive base. Dedicated wards as well as operating theatres were established for these patients. This further decreases the probability of transmission to other emergency patients. Our full pathway and protocol are shown in Figure 1 and Figure 2. The interventions undertaken by our section specifically and the hospital as a whole was carried out even before the outset of an outbreak. By limiting staff numbers to the bare minimum required, carrying out day-to-day patient care remotely where possible, isolating surgical COVID-19 positive patients to one specific site, and implementing a protocol based on the experiences of our Chinese colleagues, we have managed to limit and decelerate COVID- 19’s spread across our surgical floors and units. Therefore, we recommend our colleagues in an emergency surgical setting to modify their local guidelines early and put in place early protocol pathways to prevent further spread of COVID-19. Conclusion COVID-19 is a highly transmissible disease. Guidelines on the management of emergency surgical patients is the need of the hour. Each institution should put together their set of guidelines and institute changes that are in line with the international recommendations and local regulations. Conflict of interest: All authors declare no relevant conflict of interest. Ethical Approval: Not needed as the per our MRC regulations. Funding statement: None. Authors’ contribution: Drafting the manuscript and literature review: A.A.; Drafting the manuscript and proofreading: O.A.; Review of manuscript and protocols development: N.B.; Review of manuscript and protocols development: S.M.; Review of manuscript and registry: H.E.; Review of manuscript and literature review: H.M.; Algorithm design and development: S.M.; Drafting the manuscript and study concept: A.Z. International Journal of Human and Health Sciences Vol. 05 No. 02 April’21 156 Figure 1: Algorithmic guideline for management of suspected and positive COVID-19 patients in emergency surgery. جـراحـة الــحاالت الحـرجـة Acute Care Surgery Virtual review of the patient by the Consultant (full investigation, Consultant to Consultant) Patient Examination with full PPE Using “Buddy System” Tele - Instructions Follow-Up In The Clinic COVID-19 POSITIVE OR HIGHLY SUSPECTED PENDING PCR RESULT Preoperative A Emergency Outpatient Inpatient Respect OR protocols Go to dedicated OR for Covid-19 PPE, N95 mask with face shield Assure smooth post-operative course Short procedure (absorbable sutures for skin) Non-Operative Management Medical Prescriptions Follow-Up As Inpatient Follow-Up In The Clinic Team leader will assign consultant and/or specialist to evaluate the patient Life Saving Or Clear Indication For Surgery Intraoperative B P A T I E N T N E E D S S U R G E R Y Patient needs to be seen by a surgeon in-person Same team consultant and specialist /fellow assigned will do the procedure. C O V I D - 1 9 GUIDELINES FOR MANAGEMENT OF SUSPECTED AND POSITIVE COVID-19 PATIENT IN EMERGENCY SURGERY Steps to wear PPE HAND RUB WEAR DISPOSABLE GOWN (ensure back and legs are covered) WEAR N95 MASK (fit checked) WEAR FACE SHIELD GOGGLES WEAR DOUBLE GLOVES Steps to remove PPE REMOVE GLOVES HAND RUB & HYGIENE REMOVE GOWN HAND RUB & HYGIENE REMOVE MASK HAND RUB & HYGIENE POST OPERATIVE C All PPE should be removed inside the operating room. Follow PPE removal and disposal as per guidelines, take shower if possible. Return to work at the assigned facility. Site marking, consent and appropriately informing family members should be completed as usual. The surgeon must wait till the patient become intubated then enter the OR. Sign in at reception should be modified to ensure minimal staff exposure. S U R G I C A L C O N S U L T A T I O N YES NO NO YES 157 International Journal of Human and Health Sciences Vol. 05 No. 02 April’21 Figure 2: Narrative details of the algorithmic guideline for management of suspected and positive COVID-19 patients in emergency surgery Ask 3 questions to all patients (Respiratory symptoms, History of travel to affected countries, Contact with confirmed Covid-19 patient in the last 14 days) SCREENING (as per CDC guidelines) A All highly suspicious / positive patient must be referred to ID team as per CDC protocol. UNIVERSAL PRECAUTIONS B Suspected patients should wear a properly fitted mask. The number of managing staffs should be kept to a minimum. The medical personnel in contact have to wear PPE during treatment. Treat the body fluids, tissues, and other apparatus in contact with the patient as having potential biohazard. The operating theatre should be cleaned as per biohazard based on current available protocols. SURGICAL TEAM C Each surgical unit should have a core team to manage COVID-19 using the hotline. A dedicated team on standby for all suspected patients. This team should be optimally trained in handling the personal protective equipment. SURGICAL CONSULTATION D Patient should be reviewed virtually by the consultant on call. It must be a Consultant to Consultant Referral and communication. Team leader will make the decision Go / No Go and select the team to evaluate the patient +/- do the procedure. All investigations must be thorough before surgeon examines the patient in person. Head and Neck examination is high risk for aerosol transmitted infection. SURGEON IN CONTACT WITH THE PATIENT E Staff must use full PPE in addition to universal precautions , Use coverall and disposable scrubs, N95 masks, goggles with full eye protection ,face shield , shoe cover , double gloves , waterproof gown (if not available use plastic apron underneath standard gown ). Time spent with patients should be kept to the minimum. Take shower following contact with the patient if possible. If need to go for surgery add to above the following instructions: Instruct the anesthesiologist and OR nurses to do the necessary steps. Surgeon should not be in the operating room or intubation unless concurrent management of bleeding etc requires their presence. Under no circumstances should staff enter the operating room without properly applied PPE. All personal devices should be kept outside the OR. consultation phone to be kept with a nurse to answer urgent calls. Shorten the operative time as much as possible. Nonoperative management should be selected whenever feasible as an option without compromising patient safet y. Open techniques is preferable over laparoscopy whenever it is an option . With laparoscopy , use low pneumoperitoneum pressure. strict hemostasis , electrocautery at low settings , avoid using harmonic or ultrasound dissection, , liberal use of suction , reduce Trendelenburg position Patient safet y should always be a priorit y . Don’t go home with scrubs , clean your phone , GENERAL CONSIDERATIONS IN SURGICAL COVID-19 PATIENT F All tertiary hospitals should have a dedicated OR for patients suspected with COVID-19. It should ideally be easily accessible from the point of contact. Any non-urgent surgery should be deferred for at least 14 days. Version 2-2020 Prepared and approved by Acute Care Surgery (ACS) Section. International Journal of Human and Health Sciences Vol. 05 No. 02 April’21 158 References: 1. COVID-19 information page on the Ministry of Public Health website – Qatar. Accessed 25.08.2020 https://covid19.moph.gov.qa/EN/ Pages/default.aspx 2. Coronavirus disease (COVID-19) advice for the public. Accessed 25.08.2020 https:// www.who.int/emergencies/diseases/novel- coronavirus-2019/advice-for-public 3. Chen Y, Chen L, Deng Q, et al. The presence of SARS-CoV-2 RNA in the feces of COVID-19 patients [published online ahead of print, 2020 Apr 3]. J Med Virol. 2020;10.1002/jmv.25825. doi:10.1002/jmv.25825 4. COVID-19 and Surgery, Resources for the surgical community. Accessed 25.08.2020 https://www.facs.org/covid-19 5. SAGES COVID-19 / Coronavirus Announcement Archives. Accessed 25.08.2020 https://www.sages.org/category/ covid-19/ 6. Updated Intercollegiate General Surgery Guidance on COVID-19. Accessed 25.08.2020 https://www.rcseng.ac.uk/coronavirus/joint- guidance-for-surgeons-v2/