Background
At the end of December 2019, an outbreak of an interstitial lung disease caused by a novel type of coronavirus (SARS-CoV-2) was first reported in the city of Wuhan, China [
1]. The World Health Organization (WHO) subsequently designated it as the Coronavirus Disease 2019 (COVID-19) [
2,
3]. One month later, the COVID-19 outbreak was declared a pandemic [
4]. The rapid global spread of the viral infections and disease led to the introduction of far-reaching containment and reduction strategies in the affected countries around the world. To provide hospital capacity, protective equipment and ventilators for an expected increasing number of COVID-19 patients, surgical disciplines in Germany were instructed to postpone all elective surgeries and to reallocate staff to the intensive care units and COVID-19 wards as needed [
5]. Various national surgical societies and associations published statements on the guidance for triage and urgent surgical interventions that were still considered feasible or mandatory [
6‐
8]. Many surgical units were massively affected by restructuring measures [
9,
10]. At the end of April 2020, during this survey, the German Government determined that hospital capacities should gradually resume elective interventions [
5]. The long-term effects of the suspension of the elective surgical programme on the non-academic surgical departments in Germany are currently not foreseeable.
The present cross-sectional study aims to evaluate the impact of the global COVID-19 pandemic and subsequent governmental directives on surgical departments of non-university hospitals in Germany after the first infectious wave. In the survey conducted, data were collected on experiences regarding the effect of the governmental restrictions, on restructuring and financial burdens for the surgical departments, as well as on the assessment of future developments. The results may be helpful for other European countries in adapting containment strategies or resuming elective surgeries in order to regain high quality surgical care under the given circumstances, especially since further waves of the pandemic are expected.
Discussion
This cross-sectional study provides data and assessments on the impact of the COVID-19 pandemic on the work of non-academic departments of surgery in Germany during the first lockdown and suspension of all elective surgeries. Altogether 152 members of the KLK answered the survey, 148 answers were included in the analysis.
The measures taken by politicians to contain the COVID-19 pandemic were mostly positively received by the heads of the surgical departments questioned in this survey. This is an important fact, considering that Germany introduced decentralized testing and initiated an early shutdown to flatten the epidemic curve. As a possible consequence, the death rate remained much lower than in France, Italy or Spain [
13]. For future pandemic waves, this result could indicate that far-reaching and consistent political measures are well accepted by surgeons. Anyhow, the national suspension of the surgical programme was only well accepted by 47.9% of the participants, 16.2% were neutral and 35.8% disagreed. Another complete shut down of elective surgeries must be avoided. To address this point, we propose that, depending on the number of new COVID-19 infections in a particular region, only beds in hospitals in that region (and not at a national level) should be reserved and critical care capacity expanded. In addition, if necessary, another approach could be to restructure hospitals to treat only COVID-19 patients and keep other health care facilities COVID-19-free to maintain normal medical care.
The information policy of the health authories was as well largely perceived as positive, but the support of the hospital staff in general and the surgical departments with their special role in particular was judged insufficient by a majority of the responders. The cooperation between general and abdominal surgeons and their hospital administration was controversial, too. Communication was rated largely satisfactory, but in 71.7%, for example, no financial compensation was promised for the redistribution of staff, which can lead to a loss of confidence in the hospital management during further pandemic waves. Only one third of those interviewed considered their hospital management supportive. In comparison, the survey shows that the specialist disciplines worked well together indicating great trust and mutual support. Approximately one third of all respondents confirmed that initially not enough protective equipment was available at their hospitals and departments. This is not a singular problem, but rather that many healthcare facilities around the world initially lacked essential equipment such as disinfectants and personal protective equipment [
14]. The shortage threatens the life of health care professionals in Germany and throughout the world. As a consequence, a sufficient storage for future pandemics have to be built up and made available more quickly. In addition, the supply of face masks and isolation material should be optimised; the Center for Disease Control and Prevention (CDC) of the US, for example, makes recommendations in this regard [
15].
As mentioned before, in mid-March the German Government advised all hospitals and surgeons to postpone all scheduled admissions and operations if not absolutely necessary [
16]. To mitigate financial losses for the surgical disciplines, the "Hospital Relief Act COVID19" was passed, which refunds each reserved intensive care bed [
17]. Since May the surgical programme has been resumed step by step [
18]. Overall, this phase led to an estimated average reduction in bed capacity of 50.8 ± 19.3% and operating room capacity of 54.2 ± 19.1%. The utilization of the reduced operating room capacity was only 53.2 ± 27.9% on average. The reduction in bed and surgical capacity led most respondents to estimate a loss of revenue of 28.2 ± 12.9% for whole 2020. In view of the incisive restrictions, it seems difficult to compensate for the economic losses from own resources. This is aggravated by the fact that the population is obviously uncertain about COVID-19, as only half of the available operating room capacity was needed. In addition, at the time of the survey, most hospitals had also reduced their outpatient clinics capacity, which might prolong the period of reduced operation rates. Once measures are scaled back, political support will be urgently needed to compensate for financial losses. Furthermore, the public must be made aware that hospital treatment is safe and that measures have been taken to avoid increasing the risk of infection with COVID-19.
The significant reduction in operative capacity and the redeployment of staff members in most facilities lead to concerns that urgent or emergency operations could not have been carried out. However, the survey showed that 91.9% of the participants were able to perform emergency operations without any restrictions or delay. Interestingly, almost half of the respondents (43.9%) stated that the number of emergency operations had dropped on average by one third. The same number of respondents reported no change in the number of emergency operations. The statement about surgical emergencies in the emergency room was even clearer. Almost two thirds (63.5%) reported a decreased number of admissions. The recorded numbers as well as previously reported data indicate, that patients might avoid attendance to the hospital even in urgent cases because they fear a COVID-19 infection [
19]. Thus, initially elective operations will become emergencies in the future, which might lead to worse surgical care and postoperative outcome for the population in general and higher financial costs for the health care system.
The situation is similar with regard to the care of oncological patients. Whereas the interdisciplinary communication in tumour boards was widely unaffected, more than half of the respondents (54.1%) saw fewer patients in their outpatient clinic for both first consultation or follow-up care. This may lead to a deterioration in the early treatment or the detection of recurrences and thus impair the quality of oncological treatment in surgery. Further, the vast majority of the participants (97.3%) had to postpone or cancel a great number of elective surgeries and consultation appointments. The number of postponed treatments of patients in general and oncological patients in particular is obviously considerable. Nonetheless, exact numbers have to be further investigated, since it may have an impact on patient survival in oncological and non-oncological diseases.
Postponement of surgery during the pandemic is necessary not only to reserve beds for COVID-19 patients, but also because patients undergoing surgery are a vulnerable group at risk of hospital exposure to SARS-CoV-2. A recently published study showed that postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality [
20]. Therefore, the authors propose to consider postponing non-urgent interventions, especially in multimorbid patients, and to promote non-operative treatment. Additionally, the implementation of triage plans to prioritize operations appears essential. For instance, Ke et al. published strategies for the management of gastrointestinal surgery during COVID-19 [
21]. Another research group from the UK published a broad overview of surgical practice during the pandemic [
22,
23]. However, the elective surgical programme will be fully resumed at some point, and the postponed operations will need to be performed additionally. There is concern that the actual capacities together with the increased demand may not suffice timely surgical care for all patients in need. In regards to a recent study that estimates the total number of operations cancelled due to COVID-19 at almost 30 million, it is imperative to implement procedures allocating operating room capacity based on medical priority [
24].
The present cross-sectional study is of course also subject to limitations. On the one hand, the collected data are based on subjective assessments, on the other hand, the survey was conducted in an early phase of the COVID-19 pandemic. Therefore, the results are to be considered preliminary and the future development and final impact has to be evaluated in additional investigations. Furthermore, the limited number of participants must be considered a limitation of the study.
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