The impact of COVID-19 on emergency surgical presentations in a university teaching hospital

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Abstract

Introduction

The Coronavirus-19 (COVID-19) pandemic has led to a 50–70% reduction in acute non-COVID-19 presentations to emergency departments globally.

Aim

To determine the impact of COVID-19 on incidence, severity, and outcomes of acute surgical admissions in an Irish University teaching hospital.

Methods

Descriptive data concerning patients presenting with acute appendicitis, diverticulitis, and cholecystitis were analysed and compared from March–May 2020 to March–May 2019.

Results

Acute surgical admissions decreased in March from 191 (2020) to 55 (2019) (55%), before increasing by 28% in April (2019: 119, 2020: 153). Admissions due to acute cholecystitis reduced by 33% (2019: 33, 2020: 22), with increased severity at presentation ( P = 0.079) and higher 30-day readmission rates ( P = 0.056) reported. Acute appendicitis presentations decreased by 44% (2019: 78, 2020: 43, P = 0.019), with an increase in severity ( P < 0.001), conservative management ( P < 0.001), and post-operative complications ( P = 0.029) in 2020 compared to the same period in 2019.

Conclusion

COVID-19 has potentiated a significant reduction in acute surgical presentations to our hospital. Patients presenting with acute appendicitis during the pandemic had more severe disease, were more likely to have complications, and were significantly more likely to be managed conservatively when compared to historical data.

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Most cited references 16

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Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

Daniel Dindo, Nicolas Demartines, Pierre-Alain Clavien (2004)

Although quality assessment is gaining increasing attention, there is still no consensus on how to define and grade postoperative complications. This shortcoming hampers comparison of outcome data among different centers and therapies and over time. A classification of complications published by one of the authors in 1992 was critically re-evaluated and modified to increase its accuracy and its acceptability in the surgical community. Modifications mainly focused on the manner of reporting life-threatening and permanently disabling complications. The new grading system still mostly relies on the therapy used to treat the complication. The classification was tested in a cohort of 6336 patients who underwent elective general surgery at our institution. The reproducibility and personal judgment of the classification were evaluated through an international survey with 2 questionnaires sent to 10 surgical centers worldwide. The new ranking system significantly correlated with complexity of surgery (P < 0.0001) as well as with the length of the hospital stay (P < 0.0001). A total of 144 surgeons from 10 different centers around the world and at different levels of training returned the survey. Ninety percent of the case presentations were correctly graded. The classification was considered to be simple (92% of the respondents), reproducible (91%), logical (92%), useful (90%), and comprehensive (89%). The answers of both questionnaires were not dependent on the origin of the reply and the level of training of the surgeons. The new complication classification appears reliable and may represent a compelling tool for quality assessment in surgery in all parts of the world.

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A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study.

J R Le Gall, S Lemeshow, F Saulnier (1993)

To develop and validate a new Simplified Acute Physiology Score, the SAPS II, from a large sample of surgical and medical patients, and to provide a method to convert the score to a probability of hospital mortality. The SAPS II and the probability of hospital mortality were developed and validated using data from consecutive admissions to 137 adult medical and/or surgical intensive care units in 12 countries. The 13,152 patients were randomly divided into developmental (65%) and validation (35%) samples. Patients younger than 18 years, burn patients, coronary care patients, and cardiac surgery patients were excluded. Vital status at hospital discharge. The SAPS II includes only 17 variables: 12 physiology variables, age, type of admission (scheduled surgical, unscheduled surgical, or medical), and three underlying disease variables (acquired immunodeficiency syndrome, metastatic cancer, and hematologic malignancy). Goodness-of-fit tests indicated that the model performed well in the developmental sample and validated well in an independent sample of patients (P = .883 and P = .104 in the developmental and validation samples, respectively). The area under the receiver operating characteristic curve was 0.88 in the developmental sample and 0.86 in the validation sample. The SAPS II, based on a large international sample of patients, provides an estimate of the risk of death without having to specify a primary diagnosis. This is a starting point for future evaluation of the efficiency of intensive care units.

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Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Dmitri Nepogodiev, James C. D. Glasbey, Elizabeth Li … (2020)

Summary Background The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 82·6% (219 of 265) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p<0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p<0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p<0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

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Author and article information

Contributors

Matthew G. Davey:

ORCID: http://orcid.org/0000-0002-9892-9920

m.davey7@nuigalway.ie

Journal

Journal ID (nlm-ta): Ir J Med Sci

Journal ID (iso-abbrev): Ir J Med Sci

Title: Irish Journal of Medical Science

Publisher: Springer International Publishing (Cham )

ISSN (Print): 0021-1265

ISSN (Electronic): 1863-4362

Publication date (Electronic): 12 July 2021

Publication date PMC-release: 12 July 2021

Pages: 1-7

Affiliations

[1 ]GRID grid.412440.7, ISNI 0000 0004 0617 9371, Department of Surgery, , Galway University Hospitals, ; Galway, Republic of Ireland

[2 ]GRID grid.6142.1, ISNI 0000 0004 0488 0789, Department of Academic Surgery, , National University of Ireland, ; Galway, Republic of Ireland

Author information

Matthew G. Davey http://orcid.org/0000-0002-9892-9920

Article

Publisher ID: 2709

DOI: 10.1007/s11845-021-02709-w

PMC ID: 8274665

PubMed ID: 34254230

SO-VID: dea019b5-c62d-4316-b899-859ae9a466a1

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date received : 11 June 2021

Date accepted : 29 June 2021

Funding

Funded by: National University Ireland, Galway

Open Access :

Open Access funding provided by the IReL Consortium

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The impact of COVID-19 on emergency surgical presentations in a university teaching hospital

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Novel Coronavirus Disease COVID-19

Most cited references 16

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study.

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

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