Covid 19 and the current situation with surgery
With the reported increase in the number of COVID-19 cases in South Africa at the moment, elective surgery may have to take a backseat for a second time this year since a nationwide lock-down was introduced in March 2020.
The following is an extract from The Federation of Surgeons of South Africa consensus document detailing the various surgical categories and their classification in terms of treatment under lock-down regulations:
With the requirement for our profession to provide critical care services and the possibility
that our operating theatres may be converted into Intensive Care Units, it becomes our
collective responsibility to take appropriate steps to support measures that will “flatten the
curve”. This is a dynamic document with it’s recommendation being effective at the time of
issue and may be updated or changed at any time.
At this stage we do not propose a list of surgical procedures, but rather categories into which
we encourage surgical/ procedural teams classify their patients into. For the purposes of this
document we define elective and other surgery/procedures as follows:
Discretionary elective and Essential surgery is surgery that is scheduled in advance and
where postponement of the surgery/ procedure will not result in the patient’s outcome or
quality of life being significantly altered with a 3 month delay.
Essential surgery is a surgery that is scheduled in advance and where postponement of the
surgery will result in the patient’s outcome or quality of life being significantly altered if
extended past 2 weeks to 3 months.
Urgent, essential surgery is surgery that must be performed in order to preserve the patient’s
life or limb or prevent longer term systemic morbidity, but does not need to be performed
immediately and should be generally performed within 2 weeks.
Emergency surgery is one that must be performed without delay or until the patient is
medically stable; the patient has no choice other than to undergo immediate surgery if
permanent disability or death is to be avoided.
It is impossible to define the medical urgency of a case solely on whether a case is on an
elective surgery schedule. While some cases may be postponed indefinitely, the majority of
cases performed are associated with progressive diseases which by their nature will continue
to progress at variable, disease specific rates. Hence the judgement as to whether or not a
surgical intervention should take place can only be decided once numerous considerations
have been observed.
Given the uncertainties regarding the impact of COVID –19, delaying
some cases risks having them reappear as emergencies at a time when they will be less easy
to manage. FOSAS strongly urges communication and collaboration between hospital
clinicians and their administrative staff to consider the following recommendations:
- Hospitals and surgical teams should consider both their patient’s medical needs and
their logistical capacity to meet those needs in an appropriate time frame.
- The medical need for a given procedure should be established by a surgeon with
direct expertise in the relevant surgical speciality to determine which medical risks
will be incurred by a delay.
- Logistical feasibility for a specific procedure should be determined by management
personnel with an understanding of hospital and community limitations. This includes
facility resources (eg. beds, staff, equipment etc.) as well as the safety and well-being
of care providers and local community.
- Case conduct should be determined based on knowledge of national, regional and
local evolving conditions, recognizing that marked regional variation may lead to
significant differences in regional decision making.
- The risk to the patient should include an aggregate assessment of the real risk of
proceeding and the real risk of delay, including the expectation that a delay of
several weeks (or months) may be required to emerge from to an environment where
COVID – 19 is less prevalent.
In general, a day by day, evidence driven assessment of the changing risk-benefit
analysis will need to influence clinical care decisions and delivery for the foreseeable
future. Plans for case triage should avoid blanket policies and instead rely on data and
expert opinion from qualified (and well informed) clinicians and management teams
understanding all COVID–19 issues in play. Although COVID–19 is a clear risk to all,
it is but one of many competing risks for patients requiring surgical care. Thus, surgical
procedures should be considered not based solely on COVID–19 associated risks, but
rather on an assimilation of all available medical and logistical information.