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      Rate of COVID-19 infection and 30 day mortality between Blue and Green (Dedicated COVID-19 safe) pathways: Results from Phase 1 and 2 of the UK Foot and Ankle COVID-19 National (UK-FAlCoN) Audit

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          Abstract

          Objectives

          The primary aim was to determine the differences in COVID-19 infection rate and 30-day mortality in patients undergoing foot and ankle surgery between different treatment pathways over the two phases of the UK-FALCON audit, spanning the first and second national lockdowns.

          Setting

          This was an ambispective (retrospective Phase 1 and prospective Phase 2) national audit of foot and ankle procedures in the UK in 2020 completed between 13 th January 2020 and 30 th November 2020.

          Participants

          All adult patients undergoing foot and ankle surgery in an operating theatre during the study period were included from 46 participating centres in England, Scotland, Wales and Northern Ireland. Patients were categorised as either a green pathway (designated COVID-19 free) or blue pathway (no protocols to prevent COVID-19 infection).

          Results

          10,846 patients were included, 6,644 from phase 1 and 4,202 from phase 2. Over the 2 phases the infection rate on a blue pathway was 1.07% (69/6,470) and 0.21% on a green pathway (9/4,280). In phase 1, there was no significant difference in the COVID-19 perioperative infection rate between the blue and green pathways in any element of the first phase (pre-lockdown (p=.109), lockdown (p=.923) or post-lockdown (p=.577)). However, in phase 2 there was a significant reduction in perioperative infection rate when using the green pathway in both the pre-lockdown (p<.001) and lockdown periods (Odd’s Ratio 0.077, p<.001). There was no significant difference in COVID-19 related mortality between pathways.

          Conclusions

          There was a five-fold reduction in the perioperative COVID-19 infection rate when using designated COVID-19 green pathways over the whole study period; however the success of the pathways only became significant in phase 2 of the study, where there was a 13-fold reduction in infection rate. The study shows a developing success to using green pathways in reducing the risk to patients undergoing foot and ankle surgery.

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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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            Elective surgery cancellations due to the COVID ‐19 pandemic: global predictive modelling to inform surgical recovery plans

            Dmitri Nepogodiev, Aneel Bhangu, Savino Spadaro … (2020)
            Background The COVID‐19 pandemic has disrupted routine hospital services globally. This study estimated the total number of adult elective operations that would be cancelled worldwide during the 12 weeks of peak disruption due to COVID‐19. Methods A global expert‐response study was conducted to elicit projections for the proportion of elective surgery that would be cancelled or postponed during the 12 weeks of peak disruption. A Bayesian beta‐regression model was used to estimate 12‐week cancellation rates for 190 countries. Elective surgical case‐mix data, stratified by specialty and indication (cancer versus benign surgery), was determined. This case‐mix was applied to country‐level surgical volumes. The 12‐week cancellation rates were then applied to these figures to calculate total cancelled operations. Results The best estimate was that 28,404,603 operations would be cancelled or postponed during the peak 12 weeks of disruption due to COVID‐19 (2,367,050 operations per week). Most would be operations for benign disease (90.2%, 25,638,922/28,404,603). The overall 12‐week cancellation rate would be 72.3%. Globally, 81.7% (25,638,921/31,378,062) of benign surgery, 37.7% (2,324,069/6,162,311) of cancer surgery, and 25.4% (441,611/1,735,483) of elective Caesarean sections would be cancelled or postponed. If countries increase their normal surgical volume by 20% post‐pandemic, it would take a median 45 weeks to clear the backlog of operations resulting from COVID‐19 disruption. Conclusions A very large number of operations will be cancelled or postponed due to disruption caused by COVID‐19. Governments should mitigate against this major burden on patients by developing recovery plans and implementing strategies to safely restore surgical activity. This article is protected by copyright. All rights reserved.
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              Elective Cancer Surgery in COVID-19–Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study

              James C. D. Glasbey, Aneel Bhangu, Dimitrios Angelou … (2020)
              As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Foot Ankle Surg
                Journal ID (iso-abbrev): Foot Ankle Surg
                Title: Foot and Ankle Surgery
                Publisher: European Foot and Ankle Society. Published by Elsevier Ltd.
                ISSN (Print): 1268-7731
                ISSN (Electronic): 1460-9584
                Publication date PMC-release: 25 February 2022
                Publication date (Electronic): 25 February 2022
                Affiliations
                [a ]Trauma and Orthopaedic Consultant, Royal National Orthopaedic Hospital NHS Trust, Brockley Hill, Stanmore, Middlesex, HA7 4LP
                [b ]Trauma and Orthopaedic Consultant, University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW
                [c ]University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW
                [d ]Trauma and Orthopaedic Consultant, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL
                Author notes
                [* ]Correspondence to: Trauma and Orthopaedic Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, L9 7AL.
                [1]

                0000-0001-7589-5310

                [2]

                0000-0002-3960-3023

                [3]

                0000-0003-4940-8835

                [4]

                0000-0002-0371-3183

                Article
                Publisher Item ID: S1268-7731(22)00045-5
                DOI: 10.1016/j.fas.2022.02.017
                PMC ID: 8872704
                SO-VID: 7688212c-c8fd-46bc-9bbd-9241084b8e9f
                Copyright © © 2022 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
                License:

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

                History
                Date received : 26 September 2021
                Date revision received : 5 January 2022
                Date accepted : 23 February 2022
                Categories
                Subject: Article

                Keywords: uk-falcon,covid-19,sars-cov-2,foot and ankle surgery,national audit,pathways,mortality
                Data availability:
                Keywords: uk-falcon, covid-19, sars-cov-2, foot and ankle surgery, national audit, pathways, mortality

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