While the novelty of this pandemic has generated many published papers on management recommendations [19,20,21,22,23], few assess the degree of guidelines implementation by emergency surgical teams. This study provides an international snapshot of the level of adoption of the guidance for surgical team organization, adequacy of PPE availability and usage, OR preparation, anesthesiologic considerations, and intraoperative management of emergency surgical cases during 2 weeks of the COVID-19 pandemic. It should be noted that the study tried to capture the initial response when there was a steep curve of newly reported cases, but while that was the case in Europe at the time of the survey, the American surge came weeks later. The study analyzed the recommendations for emergency surgical management of COVID-19 suspected or confirmed cases, which may differ significantly between countries due to the variability of the number of newly diagnosed cases, resources available, and healthcare policies. Increased awareness and adoption of international societies’ recommendations for emergency surgical management with greater exposure to COVID-19 were expected amongst surgeons with higher case exposure, but the study design did not allow this assumption. Nonetheless, the study can help identify weaknesses in the surgical team response and areas of improvement, which could be useful to face the latest news that brings up attention like the possibility of a second wave of the pandemic [24,25,26].
Regarding the surgical teams’ organization, most of the published literature focuses on reducing the risk of infection by limiting the number of workforce members on each procedure [2, 27]. Furthermore, the emphasis is made on rescheduling elective surgical procedures to rationalize hospital bed capacity. However, few mention surgical teams’ leadership organizing the response to the pandemic [28]. We found out that over 80% of the teams’ members have been doing so, either developing protocols (71%) and implementing safety precautions (69%), which confirms the capacity of emergency surgical to rapidly adapt to complex crises, organizing proactive medical responses when facing natural or human-made disasters [29].
The 2009 H1N1 pandemic revealed that communication dynamics are vital for crisis management, and the use of practical tools for the transmission of health recommendations increases compliance [30]. Social media and online resources are now used by more than 3.8 billion, Twitter, and other social media channels can be a reliable source of health-related information [31]. The COVID-19 pandemic has demonstrated that emergency surgical teams and healthcare bodies could use online tools to disseminate guidelines and maintain communication in times of uncertainty [32]. Our study reveals the use of these tools by 91% of the respondents and the utilization of video conferences by 66% to improve communication between team members during social distancing. They also had to adapt to new roles when they were assigned to the emergency department triage, ICU, or the management of mechanically ventilated patients, 60% had to endure long working shifts, and 52% had 24 h or more in extremely stressful situations.
Focusing on PPE, current literature reports that there are four essential elements regarding PPE: training, availability, adequate use, and re-use strategies in case of shortage [33,34,35,36]. Our study reflects that following PPE recommendations had been a significant issue among respondents; over half expressed concerns for insufficient training, 71% have reported shortages, and 53% improvised part of their protective equipment. Training of proper donning/doffing techniques is essential, it will lower the probability of self-contamination, and educational campaigns must emphasize biosafety breaches to reduce surgical team members’ exposure to it [37,38,39,40]. A critical shortage of N95/FPP2/3 respirators was reported. This can be explained by the underestimation of equipment needs, coupled with the abrupt increase of its global demand. A recent survey about PPE supplies in the US reported that 91% of the 213 queried cities had inadequate face mask supplies, and 88% did not have enough PPE for medical personnel and first responders [41]. Tabah et al. in a recent international survey among 2711 intensive care unit healthcare workers, reported widespread shortage and adverse re-use [42]. Another aspect that stands out in our study is that over half (53%) of the population had to improvise PPE, undermining front-line workers’ trust and confidence with their employer institutions [43]. Additionally, equipment shortage, re-use, and improvisation elevate the risk of infection, adding to the sense of hazardous exposure, and increasing work-associated stress.
Concerning the operating conditions, 71% had prepared COA and most followed guidelines to adapt the existing conditions to the suggested recommendations [3]. Information regarding negative pressure OR suites was not addressed in the survey, but if available, negative pressure ORs should be used to reduce the risk of viral spread and minimize infection risk [44]. One element that should be pointed out is the management of surgical smoke during the pandemic. At the beginning of the COVID-19 outbreak, many guidelines recommended avoiding laparoscopy due to the possibility of viral aerosolization and team infection due to smoke inhalation. Current publications have downsized these risks with measures of smoke/aerosol containment and proper smoke evacuation. However, only 26% reported to have purposed design smoke evacuation systems, and almost half had to improvise them using standard filters, and waters seal devices [45], which could be useful for smoke and vapors generated electrosurgical and ultrasonic devices until more evidence-based research in this field is available.
Reported results of anesthesiologic protocol adoption by the emergency surgery teams reflect a significant lack of implementation of the official recommendations promoted by international anesthesia societies [46, 47]. Our results suggest that improvements must be addressed, especially with equipment preparation during airway manipulation. The importance of having prepared an individual COVID-19 airway trolley with printed airway guidelines should not be underestimated. We consider these elements essential since the use of PPE in the OR has been associated with communication interference and visibility impairment [47]. Using a specific trolley with printed instructions would help avoid errors and reduce team members' risks. Because of the limited number of questions in this area and the reduced number of anesthetists participating in our study, we consider our finding as limited and that further analysis is needed.
Answers received about the operative management reflect the existing differences in the number of new COVID-19-positive registered cases in the participating countries during the studied period. During April 2020, the number of new cases was counted by the thousands in several European countries, with Spain and Italy among them, while in America, it was only starting to be diagnosed. Despite these differences, 44% of the respondents had performed emergency surgery on COVID-19-positive patients. It is essential to highlight the need to use aerosol-generating procedures (AGP) checklists in all emergency surgical procedures. Soma et al. describe how an operative team checklist can potentially reduce risks, but above all, it reduces anxiety and helps maintain the team focused on the task [48]. Results reflect the concerns with the laparoscopic approach and the risks of viral aerosolization. In our study, only 26% had performed laparoscopic procedures [49]. The low level of reported preoperative COVID-19 screening (32%) is of serious concern, and efforts should be made to perform some screening for all emergency surgical cases.
Our study had some limitations that must be noted. First, the 2-week period studied reflected a global snapshot of the pandemic, and the number of newly reported cases between Asia, Europe, and America has not been homogeneous. Second, the level of the reported adoptions of the continually changing recommendations reflects respondents’ perceptions and opinions, which may not accurately represent actual practices. Confirmation of the reported findings should be audited in future studies. This is particularly important with PPE since the massive demand worldwide had generated a global shortage of some equipment. Also, the survey design might have introduced some bias and had a relatively small sample size. Only 20% of the contacted participants; this is especially important regarding the small number of anesthetists included in the study (n = 6). Finally, our sampling strategy recruited mostly European and American respondents, with very few emergency surgeons from Asia and the Middle East, so that results may be biased. Despite these limitations, the findings reflect the leadership and level of involvement of surgical teams during the pandemic. It identifies the urgent need for more training and better endowment of PPE among emergency surgical teams worldwide. The addressing of these issues will allow better preparation for future similar scenarios and guarantee a better response in case of a second wave of the pandemic to be registered in the coming months.