Making surgery safer during the pandemic

Routine testing for COVID-19 can make surgery safer according to a study led by the University of Birmingham:

• Using nasal swab tests before surgery to detect COVID-19 in patients with no symptoms linked to lower rate of serious breathing complications;
• Routine pre-operative swab testing should be part of a broader strategy to reduce COVID-19 exposure for patients undergoing surgery;
• Researchers have launched a ‘toolkit’ that will help healthcare chiefs use such testing, ‘COVID-free’ hospital zones and other measures to ‘re-boot’ surgery safely and prevent further delays

Routine testing patients for COVID-19 before major surgery could reduce the risk of respiratory complications and save lives, a new study reveals.

Researchers working together around the world found that using a nasal swab test to confirm that asymptomatic patient were not infected with SARS-CoV-2 was associated with a lower rate of post-operative complications. The main benefit was seen before major surgery and areas with a higher rate of COVID-19.

Swab testing gave opportunity for surgeons to identify asymptomatic infected patients and postpone their operation, avoiding the severe risk of COVID-19 complications after surgery. Routine testing also helped to prevent cross-infection from patients with no symptoms to other elective surgical patients upon admission to hospital.

Led by researchers at the University of Birmingham, the COVIDSurg Collaborative comprises of experts from over 130 countries. The group has published its findings today in the British Journal of Surgery and is calling for pre-operative swab testing for all patients as part of a broader strategy to continue surgery safely during the pandemic.

The collaborative is backing this call with the launch of a dedicated ‘toolkit’ that will help hospitals and healthcare providers around the world to get elective surgery ‘up-and-running’ again, after more than 28 million procedures were postponed in the first phase of the global pandemic.

Collaborative lead Dr. Aneel Bhangu, from the NIHR Global Health Research Unit on Global Surgery, at the University of Birmingham, commented: “Our findings demonstrate major variation between countries in the application of preoperative testing. Whilst a clear benefit to testing was seen, just 1 in 4 patients were screened for infection. This illustrates the need for global expansion and standardisation of swab testing worldwide.

“Preoperative swab testing should not be considered in isolation, but as part of a broader plan to minimise risks for patients, including setting up COVID-19 free surgical pathways in all hospitals performing elective surgery. For major surgery one serious postoperative complication was avoided for every 17 tests performed. We urge care providers to provide a routine swab test for all patients undergoing elective surgery whether or not they have symptoms.”

The COVIDSurg toolkit will support individual hospitals, regions, and countries during a major global reorganisation of surgical services during the pandemic and beyond, by:

• Summarising published data to support safe surgical practice;
• Guiding effective surgical recovery plans; and
• Creating a five-year vision of safe and effective surgery that addresses global challenges, including shortfalls in access to surgery that existed before the pandemic.

Dr. James Glasbey, study lead at the University of Birmingham, commented: “Surgery is an essential part of all health systems. On average, you will undergo 3 to 4 operations during your lifetime. Surgery remains the cure for most cancers and underpins the treatment of many non-infectious diseases.

“Our new toolkit will help everyone involved in surgical planning over the next 5 years, including providers, healthcare leaders, patients, governments, financers and industry. It addresses global challenges, but is locally adaptable to hospitals and environments with varying access to resources.”

Before the COVID-19 pandemic, 5 billion people lacked access to surgical care and 143 million more operations per year were required globally. There was already a major global inequity in access to safe and affordable surgery across low and middle-income countries, with an urgent need to expand capacity.

This pandemic has acutely worsened that situation and placed a spotlight on the need for change in how surgery is delivered. Launched in March 2020, the COVIDSurg collaborative has provided data needed to support this change in the fastest time frame ever seen by a surgical research group, with data from 150,000 patients across 2000 hospitals collected over the past 9 months.

Last month in their previous report, COVIDSurg researchers called for hospitals to set up ‘COVID-19 free’ zones for surgical patients to help save lives during the second wave of the pandemic – reducing the risk of death from lung infections associated with coronavirus.

They found that that patients who had their operation and hospital care in ‘COVID-19 free’ areas had better outcomes – improving the safety of surgery by having a strict policy that no patients treated for COVID-19 were mixed with those undergoing surgery.

A copy of the global toolkit can be downloaded at https://redcap.link/siureport

• The University of Birmingham is ranked amongst the world’s top 100 institutions. Its work brings people from across the world to Birmingham, including researchers, teachers and more than 6,500 international students from over 150 countries.
• ‘Preoperative nasopharyngeal swab testing and postoperative pulmonary complications in patients undergoing elective surgery during the SARS-CoV-2 pandemic’ – James C Glasbey (UK), Omar Omar (UK), Dmitri Nepogodiev (UK), Ana Minaya-Bravo (Spain), Brittany Kay Bankhead-Kendall (USA), Marco Fiore (Italy), Kaori Futaba (Hong Kong), Alodia Gabre-Kidan (USA), Rohan R Gujjuri (UK), Arda Isik (Turkey), Haytham MA Kaafarani (USA), Sivesh K Kamarajah (UK), Elizabeth Li (UK), Markus W Löffler (Germany), Kenneth A McLean (UK), Outani Oumaima (Morocco), Faustin Ntirenganya (Rwanda), Sohei Satoi (Japan), Richard Shaw (UK), Joana FF Simoes (Portugal), Grant D Stewart (UK), Stephen Tabiri (Ghana), Isobel M Trout (UK), Aneel A Bhangu (UK) on behalf of the COVIDSurg Collaborative is published in the British Journal of Surgery, Europe’s leading surgical journal.
• The research was funded by several charities including the Association of Coloproctology of Great Britain and Ireland; Bowel Research UK; Association of Upper Gastrointestinal Surgeons; British Association of Surgical Oncology; British Gynaecological Cancer Society; European Society of Coloproctology; NIHR Academy; Sarcoma UK; The Urology Foundation; Vascular Society for Great Britain and Ireland; Yorkshire Cancer Research.
• The countries that participated in this study report include: Argentina, Armenia, Australia, Austria, Azerbaijan, Barbados, Belgium, Brazil, Canada, Chile, Colombia, Croatia, Cyprus, Czech Republic, Denmark, Egypt, Ethiopia, Finland, France, Germany, Greece, Hong Kong SAR, China, Hungary, India, Ireland, Italy, Japan, Jordan, Libya, Madagascar, Malaysia, Mexico, Morocco, Netherlands, Nigeria, Oman, Pakistan, Peru, Poland, Portugal, Puerto Rico, Reunion, Romania, Russian Federation, San Marino, Saudi Arabia, Serbia, Singapore, Slovak Republic, South Africa, Spain, Sweden, Switzerland, Turkey, United Kingdom, United States, Uruguay.
• The National Institute for Health Research (NIHR) awarded £7 million to the University of Birmingham to establish the NIHR Global Health Research Unit on Global Surgery. This unit is engaged in conducting multi-country randomised controlled trials testing interventions to reduce SSI across a range of low- and middle-income countries. It has established sustainable partnerships with the aim of leveraging global policy change:
  • § Benin – University of Abomey-Calavi, Cotonou
  • § Ghana – University of Development Studies, Tamale
  • § India – CMC Ludhiana, Punjab
  • § Mexico – Hospital Espanol, Veracruz
  • § Nigeria – Lagos University Teaching Hospital, Lagos & Obafemi Awolowo University Teaching Hospitals, Ile-Ife
  • § Rwanda – University of Rwanda; University Teaching Hospital, Kigali
  • § South Africa – Chris Hani Baragwanath Academic Hospital, Johannesburg
• The National Institute for Health Research (NIHR) awarded £7 million to the University of Birmingham to establish the NIHR Global Health Research Unit on Global Surgery. This unit is engaged in conducting multi-country randomised controlled trials testing interventions to reduce SSI across a range of low- and middle-income countries. The NIHR is the UK’s largest funder of health and care research. The NIHR:
  • § Funds, supports and delivers high quality research that benefits the NHS, public health and social care
  • § Engages and involves patients, carers and the public in order to improve the reach, quality and impact of research
  • § Attracts, trains and supports the best researchers to tackle the complex health and care challenges of the future
  • § Invests in world-class infrastructure and a skilled delivery workforce to translate discoveries into improved treatments and services
  • § Partners with other public funders, charities and industry to maximise the value of research to patients and the economy

The NIHR was established in 2006 to improve the health and wealth of the nation through research, and is funded by the Department of Health and Social Care. In addition to its national role, the NIHR commissions applied health research to benefit the poorest people in low and middle-income countries, using Official Development Assistance funding.