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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 10  |  Page : 1558-1564

Impact of COVID -19 Pandemic on Plastic Surgery Practices in a Tertiary Care Set Up in Southern India


Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education and Research, Sri Ramachandra Nagar, Porur, Chennai, Tamil Nadu, India

Date of Submission16-Feb-2021
Date of Acceptance19-Mar-2021
Date of Web Publication16-Oct-2021

Correspondence Address:
Abiramie Chellamuthu
Department of Plastic Surgery, Sri Ramachandra Institute of Higher Education and Research, No: 1, Ramachandra Nagar, Porur, Chennai, Tamil Nadu - 600 116
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_80_21

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   Abstract 


Background: The COVID-19 pandemic has modified the way, plastic surgeons treat their patients. This article depicts how we as a plastic surgery department in a tertiary care setup handled the pandemic with an emphasis on infection control policy. Methods: Data was collected from hospital records and quality assurance cell from March 21, 2020 to June 19, 2020 in terms of patient triaging, consultations, perioperative protocols, duty rosters, and academic activities. The changes on these with the impact of COVID-19 were studied with the same period of previous year. Results: Outpatient clinics were closed and emergency consultations were reduced. Number of consultations reduced from 2591 to 75 and surgeries from 320 to 46 during the same period in 2019 and 2020 respectively. Though tele-consultations were helpful, the overall benefits were subpar. Emergency services continued with the guidelines of institute's infection control committee, such as area specific personal protective equipment, allotment of operating rooms, minimizing the crowd in operating room. There was some compromise in using accessories for microsurgical procedures. Duty rosters were designed to maintain uninterrupted services. Academic activities were continued with virtual platforms. Conclusion: Adequate preparation of health care setup and nation-wide lockdown has helped to handle emergency cases and in reduction of trauma-surgeries respectively. Though there were obstacles for some patients in accessing health care, our institutional response made us to render maximum possible care. Advancements in virtual platform helped in consultations and academics. Delayed conservative approach was used in most cases at the expense of cosmetic compromise.

Keywords: COVID-19, microsurgery, plastic surgery practice


How to cite this article:
Chellamuthu A, Kumar J S, Ramesh B A. Impact of COVID -19 Pandemic on Plastic Surgery Practices in a Tertiary Care Set Up in Southern India. Niger J Clin Pract 2021;24:1558-64

How to cite this URL:
Chellamuthu A, Kumar J S, Ramesh B A. Impact of COVID -19 Pandemic on Plastic Surgery Practices in a Tertiary Care Set Up in Southern India. Niger J Clin Pract [serial online] 2021 [cited 2022 Dec 8];24:1558-64. Available from: https://www.njcponline.com/text.asp?2021/24/10/1558/328246




   Introduction Top


A novel human corona virus named severe acute respiratory syndrome corona virus 2 (SARS CoV-2) was first reported in Wuhan, China in December 2019, a global outbreak occurred and World Health Organization (WHO) declared it a global pandemic on March 11,2020.[1] Despite the disease prevention and management is under epidemiologists, physicians, microbiologists, and basic scientists, the effect of the disease spills over to the surgical specialties also. In our institution non-essential elective surgeries were postponed, with restriction of new admissions and cancellation of routine outpatient clinics as per government guidelines issued on 20.3.2020.[2] But there is no clear-cut definition of elective procedures. Sometimes patients' condition may worsen without the elective procedure.

The limitations imposed by lockdown on patients' mobility and transportation, risk of non-COVID patients getting the infection during hospital visits, infected asymptomatic patients spreading the infection during hospital visits, and risk of health care workers (HCW) contracting the infection from the patients, lead us to alternative ways of providing care to patients on consultation as well as performing surgeries. Many of the infected or potentially infected patients needed surgical procedures which can't be avoided. Plastic surgeries were required in emergencies like polytrauma, hand injuries, maxillo-facial fractures, burns, and semi-emergencies like oral/other malignancies where there is contact with oral cavity with risk of aerosol generation in potentially COVID-19 infected patients.

In this article, we discuss the ways by which we formulated guidelines to deal with these scenarios in our department and also highlight the limitations imposed by the pandemic on surgeries and consultations performed during the three months of lockdown with respect to the same period of previous year. We also highlight, how tele-consultations helped staying in touch with the patients and helped us in categorization and performing elective procedures before they become emergencies. As we come to know more about the virus strategies outlined in this article will change accordingly.


   Materials and Methods Top


The overall COVID-19 period observed, was from March 21 2020 to June 19 2020 – a total period of 13 weeks. We also examined pre-COVID period of the same dates in the previous year. All the data was collected from hospital medical records department and Internal Quality Assurance Cell in terms of patient triaging methods, out-patient consultations, perioperative protocols, duty roster of HCW, and mode of conduction of academic activities.

Calculation

The data collected from above sources was entered in excel sheet and an attempt has been made to emphasize on the effect of COVID-19 pandemic over routine Plastic surgical teaching and patient care.


   Results Top


Our institution followed the guidelines issued by Indian Council of Medical Research and the Ministry of Health and Family Welfare, Government of India, and other Surgical Associations all over the world regarding safe surgical practices.

Plastic surgery consultation

The outpatient clinics remained closed during this period. Only emergency services remained open and patients who were given appointments from before the period of cancellation of elective procedures, previously treated patients coming for follow up and new non-emergency referrals were encouraged to use our telemedicine services. Telemedicine, the distribution of health-related services and information via electronic information and telecommunication technologies, has potential applications in plastic surgery given the visual nature of this field. Telemedicine consultations were carried out with our institute's Telemedicine website. Though it was helpful for communication between the patient and the surgeon, allowed us to risk stratify the patients requiring emergency surgical procedures, we felt that the consultations were sub-optimal, since the clinical examination is of paramount importance in the decision making. We also had concerns about patient privacy and patient satisfaction. All consultants in our institution underwent online training in telemedicine consultation which was conducted by Telemedicine Society of India.

All patients coming in for emergency services were triaged as shown in [Table 1] and managed.
Table 1: Triage Protocol (original)

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  • The patients and their attendant coming in for emergency were screened at the entrance of the hospital with thermal screening and fever proforma was duly filled.
  • One attendant policy was followed strictly.
  • Face masks were made compulsory as per government guidelines.
  • During the consultation, strict social distancing was maintained and the attending consultant and the nurses wore surgical scrubs, caps, N95 masks, face shield, and gloves. Hand hygiene was practiced using alcohol-based hand sanitizer after seeing each patient.
  • The lab investigations and radiological films were viewed using electronic methods to avoid contact with printed medical reports and films.


The emergency cases were defined as those who needed immediate surgery to restore anatomy and function. All patients admitted for emergency surgical procedures were isolated in separate wards, pending their COVID results. After the patients and their attendant were tested negative for COVID, the patients were transferred to non-COVID Operating Rooms (OR). Patients testing positive were transferred to COVID OR.

Perioperative protocols

We had separate COVID and non-COVID OR. All consultants and residents underwent training in personal protective equipment (PPE) donning/doffing. Due to the risk of false negatives in RT-PCR (Reverse Transcriptase Polymerase Chain Reaction), we followed droplet precautions even when patients tested COVID negative. There were separate donning/doffing areas. Adjacent OR had been converted into preparation area for preparing surgical instrument trolley and anesthetic drug-dosage preparation trolley, with the rationale of minimizing the exposure from the OR, in which the patient undergoes surgery. As a protocol the anesthetic team entered the OR first, after timing out and confirming the identity of the patient just outside the concerned OR. The number of HCW in the anesthetic team was reduced considerably to a team of one consultant, one resident, and one anesthetic technologist. The surgical team and the scrub nurse with the trolley waited outside till the patient was anesthetized to reduce the risk of aerosol exposure. Number of people in the surgical team was also reduced to the minimum without compromising the assisting hands. Our institution protocol for PPE is shown in [Table 2] and [Table 3]. Intra-operatively diathermy use and drilling/cutting bone was minimized to reduce risk of aerosol generation. Surgical equipment like diathermy machines, operating microscopes, and power drill machines were covered with disposable plastic sheets.
Table 2: Institution Protocol for Operating Room Personal Protective Equipment (original)

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Table 3: Personal Protective Equipment levels (original)

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We encountered some intra-operative problems. Magnifying loupe use was required in most of our cases, which posed difficulties in wearing goggles and regular face shields. Hence, we used larger face shields which can accommodate the loupe. With larger face shields, intensive fogging was encountered despite use of adhesive tapes, due to sweat and evaporation of expired air. Moreover, the uncomfortable loupe position inside the face shield was distracting and tiring especially in longer procedures. When using operating microscope, we were not able to use face shield or goggles and had to go only with coverall PPE and N95 mask.

After using in the OR all the surgical instruments were sent for decontamination and sterilization. The surfaces of the medical equipment were cleaned with ammonium chloride wipes and the ORs were fumigated after every procedure with hydrogen peroxide vapors. In addition to the above, COVID OR had negative pressure environment with high frequency of air changes. The ventilation of these OR also had high-efficiency particulate (HEPA) filters. Post-operatively patients were discharged as early as possible and advised to avoid direct follow ups and use tele-consultations. Patients were taught to do dressings by themselves. Post-operative patients requiring second procedures underwent COVID testing again if the time after first testing was more than 72 hours. The semi-emergency cases were monitored on day-to-day basis and patients were kept in contact by telemedicine and in case of emergency, the same protocol as for emergency cases was followed. The elective cases were followed up using telemedicine tools and their surgery was postponed by 3-6 months. After seeing the patients or performing surgeries we were advised to take a shower on reaching home, sanitize our mobile phones/pens, and to wash all our used scrubs. We maintained social distancing at home too.

Duty roster of staff – faculty and residents

Our department was divided in to two teams (with equal distribution of consultants and residents) to work on alternate days to ensure availability of working hands in case of quarantine of any of the team members with COVID exposure or illness. All the HCW underwent thermal screening at the beginning of every duty. All the employees were instructed to avoid availing elective leaves and have been prohibited to travel to out stations especially the containment zones except in emergent situations, in which case, the travel has been intimated to the institution and adequate quarantine protocols were followed as guided by infection control committee.

Academic activities

Since ours is a teaching institution with two post graduate trainees per year and many allied health sciences' students, our academic activities had to be continued without interruption even during lockdown. All the theoretical classes like seminars, journal discussions, and case scenario-based discussions were conducted via online platforms like institution-specific G-Suite and Moodle. Being a surgical teaching department, we were not able to provide adequate hands-on training for the residents due to lack of elective cases and minimizing the number of people in the OR as a part of COVID prophylaxis even in emergency cases.

Changes in the case load and type of procedures

In the entire study period, only 46 surgical procedures were performed, whereas there were 320 surgical procedures done by same team during the previous year as shown in [Figure 1] and [Figure 2].
Figure 1: Graph showing the weekly surgical activity during the COVID 19 and the pre-COVID 19 period

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Figure 2: Procedures categorized by sub specialty

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During this period, only 75 times patients accessed us via both emergency department and telemedicine consultation. In the pre-COVID-19 period our outpatient clinics and emergency were accessed 2951 times for consultation and none of them accessed via tele-consultation [Figure 3]. [Table 4] and [Table 5] show the disease distribution and patient demographics respectively.
Figure 3: Graph showing the weekly distribution of patients accessing plastic surgery consultation

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Table 4: Diagnosis wise distribution of patients (original)

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Table 5: Patient demographics (original)

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   Discussion Top


The outpatient clinics were closed, and the emergency consultations were also reduced due to movement restriction (less road traffic accidents), closing of workplaces, and factories imposed by the nationwide lockdown. Patients feared coming to the hospitals due to the overall anxiety caused by the pandemic and also the fear of getting infected by COVID-19 in hospitals.

Telemedicine consultation was relatively new for us. Telemedicine has been shown to be advantageous especially in post-operative patients to reduce follow up, and also during lockdown where transport facilities were suspended.[3] Several authors have cited the limitation of telemedicine in performing physical examination especially in malignancies and also ethical considerations of patient safety and consent, as experienced by us.[4] To avoid legal issues with telecommunication, it is important to establish boundaries, maintaining highest ethical standards in doctor-patient relation.[5] Though telecommunication can be ideal for some conditions, it might not be appropriate to examine critically ill patients.[6]

As elective cases were cancelled as per government guidelines, these may become emergency at any time.[2] The effects of cancelling all the elective cases are not known now but will lead to constant back log of the same once the pandemic ends.[7] Conditions like non-melanomatous skin cancer, diabetic foot infections, vascular malformations which were not operated during this period might continue to worsen requiring more complex excision and reconstructions.[6]

Around 75% of patients infected from COVID-19 were asymptomatic.[8] Though all patients who were planned for emergency procedures underwent RT-PCR for COVID-19 screening, there was still risk of exposure due to false negative tests.[9] With false negative rates of around 30%, all patients should be treated as suspected COVID-19 positive.[10] Many studies have suggested to have separate COVID and non-COVID ORs with COVID ORs fitted with HEPA filters.[11] The anesthetic team has to enter first, perform the intubation, and the surgical team has to enter only after 15 minutes.[10] Few authors have suggested maneuvers to improve the comfort level during surgery along with the protective measures. Customized fitting of loupes by making holes in the shield to fit loupes, drilling small holes in the goggles can be done.[12] But the efficacy of face shields and goggles may come down.

Regarding the types of surgical procedures, studies have shown that, even COVID-19 negative patients requiring prolonged surgeries like free flap procedures will have worse outcomes if they become infected post operatively. It is advisable to defer free flap procedures especially during the peak of the pandemic.[10] Microsurgical procedures are time consuming, requiring post-operative mechanical ventilation, may need re-exploration which needs repeat testing and prolonged exposure especially with shortage of intensive care unit beds and test kits.[13] Loco regional flaps should be done wherever possible. Free flaps if needed, only the regular workhorse flaps should be done, avoiding osteo-cutaneous flaps.[10] Power air purifying respirators (PAPR) have been recommended for free flap procedures especially in head and neck regions with higher risk of aerosol generation. But using the microscope with PAPR might be practically challenging.[10] In the contrary, other authors have suggested using a full PPE with a fitted N95 mask, draping the patient fully exposing only the operating field, which was followed in our institution.[12] Decontamination of theatres has to be done with either sodium hypochlorite or hydrogen peroxide vapors after every procedure which increased the transit time between surgeries.[11] The patients had more economic burden with increased cost of the procedures due to the cost incurred for the COVID testing and the PPEs. Even with an operating team of two surgeons, one anesthetist, a scrub nurse, technicians, and support staff the requirement of PPE goes up to 8-10.[12] PPE use should be rationalized, reserving them for the HCW directly involved in COVID care.[12]

Duty roster of staff is important to protect HCW from contracting the infection. Agarwal et al.[14] has suggested forming three teams consisting of plastic surgeon, anesthetist, nursing and paramedical staff, rotating two teams every 14 days and keeping the third team on standby. It was not possible in our set up since the anesthetist and nursing staff were already working in COVID wards, so we went for a work force of 50% on all days as mentioned above.

Worldwide the learning modality has changed, transforming conferences to virtual webinars, and discussions, which allowed more attendance than in in-person meetings.[15] Traditional teaching methods in rounds, OR and classroom discussions have been stopped because of the pandemic. Though virtual classes have allowed residents to attend different sub specialties, the direct clinical examination, operating room teaching, and assisting surgeries surpassed online classes.[16]


   Conclusion Top


The pandemic has changed the working way of hospitals. Adequate preparedness of the health care set up and the timely lockdown imposed by the government helped us to handle the pandemic and continue to provide uninterrupted emergency plastic surgical services respectively. Tele-consultations may be useful even after the pandemic, in following up patients coming from long distance and bridging the gap in health care access. Virtual webinars and classes were useful in teaching our post graduates in these times when they had less OR exposure. Even after the pandemic wanes down, these virtual modalities might still be useful in reducing the sub specialty gap compared to traditional classroom teaching. Overall, the pandemic is being better handled when compared to the Spanish flu pandemic a century back, due to proactive lockdowns, improved healthcare, and virtual platforms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
20200311-sitrep-51-covid-19.pdf. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf?sfvrsn=1ba62e57_10. [Last accessed on 2020 Dec 05].  Back to cited text no. 1
    
2.
AdvisoryforHospitalsandMedicalInstitutions.pdf. Available from: https://www.mohfw.gov.in/pdf/AdvisoryforHospitalsa ndMedicalInstitutions.pdf. [Last accessed on 2020 Dec 01].  Back to cited text no. 2
    
3.
Vyas KS, Hambrick HR, Shakir A, Morrison SD, Tran DC, Pearson K, et al. A systematic review of the use of telemedicine in plastic and reconstructive surgery and dermatology. Ann Plast Surg 2017;78:736-68.  Back to cited text no. 3
    
4.
Shokri T, Lighthall JG. Telemedicine in the era of the COVID-19 pandemic: Implications in facial plastic surgery. Facial Plast Surg Aesthet Med 2020;22:155-6.  Back to cited text no. 4
    
5.
Gardiner S, Hartzell TL. Telemedicine and plastic surgery: A review of its applications, limitations and legal pitfalls. J Plast Reconstr Aesthet Surg 2012;65:e47-53.  Back to cited text no. 5
    
6.
Pignatti M, Pinto V, Miralles ME, Giorgini FA, Cannamela G, Cipriani R. How the COVID-19 pandemic changed the plastic surgery activity in a regional referral center in Northern Italy. J Plast Reconstr Aesthet Surg 2020;73:1348-56.  Back to cited text no. 6
    
7.
Stahel, P.F. How to risk-stratify elective surgery during the COVID-19pandemic?. Patient Saf Surg, (2020;14:8. https://doi.org/10.1186/s13037-020-00235-9.  Back to cited text no. 7
    
8.
Singh AK, Misra A. Impact of COVID-19 and comorbidities on health and economics: Focus on developing countries and India. Diabetes Metab Syndr 2020;14:1625-30.  Back to cited text no. 8
    
9.
Ai T, Yang Z, Hou H, Zhan C, Chen C, Lv W, et al. Correlation of chest CT and RT-PCR testing for coronavirus disease 2019 (COVID-19) in China: A report of 1014 cases. Radiology 2020;296:E32-40.  Back to cited text no. 9
    
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11.
Wong J, Goh QY, Tan Z, Lie SA, Tay YC, Ng SY, et al. Preparing for a COVID-19 pandemic: A review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anaesth J Can Anesth 2020;67:732-45.  Back to cited text no. 11
    
12.
Dash S, Das R, Saha S, Singhal M. Plastic surgeons and COVID-19 pandemic. Indian J Plast Surg 2020;53:191-7.  Back to cited text no. 12
    
13.
Chi D, Chen AD, Dorante MI, Lee BT, Sacks JM. Plastic surgery in the time of COVID-19. J Reconstr Microsurg 2020;37:124-37.  Back to cited text no. 13
    
14.
Agarwal R, Singhal M, Shankhdhar VK, Chittoria RK, Sahu RK, Singh V, et al. Plastic surgery practices amidst global COVID-19 pandemic: Indian consensus. J Plast Reconstr Aesthet Surg 2021;74:203-10. doi:10.1016/j.bjps.2020.08.003.  Back to cited text no. 14
    
15.
Cho DY, Yu JL, Um GT, Beck CM, Vedder NB, Friedrich JB. The early effects of COVID-19 on plastic surgery residency training: The University of Washington experience. Plast Reconstr Surg 2020;146:447-54.  Back to cited text no. 15
    
16.
Kumar S, More A, Harikar M, Dharini. The impact of COVID-19 and lockdown on plastic surgery training and practice in India. Indian J Plast Surg 2020;53:273-9.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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