Adaptations in the Vascular Surgery Department of the CHULN during the COVID-19 pandemic and impact on overall activity

132 Angiologia e Ci u gia Vascula / Publicação O icial SPACV / www.ac jou nal.com *Au o pa a co espondência. Co eio ele ónico: An oniomdua [email protected] (A. Dua e). An ónio Dua e*, Ryan Melo, Alice Lopes, João Ra o, Ma a Rod igues, Mickael Hen iques, Miguel Gomes, Vanda Pin o, Ka la Ribei o, Emanuel Sil a, Ma iana Mou inho, Ped o Ga ido, Vi iana Manuel, Augus o Minis o, Gonçalo Sob inho, Luís Sil es e, Ped o Amo im, Ruy Fe nandes, Nuno Mei eles, Ca los Ma ins e Luís Mendes Ped o Se iço de Ci u gia Vascula , Depa amen o de Co ação e Vasos, Cen o Hospi ala Uni e si á io Lisboa No e (CHULN), Lisboa, Po ugal. Faculdade de Medicina da Uni e sidade de Lisboa, Po ugal Cen o Académico de Medicina de Lisboa ADAPTAÇÕES NO SERVIÇO DE CIRURGIA VASCULAR DO CHULN DURANTE A PANDEMIA DE COVID-19 E IMPACTO NA ATIVIDADE GLOBAL EDITORIAL ADAPTATIONS IN THE VASCULAR SURGERY DEPARTMENT OF THE CHULN DURING THE COVID-19 PANDEMIC AND IMPACT ON OVERALL ACTIVITY Pala as-cha e COVID-19; pandemia; ci u gia ascula ; su o; SARS-CoV-2 Keywo ds COVID-19; Pandemic; ascula su ge y; ou b eak; SARS-CoV-2 RESUMO Com o su gi da pandemia a SARS -CoV-2 no início de 2020, os se iços de saúde so e am á ias adap ações de o ma a mi iga e con ola a p og essão do su o a ní el eu opeu e nacional. Es es ajus es epe cu i am-se ine i a elmen e na dinâmica da maio ia dos se iços hospi ala es, nomeadamen e no nosso se iço de Ci u gia Vascula . Pe an e a p e isí el chegada de uma segunda aga na Eu opa e em Po ugal, com des echos e epe cussões imp e isí eis nos se iços de saúde, é undamen al ap ende com as expe iências an e io es e pa ilha es a égias pa a p es a o melho cuidado aos nossos doen es, apesa das es ições impos as pela pandemia. A a és des e a igo, analisamos as adap ações no Cen o Hospi ala Uni e si á io Lisboa No e pa a supe a a pandemia e, em pa icula , no se iço de ci u gia ascula . A aliamos ainda o impac o dessas mudanças na nossa a i idade global, em compa ação com a expe iência i enciada nou os cen os nacionais e in e nacionais. Pe an e uma segunda aga iminen e, é c ucial i a lições des a pandemia po o ma a e i a uma po encial c ise na saúde. ABSTRACT Wi h he onse o he SARS-CoV-2 pandemic in ea ly 2020, heal h se ices and pe sonnel adap ed hei esou ces o mi iga e and con ol he ou b eak. These needs ine i ably led o adap a ions in mos medical and su gical depa men s, including in ou Vascula Su ge y depa men . As we a e acing a second ou b eak o his pandemic, wi h unp edic able ou comes and epe cussions in heal h se ices, i is c ucial o lea n om p e ious expe iences and sha e s a egies o pe o m he bes ca e o ou pa ien s, despi e he es ic ions ha ha e been imposed. Th ough his pape , we e iew he adap a ions in Cen o Hospi ala Uni e si á io Lisboa No e and pa icula ly in ou depa men o o e come he pandemic. We also assess he impac o hese changes in ou ac i i y and compa e wi h he expe ience o o he ellow su geons. Wi h an upcoming second ou b eak, i is c ucial o lea n om his and o he depa men s’ expe iences o o e come a po en ial heal h c isis. Núme o 03 / Volume 16 / Se emb o 2020 local ou b eak and some doc o s had also a basic ICU aining. Ou medical s a was di ided in wo sepa a e eams. Each eam pe o med p esen ial wo k e e y wo weeks unde all sa e y p ecau ions in o de o educe i us ansmission ac oss ou pe sonnel. In addi ion o his eo ganiza ion, one esiden was ealloca ed o a COVID -19 speci ic wa d and one senio assis an s ayed a home, acco ding o a decision om he Head o he Vascula Depa men . Fu he mo e, 6 membe s o ou nu se pe sonnel we e ealloca ed o o he uni s, including COVID -speci ic wa ds. All 6 membe s se ed as leade s in hei espec i e eams. Addi ionally, ou wa ds we e con e ed in o COVID-speci ic ICU uni s and ou pa ien s we e admi ed in he Ca diology and Ca dio ho acic Depa - men s, leading o a dec ease in ou o al capaci y. We also c ea ed a e e al guide o ascula eme gencies du ing nigh shi s ( able 1 ). All medical and nu se membe s ul illed all sa e y and p o ec ion ecommenda ions. So a , we epo ed no posi i e SARS -CoV-2 case in ou depa men . THE VASCULAR SURGERY ACTIVITY DURING THE PANDEMIC FIRST OUTBREAK. Acco ding o he Po uguese Medical Associa ion ecom- menda ions o he COVID-19 pandemic, all non-eme gen su gical ac i i y was supp essed o educed. All he eme gen su gical ac i i y was main ained in he cen al eme gency hea e. Howe e , as he a ailabili y o he elec i e OR o non-eme gen cases was ma kedly educed, we ocused on u gen cases, namely symp oma ic ca o id s enosis, abdominal ao ic aneu ysms wi h diame e highe han 5,5cm and ch onic limb- h ea ening ischemia pa ien s wi h a high isk o ampu a ion. (2) Mo eo e , we pe o med mo e endo ascula su ge ies wi h he collabo a- ion o he Radiology depa men and used mo e equen ly pe cu aneous accesses and local o loco egional anes hesia. This s a egy was ound o be bene icial because o a lesse isk o ae osol-gene a ing p ocedu es and c oss-in ec ion, as well as he possibili y o mo e blood p ese a ion.(3) This p io i iza ion s a egy was also adop ed by depa men s in o he coun ies highly a ec ed by he pandemic and epo ed in he li e a u e. In I aly, Pini and colleagues ocused on eme gency and acu e su gical cases while main aining he same s anda d o ca e and sa e y o hei pa ien s.(4) In Tu key, Ünal and colleagues de ined a g oup o 4 le els o p io i y o dis inguish eme gen and u gen cases om de e able su ge ies, hence imp o ing he decision-making p ocess in hei clinical p ac ice.(3) In ou depa men , simila ly o o he g oups, all pa ien s, whe he elec i e o u gen , we e es ed o SARS-CoV-2. Pa ien s deemed o g ea e eme gency we e assumed o be INTRODUCTION A no el espi a o y i us ou b eak sp ead om he p o ince o Wuhan, China in ea ly 2020.(1) Wi h he onse o he SARS-CoV-2 pandemic, heal h se ices and pe sonnel ocused hei e o s and esou ces on mi i- ga ing he ou b eak and con olling he sp ead o cases. These needs ine i ably led o adap a ions in mos medical and su gical depa men s, including in ou Se ice o Vascula Su ge y.(2) As we a e acing a second ou b eak o his pandemic, wi h unp edic able ou comes and epe cussions in heal h sys ems, i is c ucial o lea n om p e ious expe iences and sha e s a egies o pe o m he bes ca e o ou pa ien s, despi e he es ic ions ha ha e been imposed. The aim o his pape is o epo he impac o he COVID-19 pandemic in he su gical se up and ac i i y o ou Vascula Su ge y depa men . HOW DID THE CENTRO HOSPITALAR UNIVERSITÁRIO LISBOA NORTE (CHULN) REACT TO THE COVID-19 PANDEMIC? In Ma ch 2020, Po uguese heal h au ho i ies issued a se ies o ecommenda ions o pe sonnel and esou ces’ eo ga- niza ion. These adap a ions we e mi o ed by he CHULN adminis a i e boa d. Fi s , all pe sonnel we e alloca ed o con ingency g oups, should he e be a need o mo e p o es- sionals in he on line. Fu he mo e, esiden s in aining p og ams in o he depa men s we e called back o hei na i e se ices. Howe e , esiden s wo king in COVID -19 uni s and ICU acili ies con inued hei in e nships o espond o he ou b eak. COVID-19 and COVID-19 ee ci cui s we e c ea ed o cope wi h inpa ien admissions and he Gynecology ope a ing oom was con e ed o su gical p ocedu es o SARS-CoV-2 posi i e pa ien s o u gen pa ien s awai ing esul . Pa ien s we e admi ed o he sho es pe iod necessa y and immedi- a ely discha ged i no u he ea men was needed. Visi s o inpa ien s we e supp essed o a oid c oss-in ec ion om he isi o s. All pa ien s solely awai ing complemen a y exams we e also discha ged. Las ly, p esen ial ou pa ien isi s we e educed, wi h p io i y o u gen cases and s ic ly necessa y ac s. Physicians we e encou aged o pe o m non-p esen ial isi s o mos pa ien s. HOW DID OUR VASCULAR SURGERY DEPARTMENT REACT TO THE COVID-19 PANDEMIC? In ou depa men , he medical s a ecei ed aining in pe sonal p o ec ion equipmen wea ing in he e en o a A. Dua e e al. 134 Angiologia e Ci u gia Vascula / Publicação O icial SPACV / www.ac jou nal.com Adap ações no se iço de Ci u gia Vascula do CHULN du an e a pandemia de COVID-19 e impac o na a i idade global hospi al and con ac ing a SARS-CoV-2 in ec ion. Indeed, Rausei and colleagues epo ed a 45% dec ease in he numbe o eme gency su gical admissions in one o he mos a ec ed zones by he pandemic in I aly. The au ho s ela e hese ou comes o a ea o each he ER o a oid in ec ion, as well as a esul o he con inemen measu es. (5,6) A simila conclusion ega ding eme gency admissions was d awn in a publica ion om a majo hospi al in Opo o.(7) Ne e heless, con a y o hei expe ience, we did no obse e a highe dec ease in elec i e a e ial su ge y. Rega ding ou pa ien clinics, we pe o med less han 50% o he a e age numbe o episodes be ween Feb ua y and June 2018 and 2019. Addi ionally, we s a ed pe o ming non-p e- sen ial ac s. We pe o med signi ican ly mo e consul s ia phone calls, p edominan ly o ollow-up appoin men s. This adap a ion was a di ec consequence o he con inemen pe iod and he ise o elemedicine clinical ac s. Simila s a - egies we e adop ed in o he Eu opean coun ies, such as I eland. (8) A case epo om an Ame ican heal h sys em epo ed a sha p ise in elemedicine isi s close o 700%.(9) Con a y o he au ho s’ expe ience, who pe o med ele- medicine isi s bo h o eme gency and elec i e cases, we main ained p esen ial isi s o u gen and p io i y cases. Ano he g oup in Washing on also epo ed mo e han 50% o all consul s we e pe o med wi h elemedicine ools, wi h he gene al accep ance om hei pa ien s.(10) F om Feb ua y o June 2020, ou wa d o al capaci y dec eased om 32 o a minimum o 7 hospi al beds in Ap il, o 18 in June 2020. Despi e he sho age in ou wa d capaci y, he a e age du a ion o hospi al leng h o s ay was sho e du ing he COVID-19 pandemic. In a le e o he edi o , Fa oha obse ed a simila dec ease in he leng h o s ay o pa ien s in a bu n cen e .(11) In ou depa men , we belie e his may be explained by a highe a e o less in asi e, endo- ascula p ocedu es and mo e egula use o pe cu aneous access, as well as a sho e ime om admission o su ge y. Fu he mo e, ea ly discha ges we e mo e equen du ing his pe iod and pa ien s needing mo e complex wound ca e we e ans e ed o ano he acili y wi hin ou uni e si y cen e (Hospi al Pulido Valen e). Consequen ly, we ine i- ably admi ed mo e pa ien s wi h less se e e condi ions o p ocedu es, and less pa ien s wi h mo e complex p ocedu es, wi h longe leng hs o s ay. This la e popula ion emains one o ou main challenges and conce ns o a likely second ou b eak o his pandemic. Despi e he dec ease in hospi al beds and in he numbe o admissions, ou mo ali y a e did no inc ease when compa ing wi h p e ious yea s. This may be in e p e ed as a esul o he changes in p ac ice and he abili y o main ain he bes ca e o ou pa ien s wi h he coope a ion o he SARS-CoV-2 posi i e and submi ed o su ge y in a COVID-spe- ci ic ope a ing oom.(2) O e all, du ing he i s pandemic ou b eak, we epo ed a ela i e inc ease in he numbe o elec i e admissions while he numbe o eme gency episodes signi ican ly dec eased. This educ ion may be explained by a ea o going o he Table 1 Re e al c i e ia o Vascula Su ge y e alua ion in he ER in Cen o Hospi ala Uni e si á io Lisboa No e Re e al c i e ia o immedia e e alua ion by Vascula Su ge y Rup u ed o symp oma ic ao ic aneu ysm Complica ed ype B ao ic dissec ion Acu e limb ischemia Acu e-on-ch onic limb ischemia Vascula auma Hemo hage ollowing ascula in asi e p ocedu es Acu e mesen e ic ischemia Renal ischemia Lowe limb compa men synd ome Phlegmasia alba/phlegmasia ce ulea dolens Hemodyalisis AVF- ela ed complica ions (ongoing hemo hage, sep ic shock wi h AVF in ec ion) Re e al c i e ia o de e ed e alua ion by Vascula Su ge y Ch onic limb ischemia (c i ical limb ischemia only; e e o Vascula Su ge y ou pa ien clinics Le iche-Fon aine class II) Foo in ec ion Non-complica ed deep ein h ombosis Supe icial h ombophlebi is Supe icial h ombophlebi is AVF: a e io enous is ula; de e ed e alua ion: du ing he 8h-20h eme gency shi . Da a a ailable in e e al di ec i es “C i é ios pa a e e enciação de doen es pa a obse ação di e ida na u gência cen al do CHLN no âmbi o da especialidade de Angiologia e Ci u gia Vascula ”; “C i é ios pa a e e enciação de doen es pa a obse ação imedia a na u gência cen al do CHLN no âmbi o da especialidade de Angiologia e Ci u gia Vascula ” Núme o 03 / Volume 16 / Se emb o 2020 A. Dua e e al. o he Se ices o he Depa men (Ca diology and Ca dio- ho acic Su ge y). Ne e heless, we canno exclude an inc ease in ou -o -hospi al mo ali y du ing he pandemic. Th ough he analysis o Po uguese da a se s be ween Ma ch and Ap il 2020, Noguei a and colleagues es ima ed an excess mo ali y o 2400 o 4000 dea hs.(12) Acco ding o he au ho s, his inc ease canno be ully accoun ed o he inc ease in COVID-19 ela ed dea hs and may be ela ed o a dec ease in heal hca e access and an inc ease in he se e i y o non-COVID 19 condi ions. We a e deeply wo ied ha an unknown numbe o ou pa ien s migh be unable o ge adequa e access o he heal h sys em, ei he h ough hei own ea o coming o he hospi al o di icul y in he p ima y ca e access and p ope imely e e al. CONCLUSIONS The COVID-19 pandemic led o signi ican changes in hospi al ca e, including in ou Vascula Su ge y depa - men . Following pe sonnel ealloca ions and a dec ease in hospi al beds o espond o he ou b eak, we dec eased ou numbe o admissions and ou pa ien isi s. Despi e hese es ic ions, we in oduced non-p esen ial clinical ac s and ocused on eme gency and p io i y cases. This allowed us o main ain he bes s anda d o ca e wi hou an inc ease in ou pa ien s’ in-hospi al mo ali y a e. Wi h an upcoming second ou b eak, i is c ucial o lea n om his and o he depa men s’ expe iences o o e come a po en ial heal h c isis. Fu he s udies need o assess he ue long- e m impac o he pandemic on ch onic condi ions, namely ch onic limb- h ea ening ischemia o ao ic aneu ysmal disease. 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