The response to COVID 19: a journal of the initial institutional experience of general surgical units at the National Hospital of Sri Lanka, Colombo

Sri Lanka is no stranger to calamities, man-made or otherwise. It has weathered a civil war of thirty years, the Boxing Day tsunami and the Easter Sunday bombings just a year ago. The country has paid a colossal price in human lives, material losses and attendant adverse socio-economic consequences. The COVID 19 pandemic, declared by the World Health Organisation (WHO) 7 weeks ago, is the latest, and probably one of the gravest challenges to the nation in general and the health services in particular.

Ÿ Designation and organisation of hospital infrastructure and spaces in conformity with safety recommendations and education of all HCWs on enhanced safety precautions to be taken to minimise infection and transmission Ÿ Streamline manpower utilisation to minimise potential infection of HCWs leading to the subsequent shortage or absence of essential personnel Ÿ Conservation and building capacity of personal protective equipment (PPE), essential drugs and surgical consumables to provide continuity of care for critically ill and emergency patients at the very least. With the subsequent designation of the NHSL as a non-COVID 19 hospital, this extended to be able to sustain cancer surgery and procedures to prevent limb or organ compromise or loss Ÿ Institute the above while maintaining essential medical services and emergency care The initial meeting of surgeons and anaesthetists took place on 20th March 2020. Key recommendations that were instituted in concurrence with the Director, NHSL included: Ÿ All surgical and anaesthetic teams would work on a weekly rota basis to reduce non-essential staff Ÿ The male and female general surgical casualty admissions will continue to ward 33 and the respective unit's female ward as before Ÿ Diagnosed or suspected COVID 19 surgical patients to be managed in ward 31 (Christian priest ward) and ward 24 (Buddhist priest ward) Ÿ Surgery will be restricted to urgent or emergency procedures only Ÿ Theatre sessions to be limited to one per day i.e. from 8 am to 2 pm except under exceptional circumstances Ÿ Only the main table will be used in all surgical theatres Ÿ Theatre designation: Ÿ Operating theatres A and B (OTA & OTB) will be closed Ÿ All general and GI surgical units will share operating theatre D (OTD) for emergency procedures Ÿ Any diagnosed or suspected COVID 19 surgical patient will be operated in OTD Ÿ Casualty surgical theatre (GCOT) to function as normal Subsequently, a committee appointed by the Director, NHSL proposed several recommendations with regard to conducting outpatient clinics on the 27th March 2020 (see below). outpatient clinics to prescribe medication for longer periods of up to a month.
With uncertainty around the conduct of clinics, postoperative patients and others who required follow-up including wound dressings were advised to present directly to their respective wards for review.
The nursing staff in surgical wards augmented safety measures, placing hand-sanitisers at the entrance and regular intervals in the wards with clear instructions to remind staff to use them (Fig 1). In some units, nurses replaced their standard uniforms and donned theatre scrubs (Fig 2). Washbasins were placed outside surgical wards for patients and visitors to wash their hands prior to entry.
All elective and emergency admissions to surgical wards were administered a COVID 19 questionnaire (Supplementary 2) to screen for patients at high risk of infection and referral to the Infection Control Unit for a PCR test.

Outpatient clinics
Routine clinics continued to function though with a drastic reduction in patient attendance due to the curfew and the corresponding temporary closure of the VS OPD clinic. Patients who did not require urgent attention and high-risk category patients (Elderly > 60 years, immunosuppressed and those with malignancies) were discouraged from attending clinics. A proposal to issue routine medication directly from OPD pharmacies without clinic attendance was abandoned owing to concerns expressed by the pharmacists. However, arrangements were made to issue patients two months of medication on any day of the week provided it was authorised by the unit doctor. Subsequently, on a Ministry directive, medication was packed and posted to the homes of the patients. Two hotlines with WhatsApp facilities were established in surgical clinics enabling patients to contact staff and send images of their prescription.
A major concern was the lack of access to specialist surgical care for new patients in the community with potential malignant and other surgical disorders that required expedited management. This was compounded by their inherent fear of visiting hospital in the current circumstances.
In an attempt to address this, two telephone hotlines were established in the VS OPD to receive calls from the public. Communiques in all three languages were printed in state media advising those with 'red-flag' symptoms to contact these numbers for advice. Medical officers at VS OPD clinic would then be able direct them directly to the relevant surgical clinic of the day. (Supplementary 3) On 3rd April, following a two-week period, surgeons and anaesthetists reviewed the situation, and recommended commencement of limited elective surgery from 6th April 2020. This was for malignancies and other surgical conditions where delay could result in significant morbidity and mortality such as organ dysfunction or limb loss.
The basis for their revised recommendation was: Ÿ The NHSL was designated as an institution that will not cater to diagnosed COVID 19 patients and as such no such elective admissions will take place to the wards or ICUs Ÿ A surge of COVID 19 cases, ICU admissions or resultant mortality had not been observed nationally over the past two weeks Ÿ Anecdotal reports suggested a rise in non-COVID 19 related morbidity and probably mortality in excess of the COVID 19 cohort Ÿ Indefinite delay could result in malignancies becoming inoperable or causing complications, in addition to the untold psychological stress and suffering from uncertainty of future care The seven General Surgical Units, the Gastrointestinal Surgery Unit, the University Surgical Unit and the University Gynaecological Unit shared 10 theatre sessions on weekdays utilising all three theatre complexes from 8 am to 2 pm. Flexibility between units to share theatre sessions depending on case load enabled maximum utilisation of the available time.

Theatre complexes
In the initial two weeks, two general surgical theatre complexes OTA & OTB were closed. The general surgical casualty theatre (GCOT) continued to function normally. The third general surgical theatre complex (OTD) was reserved for all emergency surgery including surgery on COVID 19 suspected or confirmed patients.
Operating theatres were provided guidelines for ensuring the safety of HCWs in theatre (Supplementary 1).
Following the decision to re-start cancer surgery and other essential elective procedures each general surgical unit was allocated one theatre list per week from 8 am to 2 pm with the facility to extend if necessary. This allowed most postponed cancer procedures to be completed.

Wards & in-patient care
All non-essential admissions were curtailed from the second week of March. Most in-patients were managed and discharged on medication for up to a week, where appropriate. If required, patients were pre-registered in 47 The Sri Lanka Journal of Surgery 2020; 38(1): 46-53 The debate though on the safety of laparoscopy continues with the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association of Endoscopic Surgery (EAES) endorsing its use provided appropriate safety precautions are followed. These include small port incisions to prevent leakage, minimum CO2 insufflation pressures and safe evacuation of the pneumoperitoneum via a filtration system before closure, trocar removal, specimen extraction or conversion to open.

Personal protective equipment (PPE)
To complement stocks provided by the Ministry of Health, significant quantities of protective equipment were produced on site. Polyethene overalls were sewn by members of the infection control unit, orderlies of surgical wards and theatres working together using raw material available in the hospital and donated by well-wishers (Fig 4). High quality protective visors were made by the infection control unit in addition those donated by well-wishers (Fig 5). Fluid resistant surgical face masks were made available for all hospital staff. However, availability of N 95 respirators was limited and issued to front-line high-risk staff only. Subsequent donations of N 95 respirators contributed significantly towards establishing baseline supply in theatres, casualty wards and endoscopy units to be used in high risk situations.
Prioritisation, pragmatism and education remain the cornerstones of optimal utilisation of the limited supply of PPEs and minimising wastage.

Undergraduate and postgraduate training
The NHSL, Colombo is the biggest medical undergraduate and postgraduate training centre in the country. With the advent of the COVID 19 crisis the Faculty of Medicine, Colombo was closed, and students returned home. Postgraduate surgical training too was severely curtailed with the reduction in patient numbers and the curtailment of elective surgery. However, both undergraduate and postgraduate training continues with online sessions using platforms such as Zoom.

Institutional initiative
The NHSL, Colombo has thus far exemplified a proactive, cohesive and dynamic response at institutional level to a national challenge of yet unknown dimensions within the constraints of the available resources. It has demonstrated that the coordinated efforts of clinicians, nurses, healthcare staff and administrators are capable of developing institutional guidelines and actions prior to Ministry of Health directives. This was borne out by the fact that subsequent Ministry of Health directives mirrored what was already in practice at the NHSL. There are anecdotal reports of surgical units in other hospitals also adopting the NHSL guidelines. Based on their risk status, patients were categorised into those whose COVID 19 status was unknown or low-risk and those who were diagnosed with or strongly suspected to have COVID 19 infection. It was recommended that 'full PPE' was used for the latter group which in practice meant use of N95 respirators in addition to the standard protection kit (Fig 3).
Once the decision to re-commence cancer surgery and other essential elective surgery on 6th April 2020 was made, several measures were proposed to minimise inadvertent exposure of HCWs, especially operating theatre staff to infected patients.

Endoscopy
Being a high-risk procedure for aerosol generation, routine endoscopy lists were halted. It was continued though for acute gastrointestinal bleeds, suspected malignant lesions and stenting in obstruction. ERCP lists were operated by the Gastroenterology Unit for patients who required urgent or early biliary decompression.

Laparoscopy
In keeping with the guidance issued by the joint Royal Colleges of Surgeons of the UK, AUGIS and the American College of Surgeons, laparoscopic surgery was discouraged in the interim period. Aerosolization of blood borne virus particles by the increased pneumoperitoneal pressure was the concern behind this recommendation.     While directives and guidelines from the Ministry of Health are essential for an organised national effort, institutional guidelines facilitate their adaptation to local circumstances. This is because hospitals are heterogenous in terms of geography, accessibility, facilities, manpower, available specialities and the population catered to.

The way ahead and an exit strategy
If global and local trends are anything to go by, the medical profession at large is still struggling to size up this virus and the disease. Many unanswered questions remain with regard to the heterogeneity observed in disease prevalence, demography, presentation, morbidity and mortality. The answers probably lie in the complex interaction between factors both genetic and environmental; viral strains, host innate and adaptive immunity, population density, patterns of mobility, climate and a host of yet undetermined factors.
Nations have employed social distancing, aggressive testing, contact tracing, geospatial technology, enforcement of quarantines and national lockdowns in conjunction with capacity building of health services to tackle the crisis. The image crystallising before us hints that each nation will have to strike its own path through this crisis using these strategies in varying proportions based on their disease burden and economic realities. It is highly likely that in hindsight, the direct medical consequences this virus are likely to be dwarfed by longer lasting and more serious secondary problems.
Seven weeks since the pandemic declaration, tropical nations including Sri Lanka have been fortunate to escape the worst effects of COVID 19 ravaging Europe and the USA. While the reasons for this remain largely unknown, taking advantage of this position, tentative steps are being advanced towards an exit strategy from the lockdown.
A significant concern is the plight of patients with non-COVID surgical disorders. The true impact on this group in terms of morbidity and mortality due to delayed and suboptimal care will probably be only known much later.
With the designation of other institutions to manage COVID 19 patients, the NHSL as the largest multi-specialty tertiary healthcare institution in the country should take a leading role in providing specialist care to patients with non-COVID conditions. The guiding principles of this measured yet steady process should be the safety of HCWs and patients, capacity maintenance and enhancement and most importantly the delivery of quality surgical services expected of this institution.
Paradoxically, the advent of this crisis has also allowed for reflection of the organization and delivery of surgical services at NHSL and promises to be a stimulus for improving efficiency.