Second COVID-19 wave conveys continuing uncertainty for vascular surgery

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As 2020 draws to a close, many countries across the globe face continuing challenges arising from COVID-19. At this year’s European Society for Vascular Surgery (ESVS) annual meeting, held virtually as biweekly webinars as ESVS Month (29 September–29 October), the organisation of hospitals during the pandemic was on the agenda. Speakers from Finland, Germany, Italy, and the UK detailed the situation in their respective countries, providing a snapshot of vascular surgery over the past nine months, sharing key details and learnings, and considering what lies ahead.

“We do not have a common strategy for all the hospitals in Finland, but all hospital districts have their own plan,” began Maarit Venermo (Helsinki University Hospital and University of Helsinki, Helsinki, Finland), who detailed the organisation in the biggest hospital district in Finland—Helsinki, Uusimaa.

Venermo noted that the number of cases in Finland so far has been relatively low compared to the other countries being discussed during the ESVS webinar, citing fewer inhabitants as one of the reasons. While the population of Finland is 5.5 million, those of the UK, Italy, and Germany are at least 10 times higher, at 68 million, 60 million, and 84 million, respectively. “Maybe there is a natural distancing,” Venermo suggested.

Addressing online viewers, Venermo explained that additional staff training was implemented for those treating COVID-19 patients. In the emergency clinic, for example, the workforce received training on identifying acute respiratory failure, assessing the need for treatment, and starting treatment for COVID-19 patients.

Regarding staff transfers, Venermo detailed that approximately 1,500 employees were reassigned to another unit, with the biggest staff transfers made from different departments/hospital areas to the drive-in testing stations and to inpatient and intensive care units treating COVID-19 patients.

Considering the impact of the pandemic on non- COVID-19 treatment, Venermo expressed concern. “How many aneurysm rupture patients did not seek care because of COVID-19?” she asked rhetorically, noting that there was a dramatic decrease in the number of surgical operations performed from February to April 2020. In addition, Venermo reported that the total number of appointments was around 100,000 less in the March and April 2020 compared to the same period the year previously.

In conclusion, the first wave of COVID-19 in Finland was managed “successfully,” Venermo relayed, with Helsinki and Uusimaa hospitals able to arrange the appropriate facilities quickly, and there being more than enough capacity for COVID-19 patients.

“Only the future will show us how serious the second wave will be,” Venermo postulated, ending on the note that analysis of the damage caused by COVID-19 is yet to come, and, “we may never find out” the consequences for those needing treatment for reasons other than COVID-19.

Germany: A timeline of events

Next to speak was Eike Sebastian Debus (University Heart & Vascular Center Hamburg-Eppendorf, Hamburg, Germany), who informed online viewers about the organisation of hospitals in Germany, focusing on his centre in particular, during the pandemic.

Debus detailed the situation via a timeline, first detailing the situation in the country as a whole, before honing in on the University Heart & Vascular Center Hamburg- Eppendorf.

For the hospital, the timeline began in January, with an early emphasis on testing. Debus detailed that the microbiology laboratory in the hospital began to offer daily COVID-19 virus diagnostics. Then, in February, the Institute for Medical Microbiology, Virology and Hygiene was able to detect the virus in a sample within a few hours, which coincided with the first case of a COVID-19 infection in Hamburg.

A daily COVID-19 task force was initiated, and in March a series of clinical research projects were started. These included the Hamburg City Health Study, in which adults and children were tested for antibodies.

In April, the Clinic for Intensive Care Medicine (KIM) was built, with 154 beds. This was to be maintained until the end of May, at which time a vaccine study began.

In August, wearing a face mask in the hospital became mandatory, and it was announced that visiting doctors, students, and interns were not allowed to work at the hospital until the end of the month.

“Cases are rising in Germany,” Debus said, adding that an increase of infected patients is expected imminently at the University Heart & Vascular Center Hamburg-Eppendorf. He ended with a note of uncertainty: “We do not know how things will develop further”.

Maintenance of elective vascular surgery is possible, Italian study finds

Describing the situation in Italy, Mauro Gargiulo (University of Bologna and University Hospital Policlinico S Orsola, Bologna, Italy) was next to speak.

He outlined a report from the Italian Society of Vascular Surgery (SICVE) on the impact of the COVID-19 pandemic on the activities of vascular surgery in the country, detailing results of prospective data from 154 units of vascular surgery collected weekly from 30 March–5 April.

Gargiulo reported that in the first week there was an 80% reduction of beds and an 84% reduction of operating rooms for elective surgical activities. In addition, 43% of hospitals were conducting no elective surgery, with only 5% reporting no reduction of elective surgery.

Then, Gargiulo spoke about the impact of the pandemic on the activities of the Metropolitan Unit of Vascular Surgery in Bologna (Emilia-Romagna region). He noted that Emilia-Romagna had second highest level of documented cases of COVID-19 infections in Italy, after Lombardy.

The healthcare system of the city of Bologna maintained elective surgical activities of cardiac, oncological, and vascular surgery, he reported. Gargiulo reported that in the period of the Pandemic the Metropolitan Vascular Surgery of Bologna worked on two tertiary hospitals in the Bologna, which offered service for five peripheral hospitals.

In a study recently published in the European Journal of Vascular and Endovascular Surgery, Gargiulo and colleagues set out to evaluate the protocols for COVID-19 infection prevention and surgery activities.

The research team asked the question: Is it possible to safely maintain elective vascular surgery activity during the COVID-19 pandemic? According to the experience of the Metropolitan Unit of Vascular Surgery at the University of Bologna, the answer is ‘yes’, if an efficient safety protocol can be set to minimise the risk of infections for patients and physicians, and the choice of elective surgical intervention is one with a low impact on hospital resources and scarce or no need for postoperative intensive care.

Concern from London: “We have no idea how much trouble we are in now”

Opening a presentation on the organisation of hospitals in the UK during COVID-19, Mark Tyrrell (Guy’s and St Thomas’ NHS Foundation Trust, London, UK) highlighted a specific problem: “the ‘United’ Kingdom is not a single, homogenous entity”. In fact, the UK comprises four distinct, semi-autonomous countries, with a mix of urban and rural areas, and “huge wealth disparity,” he told viewers.

In addition, “the current model of distribution of vascular care means that it really is not possible to accurately describe one response and one outcome,” Tyrrell explained.

In the UK, vascular surgery is centralised and operated under a “Hub and Spoke” model, consisting of mainly city centre Hubs and town centre Spokes.

“What I am going to share is very London-centric,” Tyrrell specified, informing ESVS webinar viewers that if they need a wider UK view, there are various reports on the Vascular Society for Great Britain and Ireland website.

Tyrrell detailed that at St Thomas’ Hospital in London, vascular operating sessions fell from 15 per day plus emergencies to two per day in total. Emergencies were dealt with on the main site, but not electives; an off-site COVID-19-free service for urgent electives was established at London Bridge Hospital. Thresholds to surgery were reset, and a rigorous multidisciplinary daily meeting process was initiated to prioritise cases. Patient clinics stopped, with telephone clinics introduced as a replacement, and the Emergency Vascular Clinic moved to Guy’s Hospital.

Tyrrell detailed that all elective surgery stopped, and that emergency activity fell “precipitously”.

In the period from March through to June, there were six consecutive days with zero admissions and 37 total days with zero admissions. Three ruptured aortic aneurysms were turned down due to no capacity during this period, Tyrrell relayed.

Ending his presentation, Tyrrell expressed concern due to a national knowledge deficit based on “virtually non-existent” antigen testing and “initially non-existent” antibody testing. Because of this knowledge deficit, “we have no idea how much trouble we are in now”.


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