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Impact of hospital lockdown secondary to COVID-19 and past pandemics on surgical practice: A living rapid systematic review

Background The COVID-19 pandemic has disrupted surgical practice worldwide. There is widespread concern for surgeon and provider safety, and the implications of hospital lockdown on patient care during epidemics. Methods Medline, EMBASE, CENTRAL, and PubMed were systematically searched from database inception to July 1, 2020 and ongoing monthly surveillance will be conducted. We included studies that assessed postoperative patient outcomes or protection measures for surgical personnel during epidemics. Results We included 61 studies relevant to the COVID-19 pandemic and past epidemics. Lockdown measures were noted globally including cancellation of elective surgeries and outpatient clinics. The pooled postoperative complication rate during epidemics was 21.0% among 2095 surgeries. 31 studies followed the health of surgical workers with the majority noting no adverse outcomes with proper safety measures. Conclusions This review highlights postoperative patient outcomes during worldwide epidemics including the COVID-19 pandemic and identifies specific safety measures to minimize infection of healthcare workers.


Introduction
The current COVID-19 pandemic has disrupted health services worldwide. 1,2 There is a concern of nosocomial transmission, shortage of personal protective equipment (PPE), and limited resources for critical patients. 3e6 As a result, many hospitals have undergone lockdown procedures in which staffing and services are limited. These lockdown procedures have inconsistent policies, often occurring on an urgent basis with little notice or preparation. In previous outbreaks such as severe acute respiratory syndrome (SARS) and Ebola, these precautionary measures have lasted several months with downstream effects on health outcomes. 7,8 Surgical practice is particularly at risk for lockdowns during outbreaks and epidemics. 9 In particular, there may be a heightened risk for transmission of airborne pathogens during aerosolizing procedures in laparoscopic surgeries, though current evidence is unclear. In addition, there is risk of transmission of blood-borne viruses such as Ebola during accidental injuries. 9,10 Operation techniques and equipment management may also be altered to reduce contact with potential vectors. 9 In addition, intensive care units and emergency departments are often overwhelmed with critical care patients, with a limited supply of ventilators and bedspace. 4 As such, the Centers for Disease Control and Prevention recently published an interim recommendation that all elective procedures should be cancelled during the COVID-19 pandemic. 11 Surgical residents and staff may also be diverted to other specialties to provide frontline care if needed, as hospital volumes drastically increase. 9,12 While there are numerous guidelines and editorials on the topic, there has not yet been a systematic assessment of the literature regarding surgical care and epidemics. Our living rapid systematic review aims to assess all research literature related to changes in surgical practice during disease outbreaks and epidemics, especially during the current COVID-19 pandemic.

Outcomes
The primary research question for the review was to investigate the impact of epidemics on surgical outcomes of patients undergoing urgent or elective surgery amidst periods of hospital lockdown. The specific outcomes included: (1) the number and type of surgical procedures performed during lockdowns (urgent, elective, or oncologic) (2) the number of non-OR procedures performed and its complications (3) the incidence of infected patients (confirmed and presumed) at the time of the procedure, or after the procedure, and the number of patients testing negative for infection after procedure.
The secondary aim of the review was to investigate the impact of an epidemic-caused lockdown on surgical practice. The following outcomes were collected: (1) the number of HCW, the incidence of HCW infected or not infected after procedures, and the incidence of mortality among HCW (2) the type of PPE items used by HCW, modified perioperative logistics, precautionary measures and interventions enforced for HCW protection, modified OR arrangements, and duration of protection (3) the description of lockdown, and outpatient clinic volume.

Data sources and search strategy
Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed were systematically searched from database inception to April 2020, and ongoing surveillance was carried out until May 29, 2020. The search strategy (see Appendix 1) was designed in consultation with a medical librarian. This systematic review is reported in accordance with the Preferred Reporting items for Systematic Reviews and Meta-Analyses (PRISMA), with the PRISMA flow diagram presented in Fig. 1. 13 Eligibility criteria and data abstraction Studies reporting outcomes of patients undergoing surgery during an epidemic-caused hospital lockdown and studies investigating the impact of lockdown on surgical HCW and surgical practice were included. Articles were excluded from our review if they (1) were a review article, case report, letter to the editor, opinion, commentary, or editorial (2) did not contain at least one relevant outcome of interest (3) investigated a lockdown caused by a local hospital outbreak. No language or geographical restrictions were applied. Titles, abstracts, and full-text citations were screened, and conflict was resolved by the third reviewer. Two investigators extracted study data using a standardized spreadsheet, and verification of the extracted data was carried out by a third investigator. The following variables were abstracted from the included studies: study characteristics (e.g. author, year of publication, study design, study duration, country, type of epidemic, type of institution), patient demographics (e.g. number of patients included, age, sex), and study outcomes. Surgical outcomes were reported using the Clavien-Dindo Classification. 14 The Accreditation Council of Graduate Medical Education (ACGME) Staging System was used reflect the degree of disruption caused by epidemics. 15 Study quality assessment Risk of bias of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS), a 12 items-tool that evaluates the methodological quality of nonrandomized studies. 16 Discrepancies were discussed until consensus was reached. Studies were not excluded on the basis of quality.

Data synthesis
A narrative synthesis of study findings is provided along with a tabular summary of our primary and secondary outcomes of interest. Findings were reported and grouped into the following four outcome categories: (1) surgical procedures and outcomes, (2) surgical clinics and non-surgical procedures, (3) protection measures during outbreaks, and (4) patient exposures and HCW outcomes. Patient demographic data and quantitative outcomes across studies were pooled and reported using descriptive statistics. Measures of protection employed by HCW during outbreaks were further categorized into four groups: (1) PPE, PRE-OR, OR SETUP, LOGISTICS. These categories were developed via content analysis of the included studies. The synthesis without meta-analysis (SWiM) reporting guideline was followed closely for this systematic review. 17 Living and rapid review Due to the timing and relevance of our research questions during the ongoing COVID-19 pandemic, both rapid and living review approaches were employed to streamline the systematic review process, and to ensure that relevant emerging data was not omitted from our study. 18e20 Ongoing surveillance for studies will be maintained on a two-to three-month basis, and updates to our manuscript will be made accordingly. Methods for study selection and data abstraction will remain consistent.

Patient and hospital characteristics
34 retrospective studies, 16 case series, 5 descriptive studies, and 6 prospective studies represented a combined 3948 patients across 17 countries up to June 2020 (Table 1). Studies conducted during COVID-19 accounted for 98.6% of the included patients, while 1.2% were from studies during SARS, and 0.15% were from studies during MERS. Among papers describing patient demographics, 53.9% were female and median age was 62.0 years (range 1e100 years). A total of 455 health care workers were also represented with 70.1% HCW included during COVID-19, 28.1% included during SARS, and 1.8% included during Ebola epidemics.
Hospital lockdown measures were described in 26 studies ( Table 2). The most common measures included cancelation of elective surgery as specified in 84.6% of those studies, and a reduction or cancellation altogether of outpatient clinics specified in 23.1% of studies. One study reported stopping all planned activities to convert its center into a dedicated COVID-19 hospital. 21 Another study described a MERS outbreak resulting from an index case admitted to the cardiac surgery ward with no specific precautions described. 22 None of the included studies reported complete stoppage of educational activities to focus solely on patient care, as reflected by the ACGME Staging System scores.
Of the included studies, 6.6% included data on more than one surgical specialty. Among all included surgeries, 36.5% were urgent, 23.2% were elective, and 10.8% were oncologic. Post-operative complications were reported in 59.0% of studies. Four studies noted no complications following surgery. 23e26 A total of 440 complications were reported, with the most common ones being all-cause mortality accounting for 14.3% of complications, postoperative diagnosis of COVID-19 accounting for 12.0%, and hemorrhagic complications accounting for 7.3%. Of those studies reporting on complications, the pooled complication rate among 2095 surgeries was 21.0%. The pooled rate of minor complications (Clavien-Dindo Grades I-II) was 12.3%, the rate of major complications (Clavien-Dindo Grade III-IV) was 5.3%, and the rate of allcause mortality (Clavien-Dindo Grade V) was 3.4%. The complication rate among COVID-19 surgeries alone was 20.9%. Mortality secondary to complications from COVID-19 was reported in 1.1% of postoperative patients during the COVID-19 pandemic. Of note,  multiple complications occurred in a single patient in some instances.

Non-surgical procedures and surgical clinics
Non-surgical procedures (defined in this study as procedures performed outside of an OR) were performed in 21.3% of studies and included tracheostomy, nasal endoscopy, central venous catheterization, balloon dilatation of hepaticojejunostomy, intravitreal injections, peritoneal dialysis, and percutaneous drainage of various anatomical compartments (Table 3). A total of 346 procedures were specified during epidemics, with a pooled postoperative complication rate of 14.5% among studies reporting on complications. The most common complications included death accounting for 41.9% of complications and post-procedural bleeding accounting for 29.0%. As described above for surgical complications, multiple complications may have been reported following a single procedure.
Seven studies (11.5%; 7/61) reported active outpatient clinics during epidemics, though there was an overall reduction of clinic volume by 50%e75%. Eight studies, all during the COVID-19 epidemics, also reported the use of telemedicine and virtual care modalities for outpatient consults and follow-up appointments. 26e34

Protection measures during outbreaks
Measures to protect surgical personnel during outbreaks were reported in 45 studies (see Table 4; detailed overview provided in Supplementary Table 1). For the purpose of analysis, protection measures were classified into one of the following categories: PPE (any form of physical protection used by HCW); PRE-OR (any precautions taken preoperatively including modified patient screening and disinfection processes); OR SETUP (measures taken during surgical intervention, such as the use of negative-pressure or   segregated ORs); and LOGISTICS (all other measures including modification of work areas, modification of procedures, new hospital protocols and processes, and limitation/modification of HCW roles to help limit and prevent nosocomial disease transmission). Modified peri-operative logistics were reported in 40 studies describing protection measures. Examples of workspace modifications as described in 20 studies included establishing ultrasound workstations in areas managing infected patients to perform pointof-care lung imaging, having a designated corner in a dialysis unit for the treatment of patients who were suspected/confirmed infected, and designating doctors' and nurses' workstations as the "clean" area of a ward while other areas were considered contaminated. 21,30,35 Procedural and management modification for the purpose of minimizing exposure risk was reported in 25 studies and included measures such as slowing the speed of drilling intraoperatively in neurosurgical procedures, favoring use of percutaneous drainage over ERCP where possible for biliary drainage, and temporarily turning off mechanical ventilation during tracheal incision. 35e37 Modified hospital rules, protocols and patient transfer processes were described in 26 studies and included limiting or preventing visitations for patients, transferring patients between the ward and OR in a negative-pressure isolation transfer cabin, and use of designated transfer "lanes" between sections of the hospital to limit nosocomial spread. 23,29,35 Fourteen studies described modifying the roles of HCW during epidemics, including formation of an "Emergency Incident Command Team" to identify and separate infected patients from other patients, allowing only essential personnel to be present during procedures, and assigning staff to conduct patient screening full-time. 30,38,39 PPE use was the next most frequently reported measure and was implemented in 36 studies describing protection measures. Common PPE items included hair covers, N95 or PAPR masks, surgical masks, face shields, goggles, waterproof gowns, two layers of gloves, and shoe covers. More rigorous measures included use of the Stryker T4 Personal Protection system consisting of standard PPE with the addition of a helmet, short hood, and toga-style gown; use of hoods with built-in HEPA units; and powered air-purifying respirators for anesthesiologists. One study reported that PPE was changed every 3e4 h. 40 Another study reported use of surgical masks for patients before and after operation. 41 Of note, no HCW infections were described among studies implementing PPE measures.
Measures taken preoperatively for infection control were also described in 36 studies describing protection measures. The majority of these measures focused around improving screening to identify infected patients and HCW prior to operation and implementing rigorous disinfection and equipment preparation processes. Examples of preoperative measures included setting up multi-level triage systems in clinics and prior to patient admission to hospital to identify patients with fevers or concerning epidemiological history, having HCW take their temperature 4 times a day and undergo nucleic acid viral testing multiple times a week, use of disposable anesthetic devices for respiratory procedures, and enhanced decontamination procedures using chlorine disinfectant and anesthesia circuit sterilizer for anesthesia workstations. 23,28,38,40 Modification of OR setup to reduce infectious exposure risk was noted in 17 studies describing protection measures. The most common modifications included use of a negative-pressure OR for patients suspected or confirmed to be infected, as reported in 10 of these studies. Other measures included geographically segregating OR complexes to reduce cross-infection, reducing humidity level and temperature of ORs to reduce HCW perspiration, and using plastic drapes around the tracheostomy operative field to create a closed sterile environment. 40    A summary of protection measures is provided in Table 4. All studies which implemented more than 3 of the listed measures and also reported on HCW outcomes had an infection rate of 0% among HCW.  outcomes were also reported, 50.0% (4/8) noted infections in HCW. HCW outcomes were reported in 31 studies with 11 studies reporting the number of HCW included in the study. A total of 405 HCW were represented in these 11 studies, with 6.2% (25/405) having been infected during epidemics. During the COVID-19 pandemic, 8.6% (23/269) of HCW were infected. The other two infections among HCW occurred during the Ebola epidemics, where 25% (2/8) contracted the illness. Both of these HCW had died from the illness and were the only instances of death reported among the 405 HCW included in this review. One study did report the death of a nurse in its traumatology department during COVID-19, though the total number of HCW in the department was not specified and this instance was not captured in the pooled analysis. 21 No infections or adverse outcomes were reported for HCW during the SARS epidemics (0/128) from the included studies.

Patient exposures and HCW outcomes
The rate of HCW infection based on the number of surgeries performed was 3.61% (41 HCW/1136 surgeries) among studies that reported both the number of HCW infected, and the number of surgeries conducted. One HCW was infected for every 27.7 operations performed. Among studies during the COVID-19 pandemic, the HCW infection rate was 3.92% (39 HCW/995 surgeries) and one HCW was infected for every 25.5 operations performed.

Risk of bias assessment
The methodological index for non-randomized studies (MI-NORS) was used to assess risk of bias in the included studies (Supplementary Table 2). 56 studies included in this review were non-comparative with a mean global score of 10.2 (SD 1.7), indicating fair methodological quality. 16 All 56 studies had a clearly stated aim and a loss to follow-up of less than 5% (56/56). The majority of the studies adequately included consecutive patients (45/56), had adequate endpoints in relation to the stated aims (42/ 56), and had an appropriate follow-up period (44/56). One study adequately conducted a prospective calculation of study size (1/56). The remaining 5 studies included in this study were comparative studies with a mean global score of 14 (SD 2.9). Two of these studies had adequate control groups, 2 had adequate baseline equivalence of groups, and 3 had adequate statistic calculations. Prospective collection of data was reported in 7 studies (7/61). Adequately unbiased assessments of study endpoints were found in 7 studies (7/61).

Discussion
This rapid, living systematic review investigated the impact of hospital lockdown secondary to epidemics on surgical practice. We included 61 studies relevant to the Ebola, SARS, COVID-19, and MERS outbreaks. Lockdown measures, including cancellation of elective surgeries, surgical outpatient clinics, telehealth services, and hospital-based referrals were noted in approximately half of studies. Measures to protect surgical personnel, including adequate PPE and OR modifications, were reported in 45 studies. 31 studies followed the health of surgical HCWs during the epidemic, with the majority noting no adverse health outcomes with proper safety measures. However, there was minimal research on how epidemics impacted surgical practice in terms of patient care, healthcare workers, and waitlists. Specifically, there was no information reported regarding the clinical impact of delaying surgical care during lockdowns. In addition, there was insufficient comparative evidence related to institutional transmission control policies. As such, there remain significant evidence gaps for health systems to implement evidence-based surgical care during epidemics.
Overall, our findings contribute to the growing literature on surgical care during the current COVID-19 pandemic. 44 The worldwide shortages in PPE as well as the numerous cases of HCW infection have highlighted the importance of infection control, which has been outlined in our review. 44 In addition, as the novel coronavirus can be transmitted via aerosol particles, there is particular risk of exposure during certain procedures such as endoscopy. Our review outlines potential strategies that have been used to mitigate risk in previous outbreaks, such as the use of negative pressure ORs for intubation. There is also concern for triaging surgical oncology cases, due to preliminary evidence that COVID-19 is dangerous for patients for cancer. 45,46 As a result, the American College of Surgeons has released recommendations for both the triage of non-emergent surgical procedures as well as recommendations for management of elective procedures. 47,48 Many of their guidelines, such as the limitation of non-essential visitors, were similar to the strategies reported in our included studies. The American College of Surgeons especially stresses the importance of PPE, which was highlighted in the included studies that discussed infection control.
However, while the American College of Surgeons recommends the postponement of elective surgeries, this systematic review demonstrates that there is a lack of long-term evidence regarding the potential impact on patient outcomes, particularly patient morbidity and mortality due to cancellations. 47 Of note, our review also found that the overall complication rate did not seem to be increased based on the distribution of elective and emergency cases, as any association with elective surgeries is most likely due to the volume of patients rather than the distribution. In addition, while the American College of Surgeons has oncology-specific guidelines regarding deferral of surgeries and guidelines for multidisciplinary care, more pandemic-specific research is required to substantiate recommendations. 49 Of the included studies, 8 reported on postoperative outcomes following cancer surgeries. None of these studies examined oncology-related outcomes, such as remission rates or changes to chemotherapy cycles.
In addition, none of the included studies analyzed the motivations of surgeons to continue working during epidemics. During the COVID-19 pandemic, there has been increasing concern regarding HCW absenteeism and willingness to work in hazardous environments, particularly due to shortages in PPE. Previous literature has demonstrated that perceived personal safety was a large factor in whether HCW continue to practice during the previous SARS and influenza outbreaks. 50,51 As our review outlines several strategies to protect surgical HCW, implementation could be useful in alleviating the anxieties of HCW and encourage frontline practice.
Finally, we did not review the impact of COVID-19 on surgical graduate medical education, which is an emerging area of concern. There is growing evidence that surgical residencies and postgraduate medical education has been significantly impacted by the COVID-19 pandemic. 52e54 Literature has suggested that residents have decreased opportunity to participate in surgical cases. Similarly, one of our included studies noted that operations were more likely to be performed by staff surgeons in comparison to trainees during epidemics. This may be due to university-based safety guidelines, the redirection of trainees to other specialties, as well as reduced surgical volume. Technological options such as virtual curriculums and simulations have been posed in the interim to maintain the education of surgical residents. 55 The main limitation of our systematic review is the lack of published research on surgical care during epidemics. Due to the unpredictable and demanding nature of epidemics, it is often difficult for physicians to prioritize research while in the midst of disease outbreaks. This significantly limits the ability to collect prospective information. As such, much of the available literature was limited to case series and smaller scale retrospective reviews. In addition, considerations from previous pandemics may not  necessarily translate to relevance for the COVID-19 pandemic or any future epidemics. The included studies have diverse health systems and delivery models, which reduce generalizability of considerations such as infection control and lockdown guidelines. This is especially relevant for low-resourced health systems, which may face additional shortages. Another limitation of our review is that we were unable to stratify our results in terms of lockdown measures taken, given that this information was reported in fewer than half of the included studies. We are therefore unable to comment on the impact of specific lockdown measures on patient and HCW outcomes. Ultimately, it is often difficult for institutions to balance providing timely surgical care while ensuring safety during epidemics. While lockdown precautions have been used in previous outbreaks, it is unclear how the reduced access to surgical care will affect patient care in the long-term. In addition, it is unclear how to prioritize surgical care when lockdown precautions are eventually lifted. Future research should analyze the impact of COVID-19 on surgical wait-times and related complications, as well as patient and provider satisfaction. In the meantime, institutions should cooperate with policymakers to determine best precautions for surgical care. Surgical practice during epidemics affects all levels of the hospital, from creating a new demand on PPE to alleviating burden within the emergency department. As such, decisions   regarding surgical care during epidemics should not occur in isolation from other medical specialties.

Declaration of competing interest
The authors declare no conflict of interest. yAge reported either as mean (standard deviation) or median (range).

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.