Response to COVID-19 in Australia and its impact on elective surgery
« View all News items
Some reflections on the response to COVID-19 in Australia and its impact on elective surgery.
In Australia, by mid-March, there was a surge of COVID-19 cases, particularly affecting the more populous states of New South Wales, Victoria and Queensland. This led to the commencement of lockdown across Australia, which in Victoria extended from late March to the end of May. In addition, Australia’s borders and most internal borders between states were, and remain closed. In Victoria, everyone was asked to stay at home, and only to leave home for work, to exercise, to obtain essential supplies, or for medical appointments.
At the same time as lockdown, elective surgery was cancelled, except for Category 1 cases (cancers and similar patients requiring treatment within one month) and urgent Category 2 cases (those likely to deteriorate within 3 months). Emergency surgery continued. The principles underlying cancellation of elective surgery were to maintain an adequate supply of Personal Protective Equipment (PPE), to ensure adequate availability of intensive care beds and ventilators, and to ensure capacity within hospitals, both public and private, for the expected and anticipated surge in COVID-19 cases.
At The Alfred Hospital, considerable physical reconfiguration was thought to be necessary. The plan was to double the overall number of inpatient beds, and greatly expand the emergency department (ED) by taking over the whole of the ground floor, including the board room, which now accommodates a number of ED cubicles. In addition, the capacity for intensive care (ICU) was expected to go from approximately 60 to over 300 ventilated beds, and it was anticipated there could be a need for up to 20 COVID-19 medical units.
Because Australia is a Federation and Commonwealth of states, there have been variations between states, but also variations between hospitals. To provide consistent guidance and leadership, the Royal Australasian College of Surgeons and the Specialty Surgical Societies, representing the 9 surgical specialties, issued guidelines as to which elective surgery cases could reasonably be undertaken during this dramatic reduction in elective surgery. For most units in our public hospital this meant going from upwards of 10 elective operating lists per week, down to a handful or less of urgent cases.
Geographically aligned clusters of public and private hospitals were created. The Alfred Hospital was seen as the lead of its cluster, and therefore expected to have the ability to expand to a large number of intensive care unit beds at short notice. Therefore, it was not possible to continue routine elective surgery, filling hospital and ICU beds, and at the same time keep the hospital ready for the expected COVID-19 surge.
Gratifyingly by the end of April, the expected COVID-19 surge had not occurred, and the curve of new cases was significantly flattening indicating effectiveness of the various measures introduced within Australia to keep the overall case load low (Fig 1). It resulted in the unusual situation of many hospitals being relatively empty in varying degrees. This period of low activity provided the much-needed opportunity for hospitals to stockpile PPE and retrain or redeploy staff where necessary.
As a result, at the end of April, a cautious and incremental approach was recommended to restart elective surgery in small numbers, but to ensure that it would not interfere with a still possible need to deal with a significant surge in COVID-19 cases. The principles therefore were to increase the availability of elective surgery in a safe and equitable way, without increasing the risk of COVID-19 intra-hospital transmission, as well as not compromising hospital expansion capacity should it be needed. Initially it was decided to increase elective surgery by an amount of 25% more than the previous small numbers of Category 1 and urgent category 2 patients. This was to potentially allow Category 2 and some Category 3 cases to be done, although in small numbers. However, all cases had to be of high value, and low risk, in the sense of a low likelihood of post-operative deterioration and need for ICU, and a minimal need for PPE. Hospitals were required to report case numbers on a daily basis to the Department of Health.
There was to be equity of access for all patients dependent on clinical need, regardless of public or private status. Agreements were made within each state between public and private hospitals to enable public or uninsured patients to undergo elective surgery in private hospitals. This meant surgical patients on waiting lists in public hospitals could obtain timely treatment, whilst assisting private hospitals to continue their throughput and to a degree their financial viability.
By mid-May, with further flattening of the curve, and lack of a surge in cases, Australia’s National Cabinet decided to further increase elective surgery, but again this varied on a state-by-state basis. In Victoria, the plan was to have a 50% normal elective surgery load by the end of May, a 75% normal elective surgery load by the end of June, and by the end of July, a resumption of full activities. Throughout, measures such as social distancing, restrictions on numbers in theatre and ward rounds, self-isolation when necessary, and hand hygiene continued to be crucial. A significant secondary impact on medical student and surgical training has also resulted from dramatically reduced elective surgery.
Despite the disastrous health and economic impacts of the COVID-19 pandemic, and the havoc it has created for the whole world, we think there will be a number of unanticipated positive outcomes. Some of these include, the realisation that telehealth is relatively easy to use, and of significant benefit to patients and surgeons. Video conferencing using platforms such as Zoom or Microsoft Teams, has enabled greater attendances at meetings, and abolished non-productive travelling time. Video conferencing can be used effectively for multidisciplinary team meetings, morbidity and mortality audits, and business meetings. It has also now widely realised that it is no longer acceptable to attend work when unwell or with cold or ‘flu like symptoms. There has been a much higher influenza vaccination rate and a much lower seasonal influenza infection rate in the community. The value of hand hygiene and hand washing has been underlined in the general prevention of infection.
So far Australia has been fortunate with its low case load and numbers of deaths. However, there is a long way to go, a clear need for a vaccine, and the fear of second and subsequent waves. But there is also no doubt in the quest for health and economic recovery, it has probably changed the way we do things on a permanent basis.
Figure 1 – Summary statistics of COVID-19 in Australia as of 1st June 2020.
Authors:
Professor Jonathan Serpell, MB BS MD MEd FRACS FACS FRCSEd (ad hom), Professor and Director General Surgery, and Director Breast and Endocrine Surgery Unit
Mr James Lee MB BS FRACS PhD, General & Endocrine Surgeon, Senior Lecturer
Monash University. The Alfred Hospital, Melbourne
