Evaluation of patients undergoing emergency surgery in a COVID-19 pandemic hospital: a cross-sectional study

ABSTRACT BACKGROUND: The COVID-19 pandemic is threatening healthcare systems and hospital operations on a global scale. Treatment algorithms have changed in general surgery clinics, as in other medical disciplines providing emergency services, with greater changes seen especially in pandemic hospitals. OBJECTIVES: To evaluate the follow-up of patients undergoing emergency surgery in our hospital during the COVID-19 pandemic. DESIGN AND SETTING: Cross-sectional study conducted in a tertiary-level public hospital. METHODS: The emergency surgeries carried out between March 11 and April 2, 2020, in the general surgery clinic of a tertiary-care hospital that has also taken on the functions of a pandemic hospital, were retrospectively examined. RESULTS: A total of 25 patients were included, among whom 20 were discharged without event, one remained in the surgical intensive care unit, two are under follow-up by the surgery service and two died. Upon developing postoperative fever and shortness of breath, two patients underwent thoracic computed tomography (CT), although no characteristics indicating COVID-19 were found. The discharged patients had no COVID-19 positivity at follow-up. CONCLUSION: The data that we obtained were not surgical results from patients with COVID-19 infection. They were the results from emergency surgeries on patients who were not infected with COVID-19 but were in a hospital largely dealing with the pandemic. Analysis on the cases in this study showed that both the patients with emergency surgery and the patients with COVİD infection were successfully treated, without influencing each other, through appropriate isolation measures, although managed in the same hospital. In addition, these successful results were supported by 14-day follow-up after discharge.


INTRODUCTION
The first case of COVID-19 (new type of coronavirus, 2019-nCoV) in Turkey was identified on March 11, 2020, which was also the date on which the World Health Organization declared the outbreak to be a pandemic. [1][2][3] As COVID-19 has spread around the world and across Turkey, the hospitals that have been used to treat the disease have become locations where there is a high risk of infection. 4,5 Between this first case in Turkey on March 11, 2020, and a survey on April 2, 2020, a further 18,135 cases were identified. Approximately 60% of these cases were seen in the city of Istanbul where our hospital is located. 6,7 Thus, Istanbul alone accounts for more than half of all patients among the 81 cities of this country. Moreover, the hospital in which we work was the first and is now one of the four officially declared pandemic hospitals in the city. The intensity of patient demand is higher around these hospitals, which gave us a responsibility to report our data because of the high reliability of our results. 7 With the increasing incidence rate of the disease in our country, the number of patients diagnosed with or suspected of having COVID-19 infection entering our emergency service and inpatient services has also rapidly increased. It has therefore been recommended that elective surgeries should be postponed wherever possible, in regions to which the pandemic has spread. 8,9 However, this is not possible with emergency surgeries, and so it has become necessary to carry out such surgeries while taking the maximum of precautions. Healthcare professionals are at increased risk of exposure to COVID-19 and its infection, given their involvement in treat- The initial examinations on the surgical patients were made using personal protective equipment, initially using masks and gloves. However, as the number of COVID-19 cases rapidly increased, all surgical patients were assumed to have contracted this disease, and N95 or filtering facepiece (FFP) masks, protective googles and protective gowns started to be used as routine.
Patients who were scheduled for surgery and admitted to the service were taken into individual rooms. They were then moved to the operating room wearing a mask, and without spending any time in the preoperative room.
In order to avoid bringing the patient into contact with too many people prior to anesthesia, the anesthesia care team consisted only of an anesthesiologist and an anesthetic technician. Under the assumption that the patient was COVID-19 positive, the anesthetic procedures were carried out with the operative wearing an N95 protective mask with a surgical mask over it, a surgical box gown and protective googles.
Intubations were made by specialist physicians using a videolaryngoscope, with rapid induction and without mask ventilation.
Complete nasal oxygenation was ensured. During wakening, oxy- Postoperative visits to patients were conducted with a minimum of personnel (one physician and one nurse), wearing N95 masks and a surgical box gown upon each entry to and exit from the room, and using hand disinfectant. At the time of discharge, the patients were given the recommendation that they should adhere to a 14-day isolation period. On the 14 th day after discharge, these patients were called by phone, to gain information.

Ethical approval
Board of ethics approval for this study was obtained from the ethics commission of the Health Sciences University, Haseki Training and Research Hospital, under approval number 40-2020, dated April 17, 2020.

Statistical analysis
Descriptive statistics were calculated, including means, standard deviations, medians, minimums, maximums, frequencies and ratios. The SPSS 22.0 software was used for the analyses.

RESULTS
This study included a total of 25 patients, of whom nine were male and 16 were female, with a mean age of 50 years. The nine male patients all had comorbidities. Table 1

DISCUSSION
In the present study, the changes in approaches to general surgery and emergency practices resulting from the COVID-19 pan-   9 Earlier in the pandemic, anesthesiologists published various recommendations for the equipment and protection that was required to protect themselves during intubation. 8,11,12 Subsequently, recommended approaches to surgery were suggested for patients with a suspicion or diagnosis of COVID-19. 3,5,10 Although a considerable proportion of COVID-19 patients are asymptomatic, it is an infectious disease. Therefore, all our surgical patients in our pandemic hospital were approached under the assumption that they were positive, from the earliest days.
Since the virus is mainly transmitted through droplets, it is accepted that the virus will remain on contact surfaces for hours, or even days, as a potential source of infection through transmission by contact. 11 This constitutes a risk for healthcare professionals, who may come into contact with these contaminated surfaces, thus transmitting the virus to themselves or others. 13  with poor access to healthcare facilities. A total of ten patients who underwent appendectomy were discharged without event.
In a review by Di Saverio et al., 3 it was recommended that all patients who were to undergo surgery should be tested for Given that all elective surgery and diagnostic endoscopy procedures have been postponed because of the extended duration of the pandemic, there is growing concern about the increasing the frequency of presentations to the emergency services with a clinical picture of ileus due to colon and rectal tumors. The limitations of the present study are the limited number of patients, the single-center design, the lack of randomization and the retrospective nature of the study.

CONCLUSION
We believe that the risk of dissemination of COVID-19 will be reduced through isolating the emergency surgery services from the pandemic services, by means of using personal protective equipment, carrying out preoperative abdominal CT simultaneously with thoracic CT (when required) and ensuring the minimum of contact between healthcare staff and the patient.
The data that we obtained were not surgical results from patients with COVID-19 infection. They were the results from emergency surgeries on patients who were not infected with COVID-19 but were in a hospital largely dealing with the pandemic. Analysis on the cases in this study showed that both the patients with emergency surgery and patients with COVİD infection were successfully treated, without influencing each other, through appropriate isolation measures, although managed in the same hospital.
In addition, these successful results were supported by 14-day follow-up after discharge.