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Evidence Check - System capacity and evaluation

Infrastructure, hospital capacity, human resources, supplies, monitoring, surveillance, prediction, evaluation, post-pandemic

Routine border screening evidence check

Added: 7 Dec 2020

What is the evidence or existing policy for routine asymptomatic screening for COVID-19 in exposed workers at border settings (such as airports, seaports, hotel quarantine)?
Is there evidence for which workers should be screened (such as all staff, cleaning staff, compliance staff, security, catering, health)?
What is the most effective frequency of screening?
What is the most effective type of screening (such as saliva, nasopharyngeal swabs, serology)?
  • No studies were identified in the peer reviewed literature for routine asymptomatic screening for COVID-19 in exposed workers at border settings. Many articles on asymptomatic screening for travellers were identified, but not included in this review.
  • Many documents outline action plans, including monitoring and reporting of COVID-19 symptoms of workers and encouraging testing if workers have symptoms, without mentioning routine testing.
  • In Australia, hotel quarantine has been identified as a major risk for the reintroduction of COVID-19 to Australia and as a result, state health authorities have introduced weekly testing of quarantine staff.
  • Asymptomatic workers at Western Australia's borders and in quarantine hotels will be able to take up weekly COVID-19 testing (from 11 September until 30 November). This includes testing staff at: - quarantine hotels including
  • hotel employees, security staff working at the hotel, health staff, drivers of transport of quarantine guests, WA police and others such as the defence force - Perth airport including
  • workers on site, airport or airline staff, WA police, security, federal agencies, drivers of hotel quarantine buses - sea ports and border crossings including
  • anyone involved with close contact of people arriving from overseas or interstate.
  • In New Zealand, an asymptomatic testing program for higher-risk workers includes: - managed quarantine facilities and transport (testing once every 7 days) - managed isolation facilities and transport (testing once every 14 days) - Ports of Auckland, Port of Tauranga and Auckland International Airport (testing once every 14 days) - people who work in managed isolation or quarantine facilities, including those who drive people entering the country from the airport to the facilities, border workers in customs, biosecurity, immigration and aviation security at airports, people who clean in areas used by arriving travellers, or who clean the aircraft, and people working in airside services such as food-halls where people in transit may be waiting. Border workers at maritime ports such as ship pilots, stevedores and those providing seafarer welfare support as well as people working in customs, immigration and public health at maritime ports and air crew.
  • In Singapore, staff at Changi Airport who come into close contact with passengers are tested for COVID-19 every two weeks.
  • The United States - Department of Transportation have guidance for air carriers and staff based around health monitoring and screening for symptoms at the start of duty - Delta airlines announced it will start offering rapid response COVID-19 tests to its flight attendants. The optional tests will be performed by a clinician via nasal swab with results taking fewer than 15 minutes (news article) - In high-density critical infrastructure workplaces, the Centers for Disease Control and Prevention recommend a risk-based approach to testing co-workers of a person with confirmed COVID-19. General practices should include pre-screening (temperature and symptom assessment) and regular monitoring of symptoms.

Wastewater surveillance for COVID-19 evidence check

Added: 11 Nov 2020

What is the evidence for monitoring wastewater as a surveillance strategy for COVID-19?
  • The presence of SARS-CoV-2 in the faeces of infected patients and wastewater has drawn attention to the use of wastewater as an epidemiological tool. Wastewater surveillance of COVID-19 can be an efficient, cost-effective way to survey transmission dynamics of communities as a complementary approach to assessing the prevalence of COVID-19 in a community.
  • SARS-CoV-2 has been detected in wastewater samples from many regions around the world including
  • Australia, Spain, Italy, Netherlands, China, the United States of America, Germany, Japan, India, Czech Republic, Brazil and Ecuador.
  • Often in these reports wastewater samples tested positive before, at the same time, or soon after positive COVID-19 cases were reported in the respective areas. In one study, the viral titers observed were significantly higher than expected based on clinically confirmed cases.
  • While the majority of studies detect positive SARS-CoV-2 in raw wastewater, there have been some positive tests in treated wastewater. This needs to be balanced against studies that did not detect positive SARS-CoV-2 in treated wastewater.
  • The World Health Organization outlines major potential use cases for environmental surveillance for SARS-CoV-2 including: early warning, detection in locations with limited clinical surveillance, monitoring circulation of SARS-CoV-2 and research. Considerations outlined by the World Health Organization for implementing environmental surveillance include: representativeness, coordination, cost-effectiveness, ethical and legal considerations and quality assurance.
  • In Australia, the Commonwealth Scientific and Industrial Research Organisation (CSIRO) has a method for monitoring sewage for early detection of COVID-19 outbreaks over 14 days, from people being exposed to SARS-CoV-2, wastewater samples collected and tested, reporting to public health officials, through to clinical nasal swab tests for people who begin to show symptoms.

Elective surgical procedures, non-surgical alternatives and shared decision-making evidence check

Added: 7 Oct 2020

What non-surgical alternatives to elective surgery have been reported in literature?
What evidence is available on the impact of shared decision-making interventions and tools on decisions regarding elective surgical procedures?
  • Non-surgical alternatives management refers to treatments that avoid surgery and other invasive procedures.
  • This review identified 151 surgical procedures for which non-surgical alternatives have been reported in recent systematic reviews (2015-present).
  • The most common types of conditions reporting non-surgical alternatives to elective surgery were orthopaedic injuries and degenerative conditions, cardiovascular conditions, and cancers.
  • Non-surgical options include active surveillance (or ‘watchful waiting’), delayed surgery, and (non-operative) medical treatment.
  • This review is about shared decision-making between clinicians and patients for management of patients by surgical treatment or non-surgical alternatives.
  • to promote or integrate shared decision-making for elective surgical treatments and procedures included: o a decision-making checklist, which led to an informed decision to defer urogenital sinus surgery. patient education provided by a multidisciplinary team, which led to more informed and confident decision-making in patients considering treatment options for prostate cancer

Waste from personal protective equipment evidence check

Added: 7 Oct 2020

Is there any evidence or data about the amount of waste produced from personal protective equipment (PPE) during the COVID-19 pandemic?
  • There are widespread concerns that the requirements for use of PPE during COVID-19 have resulted in a significant increase in plastic pollution.
  • A recent study estimated a global monthly use of 129 billion face masks and 65 billion gloves.
  • A pre-peer review article reported an estimated carbon footprint of the PPE supplied during the first six months of the pandemic in England of 158,838 tonnes of carbon dioxide equivalent, with greatest contributions from gloves, aprons, face shields, and Type IIR surgical masks. The consequences of this pollution included a loss of 314 disability adjusted life years, a 0.67 loss of local species per year, and resource depletion equivalent to US$20.4 million.
  • Local studies focused on estimating medical waste during the pandemic have been undertaken in China, South Korea and Italy.
  • As well as concerns about the volume of waste generated, is the question of safe disposal. The United Nations Environment Program reviewed practices for managing waste from healthcare facilities, households and quarantine locations accommodating people with confirmed or suspected cases of COVID-19 and provides recommendations for policy makers and practitioners to improve waste management.

Resuming elective surgery – volume-outcome relationships in surgery evidence check

Added: 28 Aug 2020

What is the evidence regarding a volume-outcome relationship for surgical interventions?
  • For some surgical procedures, there is evidence of a volume-outcome relationship – a correlation between lower number of cases and poorer outcomes.
  • Volume-outcome relationships have been evaluated at both a surgeon and hospital level. For procedures with a shorter length of stay and specific intraoperative processes and skills, the volume of procedures performed by the surgeon are more likely to influence outcomes, while for procedures with longer lengths of stay, the volume of procedures performed at the hospital is more likely to be important.
  • Definitions of what constitutes a ‘low volume’ varies across studies, countries and conditions. Reporting of definitions of volumes is often inadequate and not consistent across studies.
  • Outcomes reported include mortality, postoperative complications, length of stay, cost of hospital stay, and readmissions and reoperations/revisions.
  • The quality of studies and strength of association between volumes and outcomes varies.
  • Conditions where a volume-outcome relationship has been reported in systematic reviews include: pancreaticoduodenectomy, colon, rectal and colorectal cancer, bariatric surgery, breast cancer, abdominal aortic aneurysm, spinal surgery, cystectomy, oesophageal cancer, stomach cancer, head and neck cancer, lung cancer, radical prostatectomy, gynaecology surgery, carotid endarterectomy, paediatric heart surgery, AIDS, hysterectomy, thyroidectomy, transcatheter aortic valve implantation, nephrectomy, hernia, acute aortic syndrome, revascularisation of the lower limbs, hip and shoulder arthroplasty.
  • Conditions where volume-outcome relationship has not been clearly established include liver resections, Norwood procedure, adrenocortical carcinoma and thoracic aortic aneurysms
  • There is mixed evidence across reviews regarding percutaneous coronary intervention, hernia, trauma and injury, and coronary artery bypass grafting.

Resuming elective surgery – the evidence for prehabilitation evidence check

Added: 16 Jul 2020
Updated: 17 Jul 2020

What is the evidence that ‘prehabilitation’ or preoperative rehabilitation before surgery improves value or outcomes for patients?
  • Prehabilitation is a process of enhancing patients’ physical functionality preoperatively to support them to deal with major surgery.
  • Studies vary widely in terms of types of intervention, study population, and outcomes assessed.

Resuming elective surgery - post-surgery innovations evidence check

Added: 16 Jul 2020
Updated: 17 Jul 2020

What is the evidence for post-surgery innovations in an outpatient setting, such as virtual follow up and rehabilitation, in improving outcomes for patients who have undergone surgery?
  • Telerehabilitation has been shown to reduce pain and improve function, with no differences observed in rates of hospital readmissions or treatment-related adverse events following total hip or knee replacement for people with osteoarthritis, compared to usual care. A further review on knee arthroplasty found that compared with face-to-face rehabilitation, telerehabilitation could achieve comparable pain relief, better Western Ontario and McMaster Universities Osteoarthritis Index improvement, significantly higher extension range and quadriceps strength. Another review for this condition found patients experienced high levels of satisfaction with the use of telerehabilitation alone.
  • A hybrid model, consisting home-based cardiac rehabilitation with direct supervised centrebased cardiac rehabilitation showed similar improvement in functional capacity, no significant difference in changes in exercise duration, systolic or diastolic blood pressure or health-related quality of life compared to standard cardiac rehabilitation programs.
  • Physiotherapy with telerehabilitation has the potential to increase quality of life, is feasible, and is at least equally effective as usual care in surgical populations.
  • Evidence on telerehabilitation after surgical procedures on orthopaedic conditions were in favour of telerehabilitation in patients following total knee and hip arthroplasty. There was limited evidence in the upper limb interventions.
  • One review examined the feasibility of remote telemedicine connection to provide in auditory rehabilitation services through hearing aids and cochlear implants. There are significant concerns regarding internet bandwidth limitations for remote clinics and a paucity of research examining reimbursement and cost-effectiveness for services.

Resuming elective surgery – productivity and efficiency approaches evidence check

Added: 13 Jul 2020
Updated: 14 Jul 2020

What evidence is available about ways to increase productivity or efficiency in operating theatres and managing elective surgery waiting lists?
  • COVID-19 has led to postponement of elective surgery in many jurisdictions. This has resulted in an immediate increase in waiting times and a significant backlog of patients.
  • Both supply and demand side interventions are implemented in OECD countries to reduce waiting lists and increase productivity and efficiency in elective surgery.
  • Lean, and Six Sigma methods can increase productivity – and point to the importance of transformational leadership and workforce flexibility in achieving productivity gains.
  • Scenario and optimisation modelling have been used to identify and quantify potential productivity gains.
  • In England, a 2019 study estimated that theatre time lost to late starts, early finishes and delays between operations could have been used to perform 16.8% more operations.
  • A number of studies have demonstrated modest efficiency gains associated with interventions to improve start times and change-over times.
  • An English regulator identified five key levers to improve theatre productivity: 1. stratifying patients by risk 2. extending clinical roles 3. increasing throughput by explicitly measuring, communicating and managing the number of procedures per theatre session 4. implementing enhanced and rapid recovery practices to reduce length of stay 5. providing virtual follow-up for uncomplicated patients.
  • In New Zealand, one district health board introduced an incentive-based and clinically led model of care in 2012, which was associated with increases in productivity and reduced costs.
  • A Queensland study found that day-long sessions (as opposed to separate morning or afternoon sessions), mid-week sessions, certain specialties (e.g. neurosurgery sessions) and not scheduling long cases first were most beneficial to theatre utilisation.
  • Specialty approaches to improving efficiency have been adopted by the Getting it Right First Time program in the UK and estimated significant potential efficiency gains.
  • In NSW an operating theatre productivity index was developed in 2014 and was piloted in four site

Daily Evidence Digest

Rapid evidence checks are based on a simplified review method and may not be entirely exhaustive, but aim to provide a balanced assessment of what is already known about a specific problem or issue. This brief has not been peer-reviewed and should not be a substitute for individual clinical judgement, nor is it an endorsed position of NSW Health.