Evidence check
A rapid review outlining the available evidence on a discrete topic or question. Evidence includes grey and peer review literature. View all Evidence Checks by date of publication.
Archive Risks associated with surgery in people with COVID-19
Added: 20 Jul 2020
Are patients with COVID-19 or who have previously had COVID-19 at risk of adverse post-operative outcomes? If so, what is the duration of the heightened risk?
- There were no studies reporting empirical data on recovered COVID-19 patients undergoing surgery. One study reported recommendations without data, advising to follow the precautionary principle and undertake the same precautions in the operating room as for a confirmed patient.
- The main surgical outcomes reported in literature for COVID-19 patients were clinical complications from surgery (e.g. pulmonary, thrombotic), including COVID-19 specific ICU admission requiring post-operative supplemental oxygenation, the impact on length of hospital stay and death (i.e. 30 day mortality)
- Studies have reported the risk factors that are associated with adverse surgical outcomes in COVID-19 patients undergoing surgery which include, age (e.g. being 70 years or older), being male, positive smoking status, presence of multi- and co-morbidities, having cancer surgery, needing emergency surgery and needing major surgery.
- Researchers from the COVIDSurg Collaborative conducted an international, multicentre, cohort at 235 hospitals in 24 countries, which included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The analysis included 1,128 patients, who had surgery between January and March 2020. The authors found that post-operative pulmonary complications occurred in half of the patients with perioperative SARS-CoV-2 infection (577 of 1128, 51.2%). The infection was also associated with high mortality, with the 30 day mortality of 38.0% (219 of 577) in these patients, accounting for 81.7% (219 of 268) of all deaths.
- Based on their findings, authors from the studies included in this evidence check advise the following: Testing and appropriate diagnosis of all patients before surgical treatment to determine COVID-19 status, especially as it is difficult to distinguish between non-COVID-19, asymptomatic, or pre-symptomatic cases. To balance the increased risks associated with SARS-CoV-2 infection against the risks of delaying surgery in individual patients. 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. COVID-19 Critical Intelligence Unit 20 July 2020 To consider postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery in COVID-19 patients. This is recommended especially for those with increased vulnerability for adverse outcomes, including elderly patients and those with comorbidities, and in various types of surgeries and procedures, including: adjuvant chemotherapy or elective surgery for stable cancer thoracic operations urological surgery orthopaedic surgery neurosurgery.
- Only one study reported that patients with asymptomatic or mild COVID-19 infection can safely undergo early surgical intervention for hip fracture after appropriate medical optimisation.
Archive Resuming elective surgery - post-surgery innovations
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.
Archive Cardiac stress testing
Added: 16 Jul 2020
Updated: 17 Jul 2020
Is there evidence that cardiac stress testing is an aerosol generating procedure and what risk to healthcare workers does it carry?
- Lists of aerosol generating procedures do not generally include cardiac stress testing. Some guides specify that cardiac stress testing is not an aerosol generating procedure, while another states that the risk is unknown
- A nuclear cardiology service in Singapore identified exercise stress testing for myocardial perfusion imaging as a high-risk procedure for droplet production in the time of COVID-19. As such, treadmill exercise stress was discouraged over pharmacological stress, and medical and nursing staff who attended to suspect patients were required to don N95 masks with appropriate personal protective equipment (PPE)
- During the COVID-19 pandemic, pharmacologic stress tests are preferred over exercise stress testing due to the risk of droplet production.
- A consensus statement from various peak bodies in Australia and New Zealand, including the National Heart Foundation, note that certain cardiac investigations, including stress testing, pose significant viral transmission risk.
- A statement from the American Society of Echocardiography states stress testing on patients with COVID-19 may lead to exposure due to deep breathing and/or coughing during exercise and that these tests should generally be deferred or converted to a pharmacological stress echocardiography. The British Society of Echocardiography notes a paucity of data with regard to the aerosol generating potential of exercise-based stress echocardiography, however the consensus opinion among UK experts is that it may be.
- Infection control considerations for cardiac stress testing during COVID-19 include general infection control guidance as well as: patient screening, PPE, and room decontamination, including consideration of the turnaround time and percentage of airborne virus remaining in the room.
Archive Resuming elective surgery – the evidence for prehabilitation
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.
Archive Resuming elective surgery – productivity and efficiency approaches
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
Archive Resuming elective surgery – low-value care
Added: 13 Jul 2020
Updated: 14 Jul 2020
What evidence is available about low-value surgery and how to reduce it?
- Very few procedures are of absolutely no value in all clinical circumstances, nor are there many that are universally beneficial. Most tests and treatments fall into a ‘grey zone’ where they may be appropriate in different circumstances.
- A multi-platform method of identifying low-value interventions in surgical interventions encompassed a broad literature search, a targeted database search and opportunistic sampling. Interventions that were identified were assessed in terms of cost (high or low) and frequency (prevalence) (high or low). (1)
Archive Resuming elective surgery
Added: 13 Jul 2020
Updated: 14 Jul 2020
What evidence is available regarding the resumption of elective surgery following cancellation and deferment of routine services during COVID-19?
- COVID-19 has disrupted the provision of elective surgery across jurisdictions but there is limited evidence-based advice regarding the resumption of services.
- Three papers estimate the time needed to clear the backlog of deferred and cancelled surgeries:
Archive Resuming elective surgery - post-surgery innovations: enhanced recovery after surgery, early mobilisation and discharge
Added: 13 Jul 2020
Updated: 14 Jul 2020
What is the evidence for post-surgery innovations in hospital such as enhanced recovery, early mobilisation and early discharge in improving outcomes for patients who have undergone surgery?
- ERAS refers to evidence-based protocols that standardise care to improve outcomes and expedite recovery following elective procedures.(1)
- Overall, ERAS has been shown to reduce length of stay without compromising morbidity across numerous surgery types.
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. Evidence checks are archived a year after the date of publication.