The Association of Coloproctology of Great Britain and Ireland has issued COVID-19 guidance for colorectal surgeons and trainees to provide a framework in which to prepare and act, and should be used in conjunction with the frequently updated national government recommendations available from Public Health England, Health Protection Scotland, Public Health Wales and Public Health Agency Northern Ireland.
The Guidance states that colorectal surgeons and trainees will need to act in their three main capacities as citizens, doctors and surgeons.
- Priority 1: Being a responsible citizen
Government advice on regular hand washing, use of tissues when sneezing, and self-isolation applies to all of us. There may be differences in advice for healthcare workers and the general public, and so regular checking of official recommendations is advisable.
Avoidance of contact, especially of large indoor gatherings, and cancelling unnecessary travel is prudent. ACPGBI has supported the government’s containment and delay strategies by cancelling or deferring all events in the next three months that may result in inadvertent spread of COVID19, and we shall continue to do so when necessary as the situation unfolds.
Protection of the elderly is particularly important, given the much greater risk of COVID-19 in this age group. There are many local initiatives to help support elderly relatives and vulnerable neighbours, especially during periods of self-isolation.
At a time of crisis, and in a world of rapid dissemination of both good information and sadly also misinformation, it will be important for our profession to propagate accurate information based on reliable sources.
- Priority 2: Being a responsible doctor
As a doctor, it is important to follow official guidance provided by authorities and your local institution. An absolute first in general is hand-washing between every patient and person contact.
There will no doubt be many pressures from working in a challenging and constrained healthcare environment. Potential scenarios include being asked to take on tasks outside of normal areas of expertise, re-deployment of team members, and flattening of hierarchy with senior surgical staff stepping in to meet day-to-day care of surgical patients. It is envisaged that there will be deployment of training grades to other specialties, and we would recommend supporting such internal processes, but also advise maintaining contact with re-deployed trainees in order to ensure pastoral care and well-being.
The ACPGBI recommends that all doctors should act within their professional competencies, but also seek opportunities for enhanced training to take on other healthcare roles. Doctors should be reassured by the joint letter from the Chief Medical Officers of all four nations in Great Britain and Ireland and the General Medical Council which specifically acknowledges that the need and protection for doctors to act outside of normal roles in an emergent situation.
Supporting Doctors in the event of a COVID19 Epidemic in the UK
In order to minimise exposure to high-risk healthcare environments while still maintaining services for ongoing health issues outside of COVID-19, remote consultations should be considered whenever possible. It is important to acknowledge and record the limitations of not examining a patient and it may be worth offering direct to test for patients with high risk symptoms. It is also worth offering the opportunity for delayed, rather than not having any, investigation in patients with lower risk symptoms. Advice from the Information Commissioner about using a variety of media for remote access, provided the clear intention is patient benefit, is both realistic and reassuring.
- Priority 3: Being a responsible surgeon
Supporting other services with prompt, high level surgical reviews of isolated or suspected COVID-19 patients will facilitate rapid decision-making and minimise unnecessary exposure of multiple members of the surgical team. Please see other links below for references on abdominal manifestations of COVID-19.
For the duration of the crisis, surgeons need to recognise and promote that there will still be an ongoing need for emergency general surgical services, to avoid excess mortality due to other causes, especially due to delayed presentations of intra-abdominal sepsis.
ACPGBI also supports that compromises may need to be made on current levels of postoperative care for emergency laparotomy patients, given the anticipated pressure on intensive care capacity. Some chance of survival is better than none in a life-saving situation. There is currently no position from the National Emergency Laparotomy Audit (NELA) on whether the current requirements for level of care based on risk of postoperative mortality will be lifted during the peak of the COVID-19 crisis. ACPGBI fully supports the NELA criteria within a healthcare service working at normal capacity, but also believes that patients should still be offered emergency surgery even if intensive care capacity results in ward level care postoperatively. Surgeons, as responsible clinicians will need to deliver decision-making in partnership with patients, with the circumstances and additional risks properly recorded.
Operating on patients isolated for, or suspected of having, COVID-19 is another key source for concern. Given that we currently do not have a good understanding of the mode of transmission, the current advice for surgery in an affected patient is very limited and currently does not recommend more than standard surgical protection although the theatre recommendations include anaesthesia taking place within the operating theatre. We have sought further clarification of this position, as the theatre would not be cleaned between the aerosol procedure and surgery. There is also no current advice on whether there is greater risk associated with either open or laparoscopic surgery.
With diminished capacity, it is likely that surgery for benign disease will be de-prioritised, and so the ACPGBI recommends case review of each postponement to minimise patient harm. There are patients with inflammatory bowel disease who may still require urgent surgical intervention after sepsis control and medical optimisation.
It is also conceivable that the system may come under such duress that elective surgery for early stage colorectal cancer in higher risk patients may be better deferred until the healthcare environment has enough resources to support them.
The ACPGBI is also working with our multidisciplinary team on strategies to temporise and ensure safety of patients with colorectal cancers during the COVID-19 crisis. Attention to the individual’s relative risks, patient communication and documentation will be essential on a case-by-case basis. Inclusion of limitations of care due to the COVID-19 can reasonably be included in the consent process and documented on the consent form.
Many ACPGBI members are major contributors to delivery of endoscopy services and the ACPGBI recommends members seeking advice about upper and lower gastrointestinal procedures look at the information provided by the British Society of Gastroenterology. The ACPGBI are also working with the Joint Advisory Group and BSG on recommendations for bowel cancer screening during this critical time of limited resources for all patients.
The best current advice to patients with inflammatory bowel disease on biological and immunosuppressive agents is to stay on treatment to avoid flares, and to access IBD support services remotely for advice if affected by COVID-19. The best current advice is available on the Crohn’s and Colitis UK website which BSG also endorses. As colorectal surgeons, members should be particularly mindful of elderly patients with IBD on thiopurine (azathioprine and 6mercaptopurine) treatment and flag these patients for remote review with our IBD gastroenterology colleagues.
To access the guidance, please click here