Tag Archive for: Coming out of lockdown safely

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Coming out of lockdown safely – A view from China

How our lives have changed. Over two months ago we published a popular blog on the effect of COVID-19 on our surgical practice (https://www.bjuinternational.com/bjui-blog/covid-19-and-urology/). In many ways it informed us as to what to do during challenging times to keep our patients safe.

As we gradually take careful steps out of lockdown, our minds are focused on the most important of all words – SAFETY. 

While every nation will have differences and nuances, the principles of learning from each other, remain the same as they did when lockdowns started.

I am not surprised by new and ever changing information about the disease almost every day and see international collaboration as a powerful and positive tool in this situation.

With this in mind I requested our friends from Italy, China, Germany and New Zealand for their own perspectives.

Here are their thoughts for your reading pleasure.

Please feel free to insert your comments under the blog and share on social media.

Yours in friendship,
Prokar Dasgupta
Editor in Chief, BJUI

 

In China, after a 3-month period of lockdown, the whole country is looking forward to run back to the normal life.  The central government of China asked the local authorities lead the economic and daily life come out of lockdown gradually. Although the atmosphere of pandemic in China has become less tense, we are still paying fully attention on the prevention and detection of COVID-19. Below are the brief measures used in our hospital after the complete lockdown. It is important to note that the rules and guidelines varied from place to place, and adjusted according to the up-to-date situation.

  • On-site registration service in out-patient clinic is still prohibited. Outpatient clinic accepts online appointment only.
  • A temporary shelter clinic was built in February in my hospital. We are now still using the temporary shelter clinic to distinguish the suspicious infectors with other patients.
  • The flow of visitors in hospital is still under control. All the entrances are still monitoring people’s temperature and travelling history.
  • In the temporary shelter clinic, urologists have to wear examination gloves, surgical masks, and disposable hat and shoe cover in a single room for face to face consultation.
  • Negative complete blood count, chest CT, and oropharyngeal swab DNA tests are compulsory before inward admission for both patients and their accompanied relatives.

With the strict application of the protective measures, no in-ward patient or staff member had been infected by COVID-19 in my hospital. Although these measures add up a lot of works for my colleagues, I believe it is worthy as the threat of COVID-19 still exist.

Guohua Zeng, Di Gu and Wei Zhu
First Affiliated Hospital of Guangzhou Medical University, China

Coming out of lockdown safely – A view from Germany

How our lives have changed. Over two months ago we published a popular blog on the effect of COVID-19 on our surgical practice (https://www.bjuinternational.com/bjui-blog/covid-19-and-urology/). In many ways it informed us as to what to do during challenging times to keep our patients safe.

As we gradually take careful steps out of lockdown, our minds are focused on the most important of all words – SAFETY. 

While every nation will have differences and nuances, the principles of learning from each other, remain the same as they did when lockdowns started.

I am not surprised by new and ever changing information about the disease almost every day and see international collaboration as a powerful and positive tool in this situation.

With this in mind I requested our friends from Italy, China, Germany and New Zealand for their own perspectives.

Here are their thoughts for your reading pleasure.

Please feel free to insert your comments under the blog and share on social media.

Yours in friendship,
Prokar Dasgupta
Editor in Chief, BJUI

After having been hit by the pandemic just shortly after Italy, Germany experienced some early waves of COVID19  especially after some carnival festivities had spread the disease in some areas. The German government decided quite early to implement a strategy to deal with the outbreak. Initially the Ministry of health gave the restriction order to potspone evey plannable / elective surgery and hospital treatment, to „flatten the curve“  and thus avoid situations like in Italy, Spain or in the USA,  so that the Healthcare system would always allow for those in need to get an unflattered access to ventilation. This order had an immediate effect on urology practice throughout Germany. Some areas in Germany struggled with severe numbers of  COVID19, others were barely affected by the pandemic.

In our department, besides the usual hygiene measures like distancing, triage of patients by questionnaire and sending staff into „home office“ (the German term for working from home),  we immediately cancelled all benign cases, as well as low risk Prostate Cancer or small kidney cancer cases. Moreover, we additionally postponed those patients who would clinically fit into a higher risk category for suffering from a severe COVID19 course if they had acquired it, i.e patients with diabetes, severe COPD, older patients etc. also, initially surgeries with a higher likelihood for the necessity of postoperative ICU surveillance and treatment were postponed if possible.

After these initial tremendous cuts in caseload and patient numbers had more or less emptied the Intensive care units as well as hospital beds throughout Germany, it slowly became clearer that the quite solid Health System offered a lot more hospital beds as well as ICU / ventilation options, and that the general hygiene measures had apparently lead to a less intense outbreak in most parts of the country, some states and counties allowed to stepwise get back to a (reduced) normality – always under the caveat that epidemiological numbers stay low.

The German Government acted with a strong scientific support by one the world’s most respected coronavirus virologists, Prof Drosten of Charité Hospital Berlin, together with a team of the German Disease Control Institution („Robert Koch Institut“), and worked closely together with the state governors of the 16 German states, to share a common bundle of measures (still with nuances from state to state). Mass testing was made available quite early (yet, usually restricted to those with symptoms or contact persons). Currently, of 174,824, nationwide confirmed cases  7,917 people have died, making the death rate hit 4.5%.

Since a couple of days, we experience a stepwise way out of the lockdown in everyday life, with every state setting up slightly different measures; still, physical distancing and face masks are mandatory and shape the picture of everyday life. Since last week, restaurants and bars  are opening up again, and even the German Premier league went back to playing (with extremely strict measures like regular testing for every team member, as well as quarantine, but without any fans at the stadiums). Of note, regular testing for hospital staff is not required throughout Germany…

The way we work in our department has changed dramatically since the beginning of the pandemic. Our staff gatherings are restricted to only a few people, everybody wears masks, and is trying to keep their distance as much as possible, staff members who have office jobs like secretaries work from home. Urologic Surgery has resumed and is now performed back to almost normal case numbers; robotic cases have resumed to 100%, now performing 10 RARPs per day again. The waiting lists are long enough to cope with the otherwise probably reduced demand (due to a lack of biopsies, or outpatient urology consults resulting in referrals). There are still no visitors allowed, our hospital still has a separated entrance gateway for an initial triage, we send patients home sooner than we used to (for various reasons, patients usually stayed as inpatient for a week after surgery).

A recent survey of the German Working Group on Laparoscopic and Robotic Surgery of the German Society of Urology, amongst the busiest minimally invasive departments in Germany, reflected the situation of a quite colourful picture of minimally invasive Urology during the pandemic; it ranged from departments that are still barely functionally operating to hospitals with little or no restrictions in numbers. In some departments, parts of the wards were closed, and urologists were taking care of COVID 19 wards instead. The huge variety of responses reflects the differences in epidemiological impact in the 16 states of Germany – resulting in different restriction order patterns by the governments and county authorities. The results of our survey are currently put together and are soon to be published.

Dr. Christian Wagner , FEBU
Head of Robotic Urology, St. Antonius Hospital Gronau , Germany

 

Coming out of lockdown safely – A view from New Zealand

How our lives have changed. Over two months ago we published a popular blog on the effect of COVID-19 on our surgical practice (https://www.bjuinternational.com/bjui-blog/covid-19-and-urology/). In many ways it informed us as to what to do during challenging times to keep our patients safe.

As we gradually take careful steps out of lockdown, our minds are focused on the most important of all words – SAFETY. 

While every nation will have differences and nuances, the principles of learning from each other, remain the same as they did when lockdowns started.

I am not surprised by new and ever changing information about the disease almost every day and see international collaboration as a powerful and positive tool in this situation.

With this in mind I requested our friends from Italy, China, Germany and New Zealand for their own perspectives.

Here are their thoughts for your reading pleasure.

Please feel free to insert your comments under the blog and share on social media.

Yours in friendship,
Prokar Dasgupta
Editor in Chief, BJUI

It is hard to believe that 9 weeks ago as USANZ President the ASM was cancelled, due to the impending wave that was the Covid-19 global pandemic. Health and safety, reputation and finances were considered, in that order. USANZ 2020 ASM was the first major medical conference cancelled – others followed lockstep. There was no blueprint for this global black-swan event!

On our return to New Zealand an island country of 5 million, where 60% of health care is delivered via the public health “free for all” system, the remainder in the private sector. Our visionary Prime Minister, Jacinda Ardern initiated a “go-hard go-early” level 4 lockdown with only essential services open – elimination was the goal.

We were all un-prepared, and it lasted 5 weeks. A surgical pause in both health sectors allowed planning, preparation and training in PPE for the disease surge that did not arrive. We zoomed in our pyjamas and made sure we were free for the 1pm daily national television briefings featuring Jacinda Ardern and Ashley Bloomfield, DG of health, who has achieved cult status, and now features on a range of t-shirts. Cell phone tracking data indicated over 90% reduction in movement. Our “team of 5 million” has been a large part of the evolving success story. Elimination was possible, is possible and was confirmed! During this time manual contact tracing was expanded, testing snowballed, and Covid cases fell to zero.

During level 4 we undertook only non-deferrable surgical cases, with case definitions agreed by all specialties. We lost only 10% of our theatre volumes. OPD were completed by phone or video, and only patients that needed a procedure were seen face to face. Medically we have had no actual Covid cases in the surgical service, a handful of Covid patients in ICUs nationally. The majority of deaths did not reach ICU due to their age and co-morbidity.

We have now welcomed stepdown, level 2 with open arms, although concerned about a second wave of cases, however our unquestionable advantage of living in this unique country – our island fortress with a salt-water moat – sees us optimistic. We’re adjusting to sign in manually to all retail premises in light of no electronic tracing App and 80% of our businesses are open with the exception of bars, gatherings are restricted, and our hard borders remain.

Currently we enter the hospital via a staff entrance, with hand sanitiser but no masks. Patients are allowed 1 visitor only and have to sign in, use hand sanitiser and have restricted duration of visit. Normal surgical volumes have now resumed with no restrictions on the type of cases allowed.

We are advised to stay home if we have any respiratory symptoms, get a swab and cancel activity – no more kiwi grit or soldiering on! Patients are screened 7 days pre op by a phone call, delayed if international travel or a Covid contact within 14 days. A swab is only recommended if the patient is symptomatic, and if negative surgery can be completed. Patients are cancelled on the day of admission if they are unwell. Cancellations are now acceptable. A 20% operating theatre throughput reduction has been observed. We feel lucky, for now. From a USANZ perspective we are looking into innovative virtual meeting formats along with cancelling or postponing all face to face meetings.

Our international borders remain hard with a 14-day voluntary lockdown for all incoming. This will be in place until a successful vaccine is available. We accept international isolation will be in place for a while and hope to enjoy this pause, while implementing any useful learned strategies. We are proud of our inspirational leader, intelligent government and unprecedented international success – at least up until now. We wait, watch, listen and hold our breath… remember we are all in this together!

Stephen Mark, USANZ President

Coming out of lockdown safely – A view from Italy

How our lives have changed. Over two months ago we published a popular blog on the effect of COVID-19 on our surgical practice (https://www.bjuinternational.com/bjui-blog/covid-19-and-urology/). In many ways it informed us as to what to do during challenging times to keep our patients safe.

As we gradually take careful steps out of lockdown, our minds are focused on the most important of all words – SAFETY. 

While every nation will have differences and nuances, the principles of learning from each other, remain the same as they did when lockdowns started.

I am not surprised by new and ever changing information about the disease almost every day and see international collaboration as a powerful and positive tool in this situation.

With this in mind I requested our friends from Italy, China, Germany and New Zealand for their own perspectives.

Here are their thoughts for your reading pleasure.

Please feel free to insert your comments under the blog and share on social media.

Yours in friendship,
Prokar Dasgupta
Editor in Chief, BJUI

I am grateful to BJU International for having had the opportunity, around 2 months ago, to share my perspective on the impact of the COVID-19 pandemic on urological practice at Careggi University Hospital in Florence, Italy. I hope that information, coming from an Italian Centre that had to timely re-organize its logistics and surgical schedule in light of the rapid spread of the epidemic across the Country, might have provided some insights for urologists in the UK and worldwide to adapt their own activity during the acute phase of the COVID-19 outbreak.

Herein I am honored to share with you my perspective on how we may safely come out of lockdown, and on what we may learn as a Community from the COVID-19 pandemic to optimize the future organization of urological services. 

First of all, I entirely endorse Prof. Dasgupta’s view that, while the way Urology Centres around the world are coping with the challenges raised by the COVID-19 pandemic, as well as the way they are trying to rebuild new “standards” during the “second phase” of the emergency, will certainly vary within Countries, Regions and Hospitals, we as urologists should be open-minded and strive to share and learn as much as possible from each other. As such, in the highly complex scenario we are all living in, every perspective and viewpoint should be leveraged to set new tiles in the “mosaic” of evidence on Urology practice in the post-COVID era.

The status of the COVID-19 epidemic in Italy has significantly changed through the last two months. As of 15th March 2020, the number of laboratory-confirmed cases in Italy was 24 747, with 1809 deaths. As of 14th May 2020, these numbers were 223 096 and 31 368, respectively (making Italy the fifth Country in the world with the higher number of infections, https://lab24.ilsole24ore.com/coronavirus/).

Fortunately, the measures undertaken by the Italian Government so far, including the lockdown, have led to a drastic reduction in the number of daily infections and deaths due to COVID-19, with a progressive parallel decrease in the burden of severely ill patients admitted in ICUs.

However, there is no doubt that this unprecedented pandemic has had a dramatic impact on Italy from all possible standpoints, including the healthcare system. In particular, urology practice has been truly revolutionized during the past two months. Indeed, not only virtually all Centres worldwide have been forced to follow strict schemes for the triage of urological procedures that should have been prioritized in light of the scarcity of resources [1-3], but also Urology training programs have suffered a significant slowdown with potential meaningful consequences on residents’ learning curve [4,5]. As such, while we are now facing the new challenge of dealing with the “adaptation” and forthcoming “chronic” phases of the pandemic (during which all urological services will be progressively reopened to patients) we should keep the focus on preventing nosocomial infection and on cost-effective use of available resources.

In this scenario, the Department of Urology of Careggi University Hospital, directed by Prof. Carini and Prof. Serni, located in Tuscany – one of the five Italian Regions that have been hit most by COVID-19 – has already planned a series of measures aiming to safely restart all Urology services in the coming weeks, ensuring patients and healthcare workers’ safety.

  • First, since late March, all patients scheduled for urological procedures (as well as patients undergoing minor surgeries in the outpatient setting, ESWL and prostatic biopsies) had to be tested for Sars-CoV-2 infection (through nasopharyngeal swaps) 48 hours before surgery. Patients who resulted positive for COVID-19 were recommended to remain in quarantine until two consecutive nasopharyngeal swaps resulted negative for the infection. Then, they could have been rescheduled for surgery. In addition, starting from May 1st 2020, all patients undergoing surgery were tested for Sars-CoV-2 infection through nasopharyngeal swaps 24-48 hours before discharge from the Hospital. Of note, patients’ relatives were not allowed to enter the Department during the whole hospitalization period; as such, the news regarding both the intervention and the postoperative course were communicated by the urologists in charge of the inpatient ward by telephone.
  • Second, beyond appropriate use of all PPE, all healthcare workers in our Department, including nurses, doctors and administrative staff, underwent serology testing (IgM, IgG) for Sars-CoV-2 infection during the first weeks of April. Those who resulted positive according to the serology underwent further testing with two consecutive nasopharyngeal swaps; if positive, they were recommended to remain in quarantine until two consecutive nasopharyngeal swaps resulted negative for the infection.
  • Regarding the Urology operating rooms, we are currently using 50% of them (two out of four) in the main Hospital pavilion, prioritizing major uro-oncological surgery (open and minimally-invasive procedures for prostate, urothelial, and kidney cancer), as well as surgery for penile and testicular cancer. Most endoscopic surgeries for bladder cancer (TURBs) were redeployed in a different Hospital pavilion (in one dedicated operating theater, active four days a week). Overall, the surgical activity of our Urology Department is currently reduced by 20-25% as compared to a “standard” period. Fortunately, we are not facing major concerns regarding the availability of ICU beds for urological patients at our Hospital.

While in the very first weeks after the spread of the epidemic, only high-priority major uro-oncological surgeries (i.e. radical cystectomy, radical prostatectomy for locally-advanced diseases, nephrectomy for cT2+ cancers, radical nephroureterectomy for high-risk upper tract urothelial carcinoma) were performed – accounting for approximately one third of all major cancer surgeries at our Centre based on a recently published study by our group [6]) – later on we progressively included in the surgical schedule also lower-priority interventions (i.e. radical prostatectomy for intermediate-risk prostate cancer, radical/partial nephrectomy for cT1b tumors, etc.).

  • Similarly, we progressively reintroduced into the surgical schedules also elective interventions for benign urologic conditions, prioritizing those patients who were symptomatic and/or at higher risk of adverse clinical outcomes. It is important to highlight that the management of the surgical waiting list during the acute phase of the COVID-19 pandemic and the planning of the weekly surgical schedule was performed according to a careful day-by-day evaluation of the available resources in the Hospitals’ ICUs, as well as the number of available theaters for urological procedures.
  • Importantly, we did not record any case of COVID-19 after elective or urgent urological procedure during the past two months (including after minimally-invasive surgery, the safety of which has been object of great debate within the Urology Community [7]).
  • Regarding urological emergencies, patients who were admitted to our Urology Unit from the Accident & Emergency Department had to be tested for Sars-CoV-2 infection (through nasopharyngeal swaps) before admission. If needed, surgery for urological emergencies was performed in a dedicated operating theater in the main Urology pavilion.
  • The kidney transplantation program from deceased donors (both donors after brain death [DBD] and donors after circulatory death [DCD]) continued without major changes at our Unit, thanks to a timely and effective reorganization of all activites related to organ procurement by the Tuscany Transplant Authority, as well as a series of logistical and clinical measures implemented early after the spread of the epidemic to prevent transmission of the disease to KT recipients. On the contrary, kidney transplantation from living donors was (and is still) suspended since the end of February 2020.
  • Most urological procedures in the outpatient setting (ESWL, minor surgeries, prostatic biopsies) were canceled during the first weeks of the COVID-19 epidemic, being the only exception cystoscopies for suspected bladder cancer. Thereafter, they were progressively re-started (especially during the last 2 weeks), provided that patients had been tested negative for Sars-CoV-2 infection and anyway after a comprehensive triage by telephone outlining the priority of such procedure.
  • Finally, while during the “acute phase” of the pandemic the vast majority of urological consultations in the outpatient setting were canceled (and replaced by telemedicine strategies, except for those visits deemed urgent by urological staff after a careful screening by telephone interview and those for medications after elective surgery). In the coming weeks most of them will be re-started, provided adequate logistics (i.e. distancing between patients and appropriate time schedules) to ensure maximal safety for both patients and healthcare workers.

Overall, the “big picture” delineated by all these facts and figures highlights that our Unit, as in many other Departments in Italy, has already started the process of rebuilding the foundations of a new “routine” urological practice, adapting (and eventually overcoming) to the challenges met during the first acute phase of the COVID-19 emergency.

Nonetheless, my global perspective is that urologists should remain vigilant and resilient, keeping the focus on ensuring safety and cost-effective use of resources. This is important, as the COVID-19 epidemic could potentially flare-up in the near future if all safety measures recommended by Hospitals and the Government were not strictly followed by the population.

Moreover, I believe this unprecedented emergency scenario, which has profoundly revolutionized our healthcare system as well as our way of thinking and behaving, should be leveraged to understand which steps should be prioritized to move Urology forward from both clinical, logistical, educational and scientific perspectives.

In this view, the lessons we can learn as a Community from this pandemic for the future include:  

– the need for appropriate (evidence-based) selection of candidates for urological procedures, taking into account also patients’ values and expectations;

– careful prioritization of surgeries, based on the potential impact of delay on important patient outcomes [8];

– rational use of all available treatment modalities for urological cancers (including active surveillance), strengthening the value of team-work and developing a truly multidisciplinary spirit;

– refinement of surgical informed consents, tailoring them to such emergency scenarios [9];

– increased use of virtual Urology learning programs for education of residents [10];

– implementation of teleproctoring and telementoring technologies into everyday surgical practice [11];

– inclusion of telemedicine into routine pathways of care for urological patients [11].

By doing so, we may be able not only to be more prepared for similar future emergency scenarios, but also to take significant steps toward improvement of Urology as a specialty, as well as ourselves as individuals.

Riccardo Campi, MD

– Resident in Urology, Dept. of Urology, Careggi University Hospital, Florence (Italy)
– Ph.D. student, Doctoral Program in Clinical Sciences, Dept. of Experimental and Clinical Medicine, University of Florence, Florence (Italy)
– Member of the EAU Young Academic Urologists – Renal Cancer Working Group
– Associate Member of the EAU Section of Oncological Urology
– Twitter: @Ric_Campi

References

[1] Stensland KD, et al. Considerations in the Triage of Urologic Surgeries During the COVID-19 Pandemic. Eur Urol. 2020 doi: 10.1016/j.eururo.2020.03.027.

[2] Ribal MJ, et al. EAU Guidelines Office Rapid Reaction Group: An organisation-wide collaborative effort to adapt the EAU guidelines recommendations to the COVID-19 era. Eur Urol 2020 (In Press); available at: https://www.europeanurology.com/covid-19-resourceEAU

[3] Ahmed K, et al. Global challenges to urology practice during COVID‐19 pandemic. BJU Int 2020. In Press. https://doi.org/10.1111/bju.15082

[4] Amparore D, et al. Impact of the COVID-19 pandemic on urology residency training in Italy. Minerva Urol Nefrol. 2020. doi: 10.23736/S0393-2249.20.03868-0

[5] Porpiglia F, et al. Slowdown of urology residents’ learning curve during the COVID-19 emergency. BJU Int. 2020 [Epub ahead of print] doi: https://doi.org/10.1111/bju.15076.

[6] Campi R, et al. Assessing the Burden of Nondeferrable Major Uro-oncologic Surgery to Guide Prioritisation Strategies During the COVID-19 Pandemic: Insights from Three Italian High-volume Referral Centres. Eur Urol. 2020 [Epub ahead of print] doi:10.1016/j.eururo.2020.03.054

[7] Novara G, et al. Risk of SARS-CoV-2 Diffusion when Performing Minimally Invasive Surgery During the COVID-19 Pandemic. Eur Urol Apr 2020;0(0). Available at: https://www.europeanurology.com/article/S0302-2838(20)30247-5/abstract

[8] Wallis CJD, et al. Risks from Deferring Treatment for Genitourinary Cancers: A Collaborative Review to Aid Triage and Management During the COVID-19 Pandemic. Eur Urol 2020. In Press. DOI: https://doi.org/10.1016/j.eururo.2020.04.063

[9] Bryan AF, et al. Unknown unknowns: Surgical consent during the COVID-19 pandemic. Annals of Surgery 2020. In Press. https://journals.lww.com/annalsofsurgery/Documents/Unknown%20unknowns%20.pdf

[10] Claps F, et al. Smart Learning for Urology Residents during the COVID-19 pandemic and beyond: Insights from a Nationwide Survey in Italy. Minerva Urol Nefrol 2020. In Press.

[11] Karim JS, et al. Bolstering the surgical response to COVID‐19: how virtual technology will save lives and safeguard surgical practice. BJU Int 2020. In Press. https://doi.org/10.1111/bju.15080

[12] Connor MJ, et al. COVID‐19 pandemic – is virtual urology clinic the answer to keeping the cancer pathway moving? BJU Int 2020. In Press. https://doi.org/10.1111/bju.15061

 

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