Emerging practice patterns in vascular surgery during the COVID-19 pandemic

Abstract

Objective: Ever since the first positive test was identified on January 21, 2020, Washington State has been on the frontlines of the coronavirus disease 2019 (COVID-19) pandemic. Using information obtained from Italian surgeons in Milan and given the concerns regarding the increasing case numbers in Washington State, we implemented new vascular surgery guidelines, which canceled all nonemergent surgical procedures and involved significant changes to our inpatient and outpatient workflow. The consequences of these decisions are not yet understood.

Methods: The vascular surgery division at Harborview Medical Center immediately instituted new vascular surgery COVID-19 practice guidelines on March 17, 2020. Subsequent clinic, operative, and consultation volume data were collected for the next 4 weeks and compared with the historical averages. The Washington State case and death numbers and University of Washington Medical Center (UW Medicine) hospital case volumes were collected from publicly available sources.

Results: Since March 10, 2020, the number of confirmed positive COVID-19 cases within the UW Medicine system has increased 1867%, with floor and intensive care unit bed usage increasing by 120% and 215%, respectively. After instituting our new COVID-19 guidelines, our average weekly clinical volume decreased by 96.5% (from 43.1 patients to 1.5 patients per week), our average weekly surgical volume decreased by 71.7% (from 15 cases to 4.25 cases per week), and our inpatient consultation volume decreased to 1.81 consultations daily; 60% of the consultations were completed as telemedicine "e-consults" in which the patient was never evaluated in-person. The trainee surgical volume has also decreased by 86.4% for the vascular surgery fellow and 84.8% for the integrated resident.

Conclusions: The COVID-19 pandemic has changed every aspect of "normal" vascular surgical practice in a large academic institution. New practice guidelines effectively reduced operating room usage and decreased staff and trainee exposure to potential infection, with the changes to clinic volume not resulting in an immediate increase in emergency department or inpatient consultations or acute surgical emergencies. These changes, although preserving resources, have also reduced trainee exposure and operative volume significantly, which requires new modes of education delivery. The lessons learned during the COVID-19 pandemic, if analyzed, will help us prepare for the next crisis.

Keywords: COVID-19; Coronavirus; Pandemic; Seattle; Washington.

Fig 1

COVID-19 confirmed positive case (blue) and death (orange) trends in Washington State from March 1, 2020 to April 13, 2020.

Fig 2

Number of confirmed positive cases within the University of Washington (UW) system (blue) and intensive care unit (orange) and floor (gray) bed usage. The number of cases within the UW system has increased over time, with an increase in both the number of floor and intensive care (ICU) beds used. Note ICU and floor bed information were only available beginning March 19, 2020, and no information on floor or ICU bed use was provided on April 12, 2020.

Fig 3

Distribution of telemedicine (“e-consults”) versus in-person consultations; 60% of consultations were performed as e-consults and did not require an in-person evaluation.