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Perspective: The Practice of Vascular Surgery in The ‘New Normal Times’

Dedy Pratama
Vascular and Endovascular Division, Department of Surgery, Cipto Mangunkusumo Hospital – Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia

“The efforts and actions we make should not compromise the quality of care we to our patients, while on the other hand, be cost-effective and financially sustainable for the long term. In this “new normal”, every vascular and endovascular specialist has to be well-prepared, well-adapted, and well- equipped to provide the highest quality of care for the community.”

Dedy Pratama, 2020

The coronavirus disease (COVID-19) pandemic represents one of the toughest challenges to the global public health and modern healthcare systems. Since the first case of COVID-19 was confirmed in Indonesia on March 2, 2020, all stakeholders in healthcare along with the government of Indonesia through the Ministry of Health and its recently assembled COVID-19 National Task Force started to prepare for the surge of patients while simultaneously implementing various preventive public health measures. In terms of public policy, the government has been recommending people to maintain social and physical distancing, advocating the routine use of fabric face mask, encouraging workers (notably those who work in ‘non-essential’ sectors) to stay home and work from their home, if possible; applying large scale social restrictions in certain areas, and rapidly constructing designated facilities for both treatment and quarantine purposes. In terms of healthcare services, several professional medical organizations and nearly all healthcare facilities recommend and impose various measures, such as wearing certain levels of standard personal protective equipment (PPE) appropriately, converting standard hospital wards and operating rooms (OR) to makeshift isolation wards, high care units (HCU), and intensive care units, creating and publishing care guidelines to help clinicians manage their practices more safely during COVID-19 crisis, devising algorithms for the screening of COVID-19 infection, and triaging elective surgical and medical cases to avoid further burden on the already strained healthcare capacity due to COVID-19 pandemic.

As an integral part of a healthcare system, the global community of vascular and endovascular surgeons has actively been contributing its share in the efforts of preventing and controlling as well as tackling the enormous burden of COVID-19. Ng et al. from Yong Loo Lin School of Medicine, National University of Singapore (NUS), recently reported the results of surveys consisted of seven questions regarding vascular and endovascular surgery practices to vascular surgeons all over the world. They found that the majority of vascular and endovascular surgery services, including outpatient services, inpatient care, and elective procedures were either suspended or scaled-down temporarily to allow for better allocation of medical resources.1 Mirza from Abbott Northwestern Hospital, Minneapolis,

Minnesota, described the change of vascular surgery practice at his institution, which comprised of rescheduling all elective vascular and endovascular surgery cases except emergency procedures for life- or limb-threatening conditions, and utilizing telemedicine for a significant proportion of outpatient consultations and services.2 The Society for Vascular Surgery (SVS) and the American College of Surgeons (ACS) has also published the Vascular Surgery Triage Guidelines to aid clinicians in triaging vascular and endovascular surgical patients.3,4

When and how will the COVID-19 pandemic end? Will people continue to work from home and avoid commuting, even after the crisis phase of the pandemic has passed? Will surgeons and physicians need to delay elective services further until safe and effective vaccines for COVID-19 are available?

All measures previously described were aimed to manage and better allocate healthcare capacity for COVID-19 cases, chiefly during the time of crisis so that the surge of new cases wouldn’t put too much burden on healthcare systems that were already stretched to their limits. Based on the officially daily-released information regarding the number of new COVID-19 cases, Indonesia arguably has not yet passed the peak of the epidemiological curve so that those practices will be, or at the very least, should be, remain in place for some time to come. However, such aggressive approaches in tackling the COVID-19 pandemic require enormous economic sacrifice, making some of those strategies unsustainable for the long term. While some researchers are optimistic that a vaccine will be ready by the end of 2020, it won’t be possible to postpone elective surgical services and keep people working from their homes for 4–6 months, considering the economic catastrophe it would bring.5 From the perspective of healthcare management, elective surgical services, along with outpatient consultations, are one of the primary sources of revenue for private hospitals, and, as a result, the suspension of elective procedures could potentially jeopardize their operations and drive them towards bankruptcy.

The term “new normal” in Indonesia was popularized by Prof. drh. Wiku Adisasmito, MSc. Ph.D., the chair of the expert panel for COVID-19 National Task Force, essentially meaning “living as usual while practicing additional health and safety measures”, especially for the public. People are always advised to wear fabric face masks (medical- grade masks for the elderly) when they are out and unable to safely distance themselves, maintain good personal hygiene, keep a safe physical distance of at least 1 meter when interacting with others, and refrain from gathering in large numbers.

For healthcare professionals, the term “new normal” essentially carries more or less equal implications, which includes adapting medical and surgical practices to safer models that protect healthcare workers, patients, families, and communities from COVID-19 infection during the time of crisis while concurrently economically sustainable for the long term. In the United States, the American Society of Anesthesiologists (ASA), along with ACS, has issued Joint Statement for the resumption of elective surgical services after COVID-19 pandemic; one of the prerequisite of which is a decline of newly diagnosed COVID-19 cases over a consecutive 14-day period in a region.6 ASA guidelines also warn hospitals to be prepared for the surge of elective surgical and procedural volume, since there will be a backlog after the temporary postponement of elective services; thus, before these services can be resumed, hospitals need to ensure that they have the necessary capacity to handle these increase in volume without reducing its standard of care.6 Some professional medical organizations in Indonesia, including the Indonesian Society for Vascular Surgery (INASVS), has also published a set of recommendations regarding vascular and endovascular surgical practice in the time of “new normal”. Among these recommendations is the use of PPE in clinical practices, whether during outpatient consultations and inpatient care or when performing procedures in the OR or cath lab. Additionally, the recent INASVS guidelines also emphasized for the development and implementation of screening algorithm for all vascular patients, especially those who need to undergo both elective and emergency vascular surgical and endovascular interventions for their conditions, to assure sustainability, this algorithm needs to encompass both accurate and affordable COVID-19 screening tests. Surgeons will also need to take into account the “attitude” of the virus, asymptomatic patients are large in numbers, and they are very infectious indeed. For doing elective operations, surgeons need to be accountable for the patient, not only pre or intraoperatively, but also when it is required to ensure that the patients are COVID-19 free when they are discharged from the hospital.

The COVID-19 pandemic certainly is neither the first global pandemic in recorded history, nor will it be the last. In the past, humanity has faced several catastrophic and deadly pandemics, including the Black Death, which ravaged Europe and parts of Asia in the 14th century, and the Spanish flu pandemic in 1918 to 1920 coinciding with the First World War. However, the COVID-19 pandemic is the first-ever pandemic in modern history that has caused both millions of deaths globally and, at the same time, impacted the global economy so severely, prompting businesses, big and small, to cease their operations and threatening people’s livelihood, both directly and indirectly. It has put a heavy burden on the healthcare systems in an era when the right to health is considered as a fundamental human right, and universal health coverage is the norm in virtually all industrialized and even some developing countries. Thus, it is imperative for all stakeholders in healthcare, including vascular and endovascular surgeons, to actively contribute and ensure healthcare systems will not be overwhelmed in facing the COVID-19 crisis. The efforts and actions we make should not compromise the quality of care we to our patients, while on the other hand, be cost-effective and financially sustainable for the long term. In this “new normal”, every vascular and endovascular specialist has to be well-prepared, well-adapted, and well-equipped to provide the highest quality of care for the community.

Jakarta, 9th June 2020

Dedy Pratama
President of Indonesian Society for Vascular and Endovascular Surgery

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