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Asthecurrentpandemicthreatenstodivertvaluableresourcesfromchildren’ssurgicalcaretootherpressingpublichealthandclinicalpriorities,theGlobalInitiativeforChildren’sSurgerysoughtinputfromcolleaguesworldwideonwhatwerethebiggestchallengesfacingthemandwhatGICScoulddotohelp.Werecognizethisisarapidlyevolving,dynamicsituationwithmostcountriesandhospitalsfacingdifferentsetsofchallenges.Inthisfollow-upsession,weaskourpanelistshowGICScouldhelpwiththefollowing:

KENWONG|PediatricGeneralSurgeon,HongKongLEECARLOMILLANO|PediatricGeneralSurgeon,IndonesiaBEDAESPINEDA|PediatricGeneralSurgeon,ThePhilippinesLUBNASAMAD|PediatricGeneralSurgeon,PakistanVRISHAMADHURI|PediatricOrthopedicSurgeon,India

SAMEHSHEHATA|PediatricGeneralSurgeon,EgyptALAWAL-AIYEDUNOLUBUNMI|PediatricNurse,NigeriaNABULINDOSUSANE|PediatricAnesthesiologist,KenyaFABIOBOTELHO|PediatricGeneralSurgeon,BrazilEMMANUELAMEHandKOKILALAKHOO|Moderators

SeeourwebsiteforextensiveCOVID-19resourceswww.GICSurgery.org

PlansforAction:MitigatingtheImpactofCOVID-19onChildren’sSurgery

Thursday,2July202015h00–16h30BST(LondonUKtime)

§  Educationalresources§  Guidelines§  Backlogofpatients§  Research

ThankstoourPartners

PREVIOUSWEBINAR:

Whatarethegreatestchallengesfacingyou?WhatcanGICSdotohelp?

MitigatingtheImpactofCOVID-19onChildren’sSurgeryEmmanuelAmeh,PaediatricGeneralSurgeon,Nigeria,GICSChair

KokilaLakhoo,PaediatricGeneralSurgeon,Oxford,UK,GICSPastChair

GICSPastChairGICSChair

Whatarethegreatestchallengesfacingyou?• Cancellationofelectiveoperationswithoutproperguidelinesonwhichcasesshouldbedelayed• Noguidanceonwhentoresumeelectivesurgery,therateatwhichtoresume,andwhichcasesshouldbeperformedfirst• Alargebacklogofcasestobedonewhenelectivesurgeryresumes• Cessationofoutreachandsurgicalvisitingteams



Whatarethegreatestchallengesfacingyou?•  Latepresentationforemergentconditions•  Increasedlengthofstayduetolatepresentations•  LessendoscopyandMIS•  Treatmentofchildrenbyless-experiencedprovidersatlocalhospitals•  Inabilitytoseepatientswithcongenitalanomaliesinclinicsinatimelyfashion



Whatarethegreatestchallengesfacingyou?• Cessationofeducationoftraineesandmedicalstudents• UnavailabilityofCOVID-19testing•  ShortageofappropriatePPE•  LackofguidelinesforuseofPPE•  InfectionanddeathofHCWs• AnxietyandfearofHCWs



HowcouldGICShelpwiththefollowing?• Educationalresources• Guidelines• Backlogofpatients• Research




ActionPlanningForum:MitigatingtheImpactofCOVID-19onChildren’sSurgery

MitigatingtheImpactofCOVID-19onChildren’sSurgeryKennethWong,PaediatricGeneralSurgeon,HongKong

HowcouldGICShelpwitheducationalresources?

•  Educationforpatientsandcarers


HowcouldGICShelpwithguidelines?

• Pre-optestingàWhatisthebesttest?How?


HowcouldGICShelpwithbacklogofpatients?

• Raisefundingfor:•  Extraequipment•  PPE•  COVID-19testing

• Redistributecasestootherunitstocatchup?


HowcouldGICShelpwithresearch?

• Detailsofbacklogofoperations•  Long-termeffectsofpandemiconchildren

MitigatingtheImpactofCOVID-19onChildren’sSurgeryLeecarloMillano,PaediatricGeneralSurgeon,Jakarta,Indonesia


• Safetyofconductingsurgicaloperationsonchildren•  Laparoscopy,thoracoscopy

• Safetyofdeliveringteachingmaterialsforresidents• Currentlydeliveringlecturesforresidentsthroughonlinemeetings



• Protocolsforsafepre-op,intra-op,post-opcare



• Developmentofprotocolsduringthepandemic•  Teachingofresidents,disseminationofknowledge• Afterelectiveoperationsresume:•  Assistinthetrainingofsurgeons•  Exchangeofknowledgeandskillsthroughonlinemedia

• Aftertravelrestrictionslifted:•  Supportdevelopingcountriesthroughcollaborationofresearchandtrainingofpediatricsurgeons



• Researchonsafetyofprocedures• Whatsafealternativescanweapplytokeepmeetingthedemandofpediatricsurgery,atthesametimekeepingthepatientandthehealthworkerssafe?

• Researchonsafealternatives•  Forinstance,theuseoflaparoscopyissaferthanlaparotomyduringthepandemic

MitigatingtheImpactofCOVID-19onChildren’sSurgeryBedaEspineda,PaediatricGeneralSurgeon,PhilippineChildren’sMedicalCenter


EDUCATIONFORGICSMEMBERS•  Topics

•  Updatesonthevarioustopicsofpediatricsurgeryanditssubspecialties•  TumorBoardconferences•  “HowIdoit”videos

•  Format• Webinar,teleconferencelivestreaming,YouTubes,etc



EDUCATIONFORTRAINEES/FELLOWS•  Topics

•  Didacticlecturesonneonatalandpediatricsurgery•  TeachingandsurgicalcurriculummoduleswithPre-andPost-Tests•  Skillssimulationtrainingvideosfortrainees

•  Format• Webinar,Zoom,orWebexconferences



•  Howtopreparepatientspriortosurgery•  RoleandimportanceofRT-PCRtesting,othertypesofrapidantibodytesting•  PrioritizationofsurgicalcaseswhenschedulingintheOR•  Issuesonthecorrectandproperphysicalsetupoftheoperatingroomsandanesthesiaunit•  IssuesofsafetyofallhealthcareworkersandotherpersonnelintheOR,anesthesia,andPACU



• Designandprovideguidelinesonhowtoincreasethecensusofsurgicalcasesandminimizethebacklog•  SendorprovidefundstoLMICstopurchasemuch-neededPPEs,goggles,andothersurgicalmaterials• Aftertravelrestrictionslifted:

•  HICsurgeonsshouldcontinuetosupportLMICproviderstoattendandparticipateinconferences/conventions



• ProfileofpediatricsurgicalcasesdoneduringpandemicinbothHICsandLMICs•  FactorsaffectingprognosisandsurvivalofCOVID-19pediatricsurgicalcasesdoneduringemergentandelectivecases



• Whathasbeengatheredalready?•  Dataonthenumberandtypesofcases,andoutcomesofemergencycasesdoneduringthis4monthslockdown

• Whatisthebestmeansofgatheringthisinformation?•  REDCapmulticenterstudies

• HowcanGICShelp?•  GICScouldinitiateandfundamultinationalinternationalstudybycommissioningaresearchgrouputilizingtheREDCapdatacollectionsystem

MitigatingtheImpactofCOVID-19onChildren’sSurgeryLubnaSamadandMaryamAftab,PaediatricGeneralSurgeons,Karachi,Pakistan


• Format•  Interactivesessions,smallgroupsessions,nowebinars!

• Topic• Precautions,riskcategorizationofcases,management



• Electivesurgeries • Whatisthebestpracticeforthesecases(eghernia,circumcision)

• PrecautionsforsurgeryofCOVID-19andnon-COVID-19patients• Guidelinesonlaparoscopicsurgery• SurgicalmanifestationssecondarytoCOVID-19



• Financialresourcesforovertimeinpublicsectorfacilities• SupportatallHRlevels,notjustsurgeons



• Community-basedassessmentofunmetneed• ImpactofCOVID-19onsurgicaloutcomes

MitigatingtheImpactofCOVID-19onChildren’sSurgeryVrishaMadhuri,PaediatricOrthopedicSurgeon,IndiaHowcouldGICShelpwitheducationalresources?

•  Structuredcourses(2-3times/week),whichincludepracticalexercisesthatallowthemtoacquireskills•  GICScoulddevelopcertificationcoursesineachsubspecialty,providingacertificateatcompletionforasenseofachievement

•  WouldrequirealotofinputfromGICSfaculty•  Bestdoneasawebinarwithinteractivecomponent,suchasexercises,tests,andparticipantresponses

•  Onlinetheoreticalcoursesandskillsupgrades•  YouTubevideosofproceduresineachsubspecialty,butnotlikelytobeabletodothisnowduetohighrisk

FORPOST-GRADUATESWHOSETRAININGHASCOMETOAVIRTUALHALT:

MitigatingtheImpactofCOVID-19onChildren’sSurgeryVrishaMadhuri,PaediatricOrthopedicSurgeon,IndiaHowcouldGICShelpwitheducationalresources?

•  InformationaboutavailablePPE,drugs,andprotocolsforsymptomaticandasymptomaticpatients,bearinginmindthat:•  EachcountryandregionhasitsownguidelinesforPPE,testing,quarantine,andtreatment

•  SomeoftheseresourceswillnotbeavailableinallLMICsettings•  LMICscanproducesomethingslocallyatlowcost

•  Onlineresourcewhereallinformationandrecommendationsareinoneplace(seewww.GICSurgery.orgCOVID-19resources)•  Forexample,D-dimertestsforhypercoagulopathycanindicateneedforearlyanti-coagulation

COVID-19INFORMATION:

MitigatingtheImpactofCOVID-19onChildren’sSurgeryVrishaMadhuri,PaediatricOrthopedicSurgeon,India


•  MusthavesufficientLMICrepresentationtoknowwhatisavailableandpractical•  Needtohaveguidelinesforallsubspecialties•  Eventuallyeachlocalsettingwillneedtomakeitsownguidelines,basedontheirneedsandsituation•  RepeatconsultationscouldbemanagedviatelemedicineorWhatsApp--ifallowed,safe,andlegal•  Safedocumentationessential

•  GICScouldhelpdevelopappstoincorporatedocumentationintopatientmedicalrecords

•  Mightneedtoinvolvelocalproviderstoelicitsomefindings



•  Increasingworkforcetoaddressthebacklog•  Sincebuildingupworkforcewouldtaketime,morelikelyexistingworkforcewillworkovertimeandcancelleave

•  Couldfundingbeprovidedforthisextraworkforlocalproviders?•  Patientsneedmoneytotravelbacktoreferralcenters

•  ManyinVellorehadtobesupportedbydonationsforfoodandaccommodationwhentheirfundsranout

•  ConsiderindividualdonationsfromGICSmemberstosupportpatients,withfeedbackonhowthefundswereused



•  Dataonnumberofpatientsunabletoconsultforprimaryvisit,aswellasrepeatvisits•  Comparenumbersduringpandemicwithprevious2years

•  Changesinthesurgicalcaseloadprofile

WHATACTION-ORIENTEDRESEARCHISIMPORTANT?



• Percentageofpatientsunabletokeepappointments• Reductioninnumberofnewpatientsandrevisits• Numberofpatientsgettingtreatmentbyphoneandtelemedicine

WHATINFORMATIONHASALREADYBEENGATHERED?



• Adverseoutcomes• Delayinstartingessentialtreatments,suchascastingclubfoot,delayinDDHsurgery,delayinremovalorapplicationof8plate•  Financialstressassessmentbyinterviewingfamilies• Reviewofpatientrecordsforlast6-12monthstoassesshowmanyaremissingessentialvisitsthatmightaffectthemadversely

WHATINFORMATIONSHOULDBEGATHEREDNOW?



• Utilizestudentsandprovideincentives• Contactthroughphones/email/socialmedia• REDCapcouldbeusedtogathermulti-centerdata

WHATISTHEBESTMEANSOFGATHERINGTHEDATA?


HowcouldGICShelp?

• Provideperson-to-personfundingforseveredistressinpatientsanddoctors•  Setupmulti-institutionalstudiestoassessstress• Developsoftwaretoidentifyandcallbackpatients,toguidethosewhoneedessentialfollow-ups,suchastumors/8plates/frames• Assesslocalissuesandfundraisingtoaddressthese,astheyvaryfromplacetoplace• Discussiononfrugalinnovationinareasofneed

MitigatingtheImpactofCOVID-19onChildren’sSurgerySamehShehata,PaediatricGeneralSurgeon,Alexandria,Egypt

HowcouldGICShelpwitheducation?

• Onlinewebinars• Webinarsdedicatedtospecificgeographicallocationstoassesslocalproblems

•  YouTubevideos• Guidelinesstatements

•  Prioritizationofbacklogcases



SettingpriorityofsurgeriesduringCOVID-19PediatricsurgeryconsultationGuidelinesForTheSurgicalPatientsInwardsScreening/testingofpatientsforsurgerySOP’SForOperationTheatresAerosolgeneratingdevicesandprocedures:PersonalProtectiveEquipment’sduringsurgerySOPsforAnesthesiaOperationtheater,Ventilation,andfiltrationLaparoscopyandthoracoscopyHistopathologyanddocumentation



•  Suggestingaguidelineforprioritizingelectivecasesbasedonindication,age,potentialforcomplication,localresources•  FundraisingtocoverneededequipmentandhumantaskforcetoincreaseratesofORlistturnovertofinishtheaccumulatedbacklog•  Fundraisingtoassistspeedyresolutionofthebacklog



• Dataneeded•  Theexactvolumeofbacklogandspecificdiseaseentitiestobeabletotakeinformeddecisions•  Theeffectofdelayingelectivecasesonincreasedmorbidity

•  Wehavecollectedthewaitinglistswiththenumberanddiagnosisofcases•  TheREDCapplatformisanexcellentwayofonlinedatacollectionandmulticenterstudiesandcanbeofferedbytheWOFAPStoanycenterinneed

MitigatingtheImpactofCOVID-19onChildren’sSurgeryNabulindoSusane,PaediatricAnaesthesiologist,Nairobi,Kenya


•  Topics:•  UpdatesonnumberofCOVID-19positivechildrengloballyandtheirseverityofdisease•  OfferingemergencysurgeryduringcommunityspreadofCOVID-19

•  Format:• Webinars•  YouTubevideostoshowsomeshortprocedures



• AppropriatePPEfordifferentCOVID-19status• Classificationofurgencyofsurgeryforthebacklogofcases• Precautionsduringaerosol-generatingprocedures• Peri-operativemanagementofCOVID-19positivechildren



•  Sharingofinformationviawebinars/emailsasitevolves• PPEs…..provision,strategiestominimizemisuseandoptimalreuse• Puttingtogethersurgicalteamstotraveltodifferentregionstooffersurgeryforbacklogatsurgicalcamps•  Fundraisingtosupportaboveinitiatives



• Globalpaediatricsurgerybacklogduringthepandemicandtheimplicationsonmorbidityandmortality• OutcomesofCOVID-19positivechildrenundergoingsurgery

•  Materialgearedtowardjuniorresidents,fellows,generalsurgeryresidents,andpediatricians,ratherthanseniorsurgeons• Websiteresources• Webinars•  YouTubevideosforsurgicaltechniques•  Translationoffundamentalmaterialintootherlanguages(egSpanish,Arabic,Mandarin,Russian,Hindi,French,Portuguese)

MitigatingtheImpactofCOVID-19onChildren’sSurgeryFabioBotelho,PaediatricGeneralSurgeon,Brazil

HowcouldGICSwitheducation?

• HowtoprotectagainstCOVID-19withlowresources?•  NoNegativePressureORs•  PPEshortages

• Whichoperationsshouldreturnfirstafterlockdown?



•  Sharecontentwithothercountriesandassociations•  Forexample,BrazilianPedSurgeryAssociationhaslaunchedspecificguidelinesfortracheostomyandformanagementofsurgicalpatientsduringCOVID-19

•  TheseguidelinesareinPortugueseandcouldhelpotherPortuguese-speakingcountries

•  Promoteaninternationalsurveytodeterminewhichsurgeriesareconsideredaprioritybychildren’ssurgicalprovidersaroundtheworld•  Wewouldthenhaveagloballistofsurgicalpriorities•  Wouldneedtoconsidergeographicaldifferences

•  GICScouldencourageandsupportobservershipsorshortfellowshipsforpediatricsurgeryfellowsfromLMICsatHICinstitutions•  Aswebelievethatlotofourfellowshadtheirtrainingimpaired,itwouldbeimportanttopromoteeducationofthefuturePedSurgeons.

MitigatingtheImpactofCOVID-19onChildren’sSurgeryFabioBotelho,PaediatricGeneralSurgeon,BrazilHowcouldGICShelpwithbacklogofpatients?

•  Estimatetheburdenofchildren’ssurgicaldiseasesafterCOVID•  Itwouldhelptodeterminewhichdiseasesshouldbeprioritized

• Wehavethelistofpatientswaitingforsurgery• WeareusingappendectomiesasabellwetherproceduretodeterminetheimpactofCOVID-19inurgentconditions•  Thiswouldbeimportanttopreparebetterthefamiliesincaseofanotherpandemic

• WecouldcreateaREDCapmulticentersurveytoestimatethewaitinglistofchildren’ssurgicalpatientsaroundtheworld



•  Itwouldbeimportanttomonitorthepatientswhohaveundergonesurgicalprocedures,aswellasthesurgicalteam•  WecouldknowifCOVID-19transmissionhasincreasedintheinstitutionswheretheelectiveprocedureshavereturned

•  TheAmericanPediatricSurgicalAssociationhaslaunchedapublicGooglesheetwherepediatricsurgeonsacrosstheUSAcanenterthistypeofdata•  GICScoulddothesame



DISCUSSION:HowcouldGICShelpwiththefollowing?•  Educationalresources• Guidelines• Backlogofpatients• Research




MitigatingtheImpactofCOVID-19onChildren’sSurgeryDiscussion:HowcouldGICShelp?

KennethWongHongKong

LeecarloMillanoIndonesia

BedaEspinedaThePhilippines

LubnaSamadPakistan

VrishaMadhuriIndia

SamehShehataEgypt

SusaneNabulindoKenya

FabioBotelhoBrazil

GOINGFORWARD:•  Furtherdiscussions,summaryofneedsfromthissession• Reviewofproposedinterventions• Developmentofplansforaction• High-leveladvocacy• Harmonyofstrategieswithothergroups

MitigatingtheImpactofCOVID-19onChildren’sSurgeryKokilaLakhoo,PaediatricGeneralSurgeon,UK,GICSChair

EmmanuelAmeh,PaediatricGeneralSurgeon,Nigeria,GICSChair-Elect

GICSChair GICSChair-Elect

ThankyoutoallofourspeakersandtoLifeboxforhelpingushostthisevent

Forquestions:[email protected]

COVID-19resourcesonourwebsite:www.GICSurgery.org

ActionPlanningForum:MitigatingtheImpactofCOVID-19onChildren’sSurgery