Rearrangement of general care practices in surgical health units

As a result of the pandemic caused by the new SARS-CoV-2, health services that provide surgical care needed to reorganize their care practices. This required technical, scientific and management skills and knowledge on the part of those who run hospital and/or outpatient surgical units. A study¹⁹ pointed out that, in the current pandemic context, surgical services needed to perform their care in a resolute way in a single consultation, especially with regard to medical and nursing surgical consultations. In this way, patients would be less exposed to the virus, as they would leave the house only once to solve their health demand and would be less exposed to the virus in the hospital or outpatient environment, reducing their chances of being infected by the new coronavirus.

It is known that surgical consultations are unpredictable, therefore, identifying patients’ problems and solving them immediately will not always be possible, and, in these cases, there is a special interdependence between the client and the surgical team. Due to this fact, patients often end up traveling between many health services to have their complaint resolved as quickly as possible.⁴⁶⁾ Thus, if a patient attends a preoperative consultation without presenting the requested or legible exams or with the absence of some important document, for example, it is a challenge for qualified professionals to continue with this service, even though they understand the current public health chaos. Some institutions were unable to employ resources, such as telemedicine, to solve this problem, while others were successful.⁴⁷

More than ever before, this new era requires healthcare and management professionals to become increasingly skilled in their decision-making to ensure the safety of clients who seek help and professionals who risk their health to stay working.²¹ Certainly, this is one of the main challenges that health services around the world face, including surgical ones. In the same proportion that the client lacks safe, error-free and damage-free care, professionals who offer this care must be well directed, in terms of their conduct, to remain free from legal proceedings, violence and health problems. More has been demanded of health professionals in these times, so keeping them productive amid pandemic tension and the increase in activities assigned to them is a challenge. In this scenario, surgical team professionals whose clinical-surgical attributions were expanded in order to meet the health service personnel’s needs stand out.²⁰

The current working conditions of health professionals, especially nurses, in many countries around the world, are marked by overload of activities, low remuneration and insufficient availability of personal protective equipment.⁴⁸ These factors are certainly the main responsible for the exhaustion, contamination, illness and death of these professionals who work courageously on the front line, whether in the wards, in the surgical centers or in ICUs. Many professionals at the beginning of the pandemic were removed because they had risk factors for COVID-19 and others continue to be contaminated, falling ill and/or dying, further reducing the number of professionals to work on the front line of the disease. This scenario has increasingly demanded that health units hire doctors and nurses to meet the demands of the operating room and other units.^{22,38,41,42,44}

It is important to emphasize that, since graduation, there has always been a discussion about the number of insufficient professionals in health services to provide safe and resolute care. With the pandemic, it could be inferred that a worsening of this framework of insufficient professionals is primarily responsible for culminating in work overload for those who remain working, given the high demand of patients for urgent care.

Challenges related to administration and management of the surgical sector

The difficulty faced by health units to manage the high demand of patients who require urgent perioperative care was one of the challenges highlighted, and this required important resignifications in this sector, even if temporary. Scholars^20,33,35) reveal that the high demand for patients and care, in public or private institutions, required the support of perioperative nursing to provide intensive care to patients in need of critical care in the anesthetic recovery rooms, because they ended up admitting critical postoperative patients indicative of ICU admission. Managing a surgical sector in these conditions was extremely delicate.

One of the greatest concerns of managers of these health services was regarding the control and availability of beds for intensive care for victims of COVID-19.¹¹ This led the management teams of these institutions, at the global level, to envision ways to transfer material and human resources from the operating room to the first aid units and ICUs.^{22,24,26,31,39,40,41} Concomitantly, these managers were also concerned with providing enough emergency surgical beds to meet the demand of users who needed it.²³ With material and human resources already limited in all sectors, it was certainly challenging for managers to decide the best strategies for relocating personnel and materials at this unit to those whose service demand was higher. It is also possible to reflect that managing surgical units with fewer professionals and materials has also become challenging, even more so with the condition of keeping emergency surgical beds available for patients with COVID-19.

In the waves of contagion of the disease, elective surgeries had to be postponed. As a result, the number of elective surgeries generated an increasing volume of backlogs. Managing this accumulation and the impacts of this waiting on the lives of patients worried health services.^{22,30,31,36,37,44} It became necessary, therefore, to devise ways to overcome the negative impacts on the system of care for elective surgical patients, especially those with important chronic conditions such as cancer or who need transplants.^39,44,45) Studies indicate that patients with long-deferred elective surgical indications can evolve to a poor prognosis and, at times, can be fatal. Thus, assessing the feasibility of performing elective surgeries during the COVID-19 pandemic has been extremely necessary, especially during the waves of contagion. Certain clinical conditions and diseases, especially those that present stages of evolution, can progress to a degree that manifests organic responses that cause suffering to patients and irreversible damage to patients.⁴⁹ It is also recommended that cancer patients or those in need of transplants should not have their surgeries postponed.^49,50

Due to the cases of patients who presented a bad evolution of their clinical condition because their surgeries were postponed, the need to follow up and control the clinical conditions of all patients who had their surgeries postponed because they were classified as elective.^31,39,44,45 Administration and management of all these nuances was of utmost importance during the peaks of the waves of contagion and hospitalization of patients by COVID-19.

Follow-up and control of mediate preoperative patients

The researchers⁵¹ revealed that following up patients with surgical indication has become a challenge because many patients, during peaks of contagion, do not attend their control and routine appointments and, as a result, follow-up visits are seriously interrupted. In this case, one should consider the fear that these patients have of being contaminated when seeking health services during this period, even recognizing the worsening of their health condition. Thus, considering the concern of health professionals with these patients and the negative clinical outcome of these subjects, reflections began to drive the idea that scheduled surgical activities should be restarted.^28,29

Deciding to resume elective surgical activities in the pandemic scenario, especially amidst the waves of contagion, requires constant observation about the readjustment of institutional routine surgical practices. This is necessary in order to ensure the safety of assisted patients and healthcare professionals. This challenge requires an important dedication from all those involved in the assistance and from those who are in charge of developing protocols and guidelines for institutional care.²⁷ Guidance on the return of essential and non-essential surgeries during the COVID-19 pandemic continues to be carried out, especially after the peaks of contamination by the new SARS-CoV-2. In some countries, the recommendation, before restarting elective surgical programming after a wave of contamination of the population by COVID-19, is to carry out a survey of the occupancy rate of ICU beds, analyze the moment of resumption, considering the incidence rate of COVID-19, flow of care and protocols registered in regional medical councils, in order to always maintain autonomy of patients to the best of their ability.^52,53

Patients’ and health professionals’ autonomy and mental health in this scenario

The maintenance of patients’ autonomy in the context of healthcare in these times of pandemic was widely discussed, including that of women in choosing their type of childbirth.²⁵ Therefore, the elaboration of care protocols to be implemented in childbirth, puerperium and abortion during the current pandemic in agreement with the restrictions imposed by institutional guidelines on surgical activities during peaks of contagion by this disease has been considered important, respecting the autonomy of women throughout the puerperium or abortion process.^54,55 Although the current situation seems to haunt health professionals, it is important to evoke the importance that caring holistically involves humanization. The autonomy of no patient and health professional should be questioned or disrespected.

Another important challenge to be discussed is mental health and overcoming the shaken emotional aspects of patients and professionals who make up the surgical team.^33,34 Those who care for the sick may become mentally ill; this emotional exhaustion can favor the loss of team personnel and the increase of professionals with mental disorders acquired as a result of the COVID-19 pandemic, with special emphasis on those who make up the nursing team.⁵⁶ It is important that the institutions themselves provide psychological support services for these professionals, so that they follow them up until discharge and return to activities.

Surgical patients are not exempt from being mentally affected, especially in the era of fake news, a challenging period for health professionals to be able to demystify the waves of false information that spread about the COVID-19 disease.^33,34 Unconventional issues such as loss of economic pay, mental health concerns, the impact of social media, and the wave of surveys and webinars are the main factors affecting the mental health of these patients. Violence and threats to health professionals are also due to access to false information about scientifically proven treatment and conduct.³⁴

In professional practice, patients are commonly seen emotionally hesitant, insecure and fluctuating about their thoughts and attitudes as a result of their surgical condition. In addition to these factors that affect the mental health of these patients, it is important to point out that professionals from the surgical team and their residents should pay attention to this situation of overlapping risk factors for mental illness. This is important so that these clients do not give up on their treatment and/or do not fail to adhere to the healthcare prescribed by the multidisciplinary team throughout or at some specific time during the perioperative period. Studies show that psychology residents have contributed significantly to this situation.⁵⁷

Teaching and learning of multidisciplinary health residents in the operating room

Health residents’ professional performance in surgical units is essential for holistic healthcare and for controlling the demand of patients who need clinical-surgical care. However, the education and arrangement of these professionals in these times of pandemic was seriously compromised at the peak of the disease.^32,58 These resident professionals from different professions, whether in nursing, medicine, psychology, physiotherapy, among others, have been continuously acting in the face of COVID-19, even with the limitations imposed by the pandemic.^59-61 However, due to professional inexperience, these resident professionals and trainees may be more exposed to the disease, and that is why the responsible institutions and their supervisors must continuously offer them training and qualification courses to face the pandemic over time in these services, even if they are vaccinated. It is also necessary to encourage more reflections on teaching strategies in the multidisciplinary residency that should be adopted, with a focus on overcoming the challenges imposed in the teaching and learning of these agents.

In this scenario, the presence of tutors responsible for these subjects is essential so that they can supervise the professional practice of these health residents with excellence. Surgical patients need quality care that prevents and minimizes the risks involved during surgery. Patients with COVID-19 or with COVID-19 sequels during infection or post-infection, with or without sequels, need multidisciplinary residents and qualified institutional staff.

Financial maintenance of public and private surgical health services

Finally, it should be noted that the impacts of this pandemic have not only affected the community and public health institutions, but also private outpatient services that offer elective procedures. The main challenges focused on overcoming the loss of revenue and personnel for some of these units, especially for public services.⁴³ These health units have suffered considerable economic impacts, being more significant for public services, since they need a minimum income to pay for their health personnel employed and materials. Although it was seen that many health institutions hired more professionals, many others had to be fired due to the suspension of elective procedures, which led to a decrease in the income of the institutions for this sector. Revenues that were previously destined for public health clinics, for instance, needed to be reallocated to the structuring and operationalization of field hospitals.⁴³ After the waves of contagion, these challenges were gradually overcome. Failure to fully overcome these impacts can lead to a significant lack of coverage in certain geographic regions, as well as the overcrowding of surgical reference units.

Study limitations and suggestions for future studies

Although the present study consisted of a significant sample of articles, it was not possible to exhaust all existing databases, academic search engines, portals and libraries, nor to carry out more than one crossing of descriptors. Furthermore, during the course of the study, some issues related to the challenges of current care practices in the context of surgical service units were identified. These issues pointed out and discussed may be objects of further research, such as strategies that have been proposed and discussed by scholars to overcome these challenges listed.