Effect of the COVID-19 Pandemic on Anaesthetic Workload at a Tertiary Care Hospital in Pakistan

By Aliya Ahmed, Azmeena Nizar, Gauhar Afshan

Affiliations

1. Department of Anaesthesiology, The Aga Khan University Hospital, Karachi, Pakistan

doi: 10.29271/jcpsp.2025.07.904

ABSTRACT
Objective: To compare the anaesthetic workload during the COVID-19 pandemic with the workload immediately before and two years after the pandemic at a tertiary care hospital in Karachi, Pakistan.
Study Design: Observational study.
Place and Duration of the Study: The operating rooms of the Aga Khan University Hospital, Karachi, Pakistan, over three time periods: From October 2019 to February 2020 (pre-COVID-19), from February to June 2020 (COVID-19), and from February to June 2022 (post-COVID-19).
Methodology: After approval by the Institution’s Ethics Review Committee, data were obtained from the hospital’s central repository for pre-COVID-19, COVID-19, and post-COVID-19 time periods, including the number of surgeries, type of anaesthesia, surgical speciality, patients’ age, and gender.
Results: The total number of surgical procedures performed during the COVID-19 period was significantly lower than in the pre- COVID-19 period (2862 vs. 5574, p <0.001). The highest decline of 55.51% was observed in paediatric surgery, while the lowest decline was seen in breast surgery (26.09%). In the post-COVID-19 period, a 34.74% rise was seen in cases compared to the COVID-19 period; however, there was still a 21.28% decline compared to the pre-COVID-19 period.
Conclusion: The COVID-19 pandemic had a significant impact on anaesthesia workload for elective surgical services. The highest decline occurred in paediatric surgery and the lowest in breast surgery. In the post-COVID-19 period, there was an increased workload in all surgical disciplines. However, the pre-COVID-19 pandemic workload was not re-attained despite using all administrative strategies to deliver safe services.

Key Words: COVID-19, Pandemic, Anaesthesiology, Workload, Elective surgical procedures.

INTRODUCTION

The world changed drastically following the massive impact of the coronavirus disease 2019 (COVID-19) pandemic in early 2020. The healthcare systems faced a major impact of the pandemic. All elective and non-essential surgeries and procedures were suspended to reduce the patient-care burden on front-line healthcare workers (HCWs), prevent shortages of medical resources, and limit the risk of transmission of infection.^1-3 The focus of healthcare facilities was largely diverted towards prompt diagnosis and management of COVID-19 patients while ensuring the safety of healthcare providers (HCPs). These circumstances had a considerable impact on the routine and elective workload of healthcare facilities.^1-5

The first national case of COVID-19 infection was admitted to the authors’ hospital on February 26, 2020. The authors’ hospital remained at the frontline of COVID-19 patients’ management. During the first wave of the COVID-19 pandemic, elective surgical lists were suspended, and only emergency, trauma, and oncological surgeries were performed.^5,6 There was a constant debate about restarting elective surgical procedures at the earliest with mandatory use of personal protective equipments (PPEs). The rationale was that the crucial knowledge about how the pandemic influenced the demand for anaesthetic services would help in developing strategies to better prepare for future healthcare emergencies and pandemics.

The objective of this study was to compare the anaesthetic workload in the operating rooms (ORs) of a tertiary care hospital in Pakistan during the COVID-19 pandemic with the workload over similar time periods, immediately before, and two years after the start of the pandemic with the aim of being more prepared for maintaining continuity of care in future pandemics.

METHODOLOGY

This data-based observational study was conducted at a ter- tiary care hospital in Karachi, Pakistan. Approval was obtained from the Aga Khan University’s Ethics Review Committee (ERC No: 2020-4790-10724). Data were retrieved from the hospital’s central data repository for surgical procedures conducted during the study periods.

Three time periods were included in the study termed as pre- COVID-19, COVID-19, and post-COVID-19 periods. Pre-COVID-19 period included data from 26^th October 2019 to 25^th February 2020, COVID-19 period included data from 26^th February to 25^th June 2020, while post-COVID-19 included data from 26^th February to 25^th June 2022, i.e., two years after the first patient of COVID-19 was diagnosed in Pakistan. Data from other periods were excluded.

The data included the patient’s age, gender, surgical procedure, sub-speciality, and type of anaesthesia, including general anaesthesia (GA), regional anaesthesia (RA), and others such as local anaesthesia (LA) and monitored anaesthesia care (MAC). Patients’ identity was not noted and therefore, consent was not needed. Data were analysed using Statistical Packages for Social Science (SPSS Inc., Chicago, IL, USA) version 19.0. Firstly, stratification analysis was performed to divide the data into the specified three time periods for age, gender, surgical speciality, and type of anaesthesia. Frequency and percentages were computed for qualitative variables and mean and standard deviation were estimated for quantitative variables. ANOVA test was used for quantitative variables and Chi-square/Fisher's exact test were used for qualitative data comparison to determine the difference in the number of cases in the three time periods. The proportion Z-test was conducted to compare proportions pairwise. A p-value of ≤0.05 was considered statistically significant.

RESULTS

There was no difference in the mean age of the patients who underwent surgeries in the three time periods of pre-COVID-19, COVID-19, and post-COVID-19 (p = 0.390, Table I). Gender distribution also remained similar in the three study periods (Table I).

The total number of surgical procedures performed during COVID-19 period was significantly lower than in the pre- COVID-19 period (48.65% decline, p <0.001, Table II). Numbers were decreased in all surgical specialities (Table II). The highest decline was seen in paediatric surgery (p <0.001), while the number of breast procedures was least affected (26.09% decline; p = 0.003).

In the post-COVID-19 period, an overall 34.74% rise was seen in the number of cases compared to the COVID-19 period. How-ever, the number failed to reach the pre-COVID-19 period (p <0.001; 21.28% decline). The highest rise in cases in the post- COVID-19 period occurred in obstetrics (2.20%) compared to the pre-COVID-19 numbers, while the most affected speciality was cardiac surgery with a 41.81% decline (Table II).

Table III displays the type of anaesthesia provided during the study periods. The proportion of GA, RA, and other types (LA, MAC) remained similar during the three periods.

Table  III:  Types of anaesthesia provided for surgeries performed in the pre-COVID-19, COVID-19, and post-COVID-19 period.
 

Parameters	Pre-COVID-19 (n = 5574)	COVID-19 (n = 2862)	Post-COVID-19 (n = 4388)
Anaesthesia type	-	-	-
General	4823 (86.5%)	2372 (82.9%)	3718 (84.7%)
Regional	243 (4.4%)	191 (6.7%)	240 (5.5%)
Other (LA*, MAC#)	499 (9.0%)	296 (10.3%)	427 (9.7%)
Missing data	9 (0.2%)	3 (0.1%)	3 (0.1%)
*LA: Local anaesthesia, #MAC: Monitored anaesthesia care.

DISCUSSION

The anaesthetic workload was assessed in terms of the anaesthesia provision for surgical procedures in the initial four months of the COVID-19 pandemic and was compared with similar periods, immediately before and two years after the pandemic. The anaesthetic workload was significantly reduced in the initial four months of the COVID-19 pandemic at the authors’ hospital.

Table I: Comparison of age and gender in cases performed in the pre-COVID-19, COVID-19, and post-COVID-19 periods.
 

Variables	Pre-COVID-19 (n = 5574)	COVID-19 (n = 2862)	Post-COVID-19 (n = 4388)	p-value
Age (years)	-	-	-	-
Mean (SD)	42.0 (22.5)	41.8 (22.3)	41.4 (21.7)	0.3908
Gender, n (%)	-	-	-	-
Female	2465 (44.2%)	1288 (45.0%)	2034 (46.4%)	0.104**
Male	3109 (55.8%)	1574 (55.0%)	2354 (53.6%)
p-value: *ANOVA test and **Chi-Square test, SD: Standard deviation.

Table II: Types and numbers of surgeries performed in the pre-COVID-19, COVID-19, and post-COVID-19 periods.

Specialities	Pre-COVID-19 (n = 5574)	COVID-19 (n = 2862)	Pre-COVID-19 vs. COVID-19 (%) -48.65	p-values <0.001	Post-COVID-19 (n = 4388)	Pre-COVID-19 vs. Post- COVID-19 (%) -21.28	p-values <0.001	COVID-19 vs. post-COVID-19 (%) +34.74	p-values <0.001
General	897	477	-46.82	<0.001	692	-22.85	<0.001	+31.06	<0.001
Orthopaedic	1026	495	-51.75	<0.001	792	-22.81	<0.001	+39.50	<0.001
Obstetrics	636	348	-45.28	<0.001	650	+2.20	0.313	+46.46	<0.001
Neurosurgery	545	261	-52.11	<0.001	392	-28.07	<0.001	+33.41	<0.001
Urology	646	321	-50.31	<0.001	523	-19.04	<0.001	+32.62	<0.001
ENT*	331	191	-42.30	<0.001	304	-8.16	0.153	+37.17	<0.001
Paediatrics	735	327	-55.51	<0.001	484	-34.15	<0.001	+32.43	<0.001
Breast surgery	115	85	-26.09	0.003	81	-29.57	<0.001	-4.93	0.719
Cardiac surgery	354	179	-49.44	<0.001	206	-41.81	<0.001	+13.10	0.026
Vascular surgery	289	178	-38.41	<0.001	264	-8.65	0.184	+32.57	<0.001
p-values: Proportion Z-test, ENT*: Ear, nose and throat.

Mehta et al. also reported an enormous effect on surgical ser-vices worldwide during the pandemic due to the suspension of most elective surgeries.⁷ Ayyaz et al. studied the effect of COVID-19 on the working of a tertiary care hospital in Lahore. They reported a decrease in volumes in all areas, and the most marked decrease was in the volume of elective surgeries.⁸

No difference was found in the mean age of patients who underwent surgical procedures during the three time periods in this study. Uimonen et al. have reported age-related inequality during the COVID-19 pandemic with prioritisation of surgery for older patients, resulting in increased waiting times for younger patients.⁹ Significant difference was also not observed in gender distribution in the three time periods. Similarly, Soytas et al. did not find a difference in gender distribution in patients undergoing urological procedures before and after the pandemic.¹⁰

During the initial wave of the COVID-19, elective surgical procedures were suspended, while emergency, trauma, and oncologic surgeries were continued. These results show that the least affected surgical speciality was breast surgery, with a 26.09% decline in the number of surgeries. The reason for this is that most breast procedures are oncologic surgeries that continued during the lockdown. Chiang et al. assessed the oncology workload during the COVID-19 pandemic and found that the workload remained high.¹¹ They recommended that adequate manpower should be maintained in the oncology section during a pandemic for the timely management of patients.

The decline in surgical procedures for other specialities was between 45% and 55%, with a maximum decline in paedia-tric procedures. Uimonen et al. also reported a maximum decline in the paediatric surgeries.⁹ Pavic et al. reported that the number of surgeries performed significantly decreased when compared to 2019, while the number of patients presenting for emergency care remained unchanged.³ Musajee et al. compared data from pre- and post-COVID-19 periods in patients presenting for vascular review and discovered that patients were reduced by 44% during the COVID-19 period.² Moreover, there was a reduction of 77% in vascular interventions. Nicholls et al. found a 30% reduction in the number of vascular procedures performed during the COVID-19 lockdown.¹² Gomez et al. conducted a global survey on the impact of COVID-19 on the practice of interventional radiology and reported that workload remained stable for 29% of the respondents, while it decreased considerably for 18% and mildly for 36%.⁴

The proportion of GA, RA, and other types of anaesthesia (LA, MAC) remained similar at the authors’ institution during the three study periods. In 2020, the European Societies of Regional Anaesthesia formulated recommendations which stated that RA should be preferred over GA to ensure a reduction in aerosol generation, preserve medicines for COVID-19 patients, save financial costs on PPE, establish better analgesia, and earlier discharge.¹³ While this change in practice was not apparent in the present study, other authors have reported an increase in the volume of RA during the pandemic.^13-16 Topcu et al. studied the effect of the COVID-19 pandemic on anaesthesia techniques and found that the use of RA was significantly higher compared to the pre-pandemic data.¹⁴ Uppal et al. surveyed members of the three RA societies to explore the practice of RA during the COVID-19 pandemic.¹⁵ They reported that about half of the members of the three societies had increased the use of RA techniques. Gupta et al. assessed the effect of the COVID-19 pandemic on RA practices in India and reported an increased use of RA among anaesthesiologists. However, RA techniques were more challenging with the use of PPE.

A few months into the pandemic, all stakeholders realised that postponements of surgical procedures were bound to have potentially deleterious effects on the patients’ health,^6,17,18 and elective surgery needed to be reintroduced following the recommended standard operating procedures (SOPs). After a rapid drive for vaccination of HCPs, the Government lifted the COVID-19 restrictions, and routine scheduling of elective cases was re-established at the authors’ hospital.

The number of surgeries started to increase in the post-COVID-19 period.^18,19 However, the present study’s data show that the number did not reach the pre-COVID-19 period with a 23% decline. Compared to this, Uimonen et al. reported increased numbers of surgeries, especially in elderly patients (29% increase).⁹ During the COVID-19 pandemic, some smaller private hospitals continued to perform elective procedures. Many patients approached these hospitals for the prompt conduct of surgical procedures during the pandemic. Treatment at these hospitals is less expensive compared to larger tertiary care private hospitals. Moreover, when elective surgeries were restarted, the hospital followed SOPs in accordance with WHO recommendations, which added to the expenses incurred for treatment. Prioritisation of less expensive hospitals for treatment by patients could be a reason for the failure to achieve the pre-COVID-19 numbers at the authors’ hospital.

A limitation of this study is that it presents a single-centre data. It is a snapshot of the impact of COVID-19 on anaes-thesia workload in a country of 222 million population. Its strength is that it is the first data report on anaesthetic workload from this part of the world.

CONCLUSION

The COVID-19 pandemic had a significant impact on anaes-thesia workload for elective surgical services. The highest decline was in paediatric surgery and the lowest was in breast surgery volumes. In the post-COVID-19 period, there was an increased surgical workload; however, the pre-COVID-19 pandemic workload was not re-attained.

ETHICAL  APPROVAL:
Approval for the conduct of this study was obtained from the University Ethics Review Committee (2020-4790-10724).

PATIENTS’  CONSENT:
Not applicable.

COMPETING  INTEREST:
The authors declared no conflict of interest.

AUTHORS’  CONTRIBUTION:
AA: Design of the project, analysis, interpretation of the data, and drafting of the manuscript.
AN: Acquisition of data for the work and critical revision of the manuscript.
GA: Conception, design of the work, and interpretation of the data.
All authors approved the final version of the manuscript to be published.

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