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Compliance with UK national guidance for elective surgery during the COVID-19 pandemic
  1. Christina Major1,
  2. Rachel Harwood2,3,
  3. Sanjay Valabh Patel4,
  4. Nigel J Hall1,5
  1. 1 Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK
  2. 2 Paediatric Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
  3. 3 Cellular and Molecular Physiology, University of Liverpool, Liverpool, UK
  4. 4 Paediatric Infectious Diseases and Immunology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
  5. 5 University Surgery Unit, Faculty of Medicine, University of Southampton, Southampton, UK
  1. Correspondence to Christina Major, Department of Paediatric Surgery and Urology, Southampton Children's Hospital, Southampton, UK; christina.major{at}

Statistics from

Elective paediatric surgery essentially stopped during the initial COVID-19 lockdown,resulting in significant treatment delays. As of December 2020, 210 000 children were awaiting elective surgery, with 66 000 waiting >6 months.1 To facilitate the safe and efficient recovery of children’s elective surgery, national guidance was developed.2 This child-focussed guidance accounts for lower COVID-19 prevalence in children and inability to isolate children from household contacts, and considers the impact of processes on children and families. This guidance was published in July 2020, endorsed by Royal College of Paediatrics and Child Health, Royal College of Surgeons of England, adopted by the National Institute for Health and Care Excellence and revised September 2020 and January 2021, considering rising COVID-19 prevalence and new virus variants.

National adoption of the guidance was audited with a survey distributed to anaesthetists and surgeons in all 26 UK specialist paediatric surgery centres during October 2020 (low COVID-19 prevalence). All 16 responding centres were aware of the guidance and had implemented some recommendations. We highlight areas of practice where guidance is not being followed and which may contribute to inefficiency in the delivery of surgery, or significant unwarranted negative impact on families.

Contrary to guidance, children, parents/carers, and siblings are being asked to self-isolate prior to elective admission in 75%, 50% and 31% of centres respectively (Full results available from author). Parental screening of COVID-19 symptoms was performed in 13/16 (81%) and parental swabbing in 5/16 (31%). All centres perform patient SARS-CoV-2 swabs within 72 hours of surgery, but only 11/15 (69%) use local testing. Twenty-five per cent (4/16) of centres would cancel elective surgery if the child was mildly coryzal on admission despite a negative swab, and only 2 (12.5%) centres would use rapid PCR testing. Contrary to guidance, 4/16 centres delay for up to 20 minutes between moving children from the anaesthetic room into theatre after aerosol-generating procedures (AGPs); only two centres remove laryngeal masks in recovery.

Some practices identified likely negatively impact children and families. Mandating preoperative isolation does not substantially reduce risk of infection but may affect the child’s education and family earnings. Travel to a specialist centre for preadmission testing, rather than using facilities closer to home, may be time-consuming or expensive. Some families may be unable to comply with these requirements. Low-income families may be disproportionately affected risking inequitable access to surgical care. Currently, there is little evidence of the potential harm caused by delays and non-compliance, but it is anticipated this will soon become evident. Since audit completion, and in light of increasing prevalence, consideration of rapid testing in the immediate preoperative period has been introduced to the guidance to reduce the potential risk posed by a delay of over 24 hours between the PCR swab and hospital admission. Swabbing of parents continues not to be recommended as the primary risk to healthcare workers during elective surgery is a result of AGPs. Provided infection prevention and control (IPC) measures are followed, the risk of transmission otherwise is small. While vaccination is reassuring, it is not an alternative for IPC measures and, therefore, guidance is not altered by the vaccination programme.

Recovery from the pandemic requires over 100% of prepandemic capacity for months to come. We urge centres to remove barriers to the efficient recovery of children’s surgical services and to implement the recommended practices so this vulnerable population can receive the surgical treatment they need in a timely manner.



  • Twitter @RachelHarwood10

  • Contributors NJH and SVP conceived the study; CM, NJH and RH designed the audit and collected the data; CM analysed the data; CM, RH, SVP and NJH interpreted the data; CM wrote the draft report, which was critically revised and approved by all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests NJH, SP and RH are part of the steering group that produced and continues to review the National Guidance for the Recovery of Elective Surgery in Children.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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