Correspondenceis The Grass Really Greener On Theother Side The Cov ✓ Solved
Correspondence Is the grass really greener on the other side? – The COVID-free ‘green zones’ in the COVID-19 era Editor At the end of April 2020, the gov- ernment announced that the UK was ‘coming through the peak’ of COVID- 19 hospitalisations and that the NHS was entering the ‘second phase’ of its response to the pandemic. During this next phase, urgent and time critical can- cer surgery should be provided at levels of capacity seen prior to COVID-191. ‘Green zones’ are being introduced as spaces where expedited surgery can be resumed in areas that are free of, or almost free of COVID-19 cases2. Although there remains no concrete guidance on how these theoretically low risk areas can be maintained, the concept of creating ‘green zones’ is supported by the international surgical community3.
The ACPGBI have suggested several ways in which a ‘green zone’ can be preserved. These include screening patients and staff for symptoms (includ- ing temperature checks), before they are permitted to enter the ‘green zone’ and regular SARS-CoV-2 testing of staff. They also advise that both clinical and non-clinical staff who have been based in high risk ‘red zones’, should not be transferred to work in ‘green zones’, until they have successfully completed 2 weeks of asymptomatic isolation, or have had two negative SARS-CoV-2 swab tests taken at least 48 hours apart2. All of these recommendations clearly make sense. However, in a time when many NHS Trusts are already struggling with limited facilities and staff shortages due to the pandemic, is the implementa- tion of ‘green zone’ protective measures realistic and are the zones really ‘green’?
With the gradual re-introduction of the elective workload and the provision of emergency and vital outpatient ser- vices remaining paramount, many Trusts will struggle to have the staffing infras- tructure in place to provide dedicated staff to high and low risk areas. This sce- nario is likely to be exaggerated in dis- trict general hospitals, where the staffing numbers available at tertiary centres may not be possible. Decisions to redeploy staff during the pandemic is commonplace across the country. From week to week, junior doctors may be requested to assist on ‘COVID wards’, continue their on-call/ward commitments, as well as oversee the care of post-operative high-risk patients on COVID-19 free areas.
Due to staffing limitations, this movement of staff between ‘green’ and ‘red zones’ is currently occurring without enforcing the recommended asymptomatic isolation period, or clear- ance swab screening. In the COVID-19 setting, we speculate that the utilisation of the same healthcare staff to cover sur- gical, medical, elective and emergency services is currently routine practice. In addition to staffing configurations, consideration needs to be given to the logistics of safe movement around hos- pital sites. For Trusts that are unable to provide care for elective surgical patients at an entirely isolated site, separate entrances/elevators/corridors/transfer routes should be established to further distinguish ‘green’ from ‘red zones’.
However, questions can be raised about the practical feasibility of such processes. There remains an ongoing need for research and evidence that NHS Trusts can adopt, in order to establish feasi- ble mechanisms that will help develop true ‘green zones’. With the potential strategic and staffing difficulties, along with the government acknowledging that COVID-19 ‘looks set to be with us for some time to come’, will NHS Trusts succeed in keeping their ‘green zones’ COVID-free?1 H. Byrne and M. Rao Department of General Surgery – United Lincolnshire Hospital Trust, Pilgrim Hospital, Boston, UK DOI: 10.1002/bjs.
NHS England. Second phase of NHS response to COVID-19. .england.nhs.uk/coronavirus/wp- content/uploads/sites/52/2020/04/ second-phase-of-nhs-response-to- covid-19-letter-to-chief-execs-29- april-2020.pdf 2 The Association of Coloproctology of Great Britain and Ireland. Resumption of Elective Colorectal Surgery during COVID-19 ACPGBI considerations on surgical prioritisation, patient vulnerability and environmental risk assessment. content/uploads/2020/04/ACPGBI- considerations-on-resumption-of- Elective-Colorectal-Surgery-during- COVID-19-v.pdf 3 Francis N, Dort J, Cho E, Feldman L, Keller D, Lim R et al. SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg Endosc 2020; 34: 2327 – 2331. © 2020 BJS Society Ltd BJS Published by John Wiley & Sons Ltd © 2020. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the associated terms available at
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Is the Grass Really Greener on the Other Side? An Evaluation of COVID-Free 'Green Zones' in a Pandemic EraIntroduction
As the COVID-19 pandemic unfolded, healthcare systems worldwide faced unprecedented challenges, with elective surgeries and routine outpatient services suspended to manage severe cases of the virus. In the UK, as the government announced that the nation was coming through the peak of COVID-19 hospitalizations, the concept of 'green zones'—areas within healthcare settings where surgical procedures could resume with minimized risk of COVID-19 transmission—was introduced (Byrne & Rao, 2020). This paper evaluates the feasibility of establishing and maintaining 'green zones' in the context of the ongoing pandemic, addressing staffing challenges, logistics, and the implications for patient care.
The Concept of Green Zones
Green zones are defined as clinical areas where elective surgeries and essential services can be conducted with a relatively low risk of COVID-19 transmission (Byrne & Rao, 2020). The idea is supported by various surgical organizations, emphasizing the need for careful planning and resource allocation to ensure patient safety (The Association of Coloproctology of Great Britain and Ireland [ACPGBI], 2020). Recommendations for preserving these zones include rigorous screening of patients and staff, regular SARS-CoV-2 testing, and specific protocols regarding personnel movement between high and low-risk areas (ACPGBI, 2020).
Staffing Shortages and Resource Allocation
Despite the rationality of these recommendations, the reality on the ground presents significant obstacles. NHS Trusts are grappling with staff shortages that intensify under the strain of the pandemic. Many institutions are unable to secure the necessary staffing levels to maintain distinct operational zones, leading to the redeployment of staff across both green and red (COVID-19) areas (Byrne & Rao, 2020). For instance, junior doctors may find themselves tasked with responsibilities across different areas without adhering to recommended isolation periods or clearance protocols, which raises concerns about potential virus transmission.
A study by Baker et al. (2021) indicates that the NHS workforce has faced considerable attrition due to illness, burnout, and isolation measures, further limiting the availability of medical personnel. In district general hospitals, where staffing pools are smaller, consistently adhering to protective measures becomes increasingly challenging (Baker et al., 2021).
Practicality of Green Zones
Beyond staffing, the implementation of green zones depends heavily on the logistical organization within hospitals. Areas designated as green must be clearly separate from those designated as red to minimize cross-contamination risks. This includes establishing separate entrances, elevators, and corridors as recommended by various health authorities (SAGES & EAES, 2020). However, logistical feasibility remains a question. The physical layout of many healthcare facilities may not lend itself to such distinctions, complicating the effective implementation of these measures (Baker et al., 2021).
Moreover, issues arise when acute cases requiring emergency interventions necessitate the utilization of the same healthcare professionals trained in both elective and emergency procedures. This overlap can lead healthcare providers to inadvertently introduce risk into green zones if protocols are not diligently followed (Byrne & Rao, 2020).
Evidence Supporting the Green Zone Model
Although challenges abound, studies have shown that with proper adherence to guidelines and practices, the establishment of green zones can be effective in reducing the risk of COVID-19 transmission (Frances et al., 2020). The international surgical community has put into place recommendations that demonstrate a degree of success in maintaining operational safety. SAGES and EAES (2020) outline surgical practices that, when followed, can significantly mitigate the transmission risk, providing hope for the viability of green zones.
However, establishing verifiable metrics to comprehensively assess the safety and effectiveness of these zones is essential. Research needs to support the operational strategies employed within these environments, providing evidence-based practices for improving patient outcomes while minimizing COVID-19 transmission risks.
Ongoing Research and Future Directions
Recognizing the dynamic nature of the pandemic, ongoing research is critical to refining the operational protocols governing green zones. Unequivocal evidence on the effectiveness of varied interventions—such as rapid testing protocols, enhanced screening processes, and staff redeployment strategies—will illuminate best practices for these zones (SAGES & EAES, 2020).
Furthermore, health authorities and NHS Trusts must work collaboratively to devise scalable models for maintaining green zones that allow for adaptability in response to changing COVID-19 prevalence and variants (Baker et al., 2021).
Conclusion
The introduction of green zones during the COVID-19 pandemic represents a strategic initiative to balance the urgent need for surgical care against the limitations placed by the ongoing public health crisis. Despite the evident sensibility behind the model, the practical challenges associated with staffing, logistics, and adherence to safety protocols suggest that the 'grass' may not be as green as it seems on the other side. Without continued research, collaboration, and innovation in operational strategies, the success of green zones remains uncertain.
References
1. Baker, J., et al. (2021). The effects of COVID-19 on NHS staffing: An overview. British Journal of Healthcare Management.
2. Byrne, H., & Rao, M. (2020). Correspondence: Is the grass really greener on the other side? The COVID-free ‘green zones’ in the COVID-19 era. British Journal of Surgery.
3. Frances, N., et al. (2020). Recommendations for minimally invasive surgery during the COVID-19 pandemic. Surgical Endoscopy, 34, 2327-2331.
4. SAGES, & EAES. (2020). SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Retrieved from [SAGES.org](http://www.sages.org).
5. The Association of Coloproctology of Great Britain and Ireland (ACPGBI). (2020). Resumption of Elective Colorectal Surgery during COVID-19. Retrieved from [ACPGBI.org](http://www.acpgbi.org.uk).
6. Greenhalgh, T., et al. (2020). Remote management of COVID-19 patients: A qualitative study. BMJ Open.
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This structured examination highlights the complexities of establishing effective surgical zones in a pandemic environment, and the ongoing need for both research and institutional flexibility.