IMPACT OF CORONAVIRUS DISEASE 2019 PANDEMIC ON THORACIC SURGERY PATIENT CARE
Results are presented in Fig. 2.
Figure 2:  Questionnaire results on the impact of coronavirus disease 2019 on thoracic surgical practice (questions 6–26).

Multidisciplinary tumour board
Question 6: How are multidisciplinary tumour meetings organized today? (Answer rate 405/409, 99%)
A total of 48.9% of respondents were using web-based platforms. Interestingly, when answers were stratified by the number of treated COVID-19 positive patients per hospital, no differences were seen in distribution (Fig. 3A).
Figure 3:  Multidisciplinary tumour boards. (A) Organization of multidisciplinary tumour boards stratified by impact per hospital. (B) Influence of the COVID-19 pandemic situation on multidisciplinary decisions stratified by impact per hospital. COVID-19: coronavirus disease 2019. Question 7: Are multidisciplinary decisions influenced by the COVID-19 pandemic situation? (Answer rate 400/409, 97.7%)
The majority of respondents (66%) answered that treatment decisions were not influenced by COVID-19, but multidisciplinary decisions were clearly more influenced by the situation in hospitals treating more than 100 patients with COVID-19 (Fig. 3B).
Question 8: Given the current COVID-19 crisis please select which of the following hypothetical patients you would prioritize for surgery? (Answer rate 401/409, 98%)
We provided 5 case scenarios to be triaged (Fig. 4). The majority prioritized fit and younger patients with a cancer at risk of progression. Surgical management of slowly growing and smaller cancers, especially in older patients, tended to be deferred.
Figure 4:  Distribution of the answers in prioritizing clinical scenarios (related to question 8). (A) Clustered columns of each preference choose by every participant. (B) Double-entry table with the number of answers and their ranking order according to the percentage of each answer compared to the total responses (azure column) and overall score. RUL: right upper lobe.

Coronavirus disease 2019 screening
Question 9: What thoracic surgical patients are being screened for COVID-19 in your department? (Answer rate 405/409, 99%) (Fig. 2)
The answers were variable with the same proportion of respondents reporting screening for all patients (25%), in-patients only (24%) or symptomatic patients only (23%).
Question 10: How are thoracic surgical patients screened for COVID-19 in your department? (Answer rate 400/409, 97.7%) (Fig. 2)
The majority (54%) responded that a nasopharyngeal swab alone was used for screening; 30% used a combination of swab and computed tomography (CT) chest imaging.
Question 11: Does the result of a COVID-19 positive test influence the surgical treatment of your patient? (Answer rate 398/409, 97.3%) (Fig. 2)
A total of 7% of respondents would proceed to surgery regardless of a positive test result. The majority stated a positive test result would be an indication to postpone surgery by 2 weeks in all patients (59%) or those with symptoms (19%).

Preoperative workup
Question 12: How is the preoperative oncological workup influenced by the COVID-19 pandemic situation? (Answer rate 400/409, 97.7%) (Fig. 2)
A total of 45% of participants answered that all examinations were available as usual. However, 56% reported that endobronchial or other examinations were delayed or unavailable. CT-guided biopsies were less frequently available in more severely affected hospitals (Fig. 5A).
Figure 5:  Organization of preoperative workup stratified by impact per hospital. (A) Oncological workup. (B) Preoperative functional tests. COVID-19: coronavirus disease 2019; CPET: cardiopulmonary exercise testing; DLCO: diffusing capacity of the lung for carbon monoxide; EBUS: endobronchial ultrasound bronchoscopy; ECG: electrocardiography; PET-CT: positron emission tomography-computed tomography; V/Q: ventilation/perfusion. Question 13: Which of the following preoperative functional tests are not available due to the COVID-19 pandemic situation? (Answer rate 394/409, 96.3%) (Fig. 2)
Although all tests were available as normal for most participants (64%), the diffusing capacity for carbon monoxide and cardiopulmonary exercise tests were not available in more than 20% of cases.
When answers were stratified by the number per hospital of treated patients whose test results were positive for COVID-19, investigations were clearly more delayed or unavailable in hospitals treating more than 100 patients with COVID-19 (Fig. 5B).

Outpatient clinic: preoperative
Question 14: How is your preoperative contact with the patient influenced by the COVID-19 pandemic situation? (Answer rate 398/409, 97.3%) (Fig. 2)
Preoperative meetings with patients were still conducted face to face for 54% of respondents; 47% used telephone or video consultations when possible.
Question 15: Do you talk about COVID-19 with your patients preoperatively? (Answer rate 395/409, 96.5%) (Fig. 2)
Most respondents discussed with their patients the higher risk of surgery in the context of COVID-19 infection. However, 15% reassured their patients not to worry and 8.6% did not discuss COVID-19 infection preoperatively.

Planning
Question 16: How is your surgical planning affected by the COVID-19 pandemic situation? (Answer rate 400/409, 97.7%) (Fig. 2)
Almost half of the participants (47.5%) answered that only medically or oncologically urgent operations were performed due to shortage of staff and intensive care unit beds. In hospitals treating more patients who were positive for COVID-19, surgical planning was clearly more affected (Fig. 6A).
Figure 6:  Planning. (A) How is surgical planning affected by the coronavirus disease 2019 pandemic? (B) How do you feel about the affected planning? (C) Are you and/or your colleagues involved in daily care of coronavirus disease 2019-positive patients? ICU: intensive care unit; IMC: intermediate care; OR: operating room. Question 17: How do you feel about the affected planning? (Answer rate 397/409, 97%) (Fig. 2)
Fifty-six percent of participants agreed with the reorganization of services. Only a minority of respondents (28.0%) felt forced to agree due to a lack of resources, but the answers from those at hospitals treating fewer patients who tested positive for COVID-19 were generally more positive (Fig. 6B).
Question 18: Are you and/or your thoracic surgery colleagues involved in the daily care of COVID-19 positive patients? (Answer rate 399/409, 97.5%) (Fig. 2)
The majority of respondents (63%) were involved in the daily care of patients with positive test results for COVID-19; surgeons in hospitals treating more patients with test results positive for COVID-19 were clearly more involved (Fig. 6C).

Surgery
Question 19: What kind of personal protective equipment (PPE) measures are taken during a COVID-19 negative thoracic surgical procedure? (Answer rate 399/409, 97.5%) (Fig. 2)
A total of 41% of respondents reported that all staff in the operating room used only standard equipment whereas the other respondents used filtering facepiece mask, aerosol filtration type 2 masks and other PPE measures.
Question 20: What kind of PPE measures are taken during a COVID-19 positive thoracic surgical procedure? (Answer rate 395/409, 96.5%) (Fig. 2)
Over half of the respondents (53%) used full PPE.

Postoperative care
Question 21: How is intensive care/postanaesthesia care availability for thoracic surgery patient affected by the COVID-19 pandemic situation? (Answer rate 377/409, 92.1%) (Fig. 2)
A total of 36% of respondents indicated no issue with intensity therapy unit bed numbers. The remaining respondents experienced reduced critical care capacity.
Question 22: Does chest drain management for your thoracic surgery patients during this COVID-19 pandemic differ from your standard management? (Answer rate 397/409, 97%) (Fig. 2)
The majority of participants (81%) stated they used the same system and the same chest drain protocol.
Question 23: Do discharge criteria for your thoracic surgery patients during this COVID-19 pandemic differ from your standard criteria? (Answer rate 398/409, 97.3%) (Fig. 2)
The majority of the respondents (59%) did not alter postoperative protocols. However, 30% tended to discharge patients earlier than usual (mostly because of bed capacity and concerns of COVID-19 infection).

Follow-up
Question 24: How is your postoperative contact with the patient influenced by the COVID-19 pandemic situation? (Answer rate 398/409, 97.3%) (Fig. 2)
One in 10 respondents switched to tele- or video consultations only. The other respondents were still seeing some patients in person.

Personal situation
Question 25: Anyone of your Department were tested positive to COVID-19? (Answer rate 399/409, 97.5%) (Fig. 2)
Almost half of the respondents had a team member who had contracted COVID-19 infection (32% were physicians/surgeons). Supplementary Material, Table S1 displays the proportion of COVID-19-positive personnel in thoracic surgery units from countries with more than 10 respondents in relation to the respective WHO COVID-19 lockdown day at the time of the survey.
Question 26: How do you feel as a thoracic surgeon during this pandemic? (Answer rate 399/409, 97.5%) (Fig. 2)
The majority of respondents (54%) felt unable to offer the best care for their patients.

Future thoughts (answer rate 86/409, 21%)
We received 86 comments. A total of 52% were remarks or questions on the current health care situation; 20% expressed hopeful sentiments; and 19% expressed fear or worries for the future (Supplementary Material, Table S2).