COVID-19 Pandemic Prompts Changes in OR Routines

By Will Boggs MD

April 13, 2020

NEW YORK (Reuters Health) - New procedures to protect operating room (OR) team members while conserving personal protective equipment (PPE) and new approaches to surgical patient triage are needed in the face of the COVID-19 pandemic, according to two reports.

In the first, Dr. Joseph D. Forrester and colleagues at Stanford University in California describe their institutional decision-tree algorithm for precautions for OR staff during the pandemic.

The underlying assumption of this algorithm is that every patient is potentially infected with COVID-19 until proven otherwise, they explain in the Journal of the American College of Surgeons.

For emergency procedures (or when SARS-CoV-2 testing was not possible before surgery), personnel should use full PPE, including gown, gloves, eye protection and a fitted N-95 mask.

Urgent procedures on symptomatic patients should be delayed if possible. If the procedure cannot be delayed, patients should undergo SARS-CoV-2 testing. Any urgent procedure where testing is positive should be approved by the anesthesia and surgical chair, and if the procedure is approved, personnel should use full PPE and follow the hospital's protocol for COVID-19 patients.

Asymptomatic patients scheduled for high-risk procedures who test negative for SARS-CoV-2 and asymptomatic patients scheduled for low-risk procedures can proceed to surgery where OR members use standard surgical attire.

For all intubations or extensive bag-mask ventilation, anesthesia personnel should wear a fitted N-95 mask plus face shield, and other personnel should leave the room for this portion of the procedure.

"This algorithm prioritizes patients based on disease severity, testing status, and (symptoms) while ensuring rational use of PPE in a resource-constrained setting," the authors conclude. "The algorithm has been shared with healthcare providers and stakeholders nationwide and is expected to be widely adopted."

In the second report, also in the Journal of the American College of Surgeons, Dr. Samuel Wade Ross and colleagues at Atrium Health Carolinas Medical Center, in Charlotte, North Carolina, describe their tiered plan for surgical-department management during the pandemic.

The response plan includes three levels: alert (pandemic setting but without a confirmed case at the facility); level 2 (first confirmed case at the facility, with the potential for decreases in surgical faculty, reduced hospital bed availability and staff reductions due to illness); and level 1 (facility at 100% or more capacity).

At the alert level, the surgical department should minimize clinic visits, stay home if sick, and work from home if not involved in direct patient care. Cases should be prioritized for cardiovascular, cancer, urgent and emergent status.

At level 2, non-time-sensitive cases should be eliminated, and surgical residents should be reallocated to ICU and trauma rotations. The facility should undertake aggressive discharge of all noncritical patients to any available discharge destination and limit nonemergent transfers.

Once level 1 is reached, all elective surgery is canceled, and available surgical-critical-care intensivists should be assigned to care for COVID-19 ICU patients. General surgery faculty can be employed in emergency general surgery.

Attempts should be made at the facility level to increase ICU capability by focusing on progressive care and increasing the number of monitored beds.

Other strategies employed in this tiered plan would include reducing surgery-clinic visits and moving to telemedicine, screening patients scheduled for appointments to determine whether they actually need to be seen, increasing the responsibility of surgery residents, and calling upon subspecialized surgeons to become general physicians during severe manpower shortages.

Dr. Ross told Reuters Health by email, "The most important principle to follow for physicians in any situation of crisis is to be flexible and dynamic. People on the ground, on the front lines, know the setting, resources, and constraints during normal operations and only they can know what will work or not for planning purposes. It's important for leaders to get that input, rapidly assess the changing environment, and be able to make changes without knowing all the variables in play."

"Having a tiered response where you can adapt to the situation on the ground is key to preserving optimal care to our non-COVID-19 patients and to maximizing support for virus patients when the volume at your facility increases to a certain degree," he said. "Departments of surgery have to support their acute care surgeons as they will be required to provide more critical care support and less trauma and emergency general surgery care."

"Acute-care surgeons are really the Swiss Army knives of the hospital, able to take care of any emergency, manage patients with emergent surgery, hemorrhage, and critical-care issues," Dr. Ross said. "Supporting them on the front lines with reinforcements from the Surgery roster is paramount to their success."

Dr. Forrester did not respond to a request for comments.

SOURCE: https://bit.ly/2JS3r9o and https://bit.ly/2wpKMyv, online April 2 and March 30, 2020.

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