Perioperative COVID-19 Defense: An Evidence-Based Approach for Optimization of Infection Control and Operating Room Management

Franklin Dexter, MD, PhD, FASA; Michelle C. Parra, MD; Jeremiah R. Brown, PhD; Randy W. Loftus, MD


Anesth Analg. 2020;131(1):37-42. 

In This Article

Or Management Problem Formulation

Our primary objective is to minimize the spread of infection and to achieve the lowest risk for patients and staff while caring for patients with unknown COVID-19 status at the time of anesthesia. Consider the assignment of anesthetic cases and staff (eg, anesthesiologists and certified registered nurse anesthetists) to ORs or non-OR locations under several conditions:

  • The patient is not known to have COVID-19 (eg, undergoing cesarean delivery). Ideally a single OR would be set aside for all COVID-19 patients, in a corner of the surgical suite, with separate access, and revised to be negative pressure.[25]

  • Shortages of PPE such as surgical masks and gowns are the principal constraint to elective surgery being performed. In addition, all posted cases are considered essential.

  • There are insufficient test reagents/supplies (eg, viral transfer media) to screen all patients preoperatively for COVID-19, the false-negative rate is substantively large (eg, >1%), or the time to obtain results is beyond the point of proceeding for urgent procedures.

A consequence of the second condition noted above (shortage of PPE) is that there are enough ORs, surgeons (proceduralists), anesthesiologists, certified registered nurse anesthetists, and OR nurses to perform all cases promptly. This is unlike the normal situation wherein constraints on the care of such patients are most commonly surgeons (proceduralists) and/or rooms busy with other elective cases.[26] To complete our infection-control strategy, we relied on the online bibliography of OR management articles and recent review articles.[27–30] None of the articles considered the performance objective of reducing spread of infection.[28–32] Articles include the longer turnover times associated with cleaning when a patient has known infection, but reducing infections is nonetheless not the mathematical objective in these studies.[31,32] Readers will also note that the articles cited here are primarily from the fields of mathematics and engineering, and thus will not be found in PubMed.[28–32] Therefore, we included the online bibliography used by specialists in OR management.[27] Fortunately, complex mathematics is not required to solve the situation where the daily number of cases is less than the number of rooms available. While there may be restrictions on some procedures in some rooms, for convenience we will consider the important conceptual construct that cases could be completed while performing 1 case in each room.

The following 4 steps optimize staff and case assignments in this unique scenario:

First, to reduce the use of surgical masks and to reduce potential COVID-19 exposure to the greatest extent possible, use relatively long (eg, 12 hours) shifts. In other words, aim for as few different people as possible working daily in the surgical suite or procedural locations. For instance, if there are 8 ORs sharing 1 master ventilatory system and 8 essential cases to be done (each lasting 1–2 hours), the ideal solution is to have 2 teams complete the 8 cases in the available rooms. This contrasts sharply with the traditional 8 first case starts in 8 rooms with 8 teams of providers! The benefit to staff and the organization with the "infection-control" approach is that if a patient were found to have COVID-19 after surgery, fewer personnel were exposed.

Second, personnel doing terminal cleaning between each case[12] with the addition of UV-C (see section "Evidence-Based Perioperative Infection Control") can take 1–2 hours depending on whether there are 1 or 2 housekeepers and whether the UV-C machine needs to be moved within the room.[12] Therefore, the optimal strategy is to do 1 case in each OR, followed by terminal cleaning. Note that this does not mean literally that a room can be used just once a day. Rather, let anesthesia and nursing teams (and surgeons/proceduralists if they have >1 case) work in more than 1 room so that each room receives deep cleaning between cases.

Third, do not have patients go into a large, pooled phase I postanesthesia care unit because of the risk of contaminating facility at large along with many staff. Putting a surgical mask onto each patient would result in depletion of the supply of the protective equipment, an action that is inconsistent with the second condition above. Instead, have most patients recover in the room where they had surgery. This is done routinely in Japan—with the anesthesiologist recovering their patient—because few hospitals have a phase I postanesthesia care unit.[33] When the time of patient recovery was compared between a Japanese hospital where anesthesiologist recovery was routine practice versus the University of Iowa where there is a phase I postanesthesia care unit and nurses, the longest recovery time in Japan was briefer than the shortest recovery time in the United States.[34] Clinicians should consider selecting anesthetic drugs to minimize recovery times and possibly accomplish phase 1 recovery within the OR itself.[35,36] Consider, when appropriate, using peripheral nerve block instead of general anesthesia.[37,38]

Fourth, if the surgeon (proceduralist) will be operating later in the day and is scheduled for only 1 procedure, provide notification when there is the start of closure of the preceding case being done by the anesthesia and nursing team.[39] This communication reduces their total exposure time in the OR and should not limit workflow if the preceding patient will be recovered in the OR by the anesthesiologist or certified registered nurse anesthetist.