COVID-19 Guidance for Surgeons 

Updated: Oct 14, 2020
  • Author: John Geibel, MD, MSc, DSc, AGAF; more...
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Background

Although COVID-19 is not primarily a surgical disease, it has significantly affected surgical practice in multiple ways. A number of organizations have released recommendations and guidelines for addressing the COVID-19 pandemic. Organizations focusing on concerns of particular relevance to surgeons have included, but are by no means limited to, the following:

  • American College of Surgeons (ACS) [1, 2, 3, 4]
  • Centers for Medicare and Medicaid Services (CMS) [5, 6]
  • Royal College of Surgeons of England (RCS) [7]
  • Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and European Association for Endoscopic Surgery (EAES) [8]
  • Ambulatory Surgery Center Association (ASCA) [9]
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American College of Surgeons

Triage of nonemergency surgical procedures

The medical urgency of a case cannot be defined solely according to whether the case is on an elective surgery schedule. [1] Some such cases can be postponed indefinitely, but the vast majority are associated with progressive disease that will continue to progress. Thus, the decision to cancel or perform a surgical procedure must be made in the context of numerous medical and logistical considerations. The ACS recommends the following:

  • Hospitals and surgery centers should consider both their patients’ medical needs and their logistical capability to meet those needs in real time.
  • The medical need for a given procedure should be established by a surgeon with direct expertise in the relevant surgical specialty.
  • Logistical feasibility for a procedure should be determined by administrative personnel with an understanding of hospital and community limitations, considering facility resources and provider and community safety and well-being.
  • Case conduct should be determined on the basis of a merger of these assessments, using contemporary knowledge of the evolving national, local, and regional conditions and recognizing that marked regional variation may lead to differences in regional decision-making.
  • Evaluation of patient risk should take into account both the real risk of proceeding and the real risk of delay, including the expectation that a delay of 6-8 weeks or more may be necessary.

A day-by-day, data-driven assessment of the risk-benefit ratio should influence clinical care delivery. Case triage should rely not on blanket policies but on data and expert opinion from qualified clinicians and administrators with a site-specific granular understanding of the issues in play. Consideration of surgical procedures should not be based solely on risks associated with COVID-19 but, rather, on all available medical and logistical information.

Surgical decision-making regarding triage of nonemergency surgical procedures may be further assisted by employed a tiered approach (see CMS guidelines below).

Each surgical specialty has specific guidelines that are pertinent to the procedures within that specialty, including the following [3] :

  • Cancer surgery
  • Breast cancer surgery
  • Colorectal cancer surgery
  • Thoracic cancer surgery
  • Emergency general surgery
  • Gynecology
  • Metabolic-bariatric surgery
  • Neurosurgery
  • Ophthalmology
  • Orthopedic procedures
  • Otolaryngology
  • Pediatric surgery
  • Urology
  • Vascular surgery

Overarching principles for all cases include the following:

  • In triaging elective cases, prepare for the expected markedly increased rates of COVID-19.
  • Ensure that patients receive appropriate and timely surgical care, including operative management, on the basis of sound surgical judgment and resource availability.
  • Consider nonoperative management whenever it is clinically appropriate.
  • Consider waiting on results of COVID-19 testing in patients who may be infected.
  • Whenever possible, avoid emergency surgical procedures at night.
  • For patients who are or may be infected, perform aerosol-generating procedures (AGPs; eg, intubation/extubation, bronchoscopy, bag masking, electrocauterization, laparoscopy/endoscopy) only while wearing full PPE, including an N95 mask or powered, air-purifying respirator (PAPR) designed for the operating room (OR).

The data are insufficient to recommend either open surgery or laparoscopic surgery over the other. The approach that minimizes OR time and maximizes safety for both patients and healthcare staff should be chosen. (See SAGES/EAES guidelines below.)

Surgeon safety before, during, and after operation

The ACS has provided recommendations for protecting OR personnel in the OR, as well as for minimizing the risk of COVID infection afterward. [10]

Personal protective equipment

Use of PPE is recommended by the Centers for Disease Control and Prevention (CDC) for every operative procedure performed on a patient with confirmed COVID-19 infection or a patient in whom there is suspicion for infection. [11]

N95 respirators or respirators that offer a higher level of protection should be used when one is performing or present for an aerosol-generating procedure (eg, OR patient intubation) in a patient with confirmed or suspected COVID-19.

Disposable respirators and face masks should be removed and discarded appropriately in accordance with local policy.

Hand hygiene should be performed after the respirator or face mask is discarded.

CDC videos for donning and doffing personal protective N95 masks (donning and doffing) are helpful.

Fit testing is paramount to ensure proper mask fit. [12, 13]

Healthcare institutions are encouraged to develop protocols for preserving supplies of masks and protective equipment. The CDC has outlined strategies for optimizing the supply of face masks. [14]

Intubation risks

Aerosolization and droplet transmission of the COVID-19 virus are important hazards for surgical personnel; these hazards increase with procedures such as endotracheal intubation, tracheostomy, gastrointestinal (GI) endoscopy, and evacuation of pneumoperitoneum and aspiration of body fluids during laparoscopic procedures.

Surgeons and personnel not needed for intubation should remain outside the OR until anesthesia induction and intubation are completed for patients with or suspected of having COVID-19 infection.

Negative-pressure ORs and/or anterooms, when available, are recommended.

Consideration should be given to how long COVID-19 might remain infectious on different surfaces.

Appropriate PPE must be used per local policy.

Specific operative risk issues

The minimum number of personnel should be in the OR, including during intubation, as well as throughout the procedures. No visitors or observers should be allowed.

A smoke evacuator should be employed when an electrocautery is used.

Consideration should be given to avoiding laparoscopy.

Tracheostomy considerations are important to take into account because of the high risk for aerosolization. 

After operation/recovery

If transport of a patient with or suspected of having COVID-19 to an outside recovery area or intensive care unit (ICU) is necessary, handoff to a minimum number of transport personnel who are waiting outside the OR should be considered. Personnel should wear PPE as recommended by the CDC; such PPE should not be the same as that worn during the procedure.

Recommendations for surgeon protection before and after separating from a patient with or suspected of having COVID-19 infection vary from institution to institution. Suggestions include the following:

  • Remove clothes worn from home and keep in garment bag.
  • Wear scrub clothes after arrival at hospital.
  • After separating from the patient, remove scrub clothes; consider showering before changing into a clean scrub suit or home clothes.
  • Wash hands frequently and maintain safe social distancing.

Going home: keeping families safe

Healthcare institutions and systems may make hotel accommodations available for healthcare workers who cannot or prefer not to go home after patient care activities.

Remember that viral contamination of surfaces is a known means of transmission of infection.

Keep hand sanitizer, disposable gloves, or both for use with ATM machines, vending machines, gasoline pumps, and person-to-person transfer of purchased items.

Clean cell phones frequently before, during, and after patient care activities. Cell phones may be kept in a reclosable plastic bag during work activities. The phone can be used while in the bag.

Consider removing clothes and washing them upon arrival home.

Consider reducing physical contact with family members, and wash hands frequently.

Clean hard surfaces at home with an effective disinfectant solution.

Trauma center access and care

The ACS provides the following advice for trauma medical directors (TMDs) and trauma program managers (TPMs) in view of the anticipated surge of critically ill patients related to COVID-19 infection. [2]

Regional planning

Engage with healthcare coalitions and local health departments to establish policies for regional distribution of patients and engage in ongoing discussion of regional ICU triage, regional resource allocation, and development of crisis standards of care, commensurate with community resources.

Ensure that planning considers the impact on the triage and transport of injured patients and should discuss the importance of preserving capacity at regional level I and II trauma centers.

Be involved in discussions regarding the management of injured patients as it relates to adaptation of standards of care, and be involved in ongoing regional discussions as the situation evolves.

Serve as subject matter experts in establishing criteria for early triage to palliative care for injured patients not likely to survive.

Be aware of the potential impact on trauma patients across the continuum of care, including transport limitations by emergency medical services (EMS) and aeromedical services, potential disruptions in the transfer of injured patients needing a higher level of care, and limitations in discharge disposition for COVID-19 patients.

Hospital planning

Engage in hospital planning, including development of ICU surge capability and capacity, ICU triage criteria, ICU service management, cross-training of ICU providers, and protection of the healthcare workforce.

Serve as subject matter experts in the hospital incident command structure, and ensure that hospital leadership is aware of expected needs to support trauma care during this timeframe.

When possible, ensure that COVID-19 patients are cohorted in a separate location from non-COVID-19 patients; however, optimal injury care should be a priority.

Ensure that the hospital identifies a triage and resource prioritization process for ICU admission, ventilator allocation, and resource-limited interventions; this process should be independent of the direct care providers.

Ensure that the hospital has identified trigger points and plans to request additional PPE, ventilators, and other equipment when local supplies are depleted—first from local healthcare coalitions, then from the county Emergency Management Agency (EMA), then from the state EMA, and finally from the federal EMA (FEMA).

Ensure that the hospital has a plan for limiting visitation to all patients and ensuring best-practice hygiene for all visitors.

Ensure that the hospital has a process and supporting policies for disaster credentialing and privileging, including degree of supervision required, clinical scope of practice, mentoring and orientation, electronic medical record (EMR) access, and verification of credentials.

Support policies to restrict elective appointments and procedures.

Protection and support of trauma team

Ensure that all trauma team providers undergo PPE-fit testing; are reviewing appropriate sources for training in use of PPE; and are remaining current in emerging guidance from the CDC and regional health agencies.

Promote individual behaviors that limit the risk of disease transmission (eg, handwashing, avoiding handshakes, covering the mouth when coughing, and staying home when ill).

Educate staff on community, regional, and state disaster plans and resources.

Support social distancing practices and allow providers not on service and nonclinical staff to work from home.

Transition from in-person to virtual meetings for administrative and educational activities.

When possible, restructure trauma teams and stagger cohorts to reduce the number of trauma/ICU providers in the hospital simultaneously.

Develop redundancy in backup schedules for providers who may be ill or exposed.

Develop a mechanism to monitor the well-being of team members who have had potential COVID-19 exposure or who are on quarantine.

Ensure that each trauma team member has an individual plan to support childcare and family/pet needs.

Ensure regular scheduled communication for team providers as hospital policies and procedures evolve, provide situational awareness on the patient load, and support development of a centralized, online resource for the health care system to disseminate information and policies and procedures.

Allow personnel with specific critical skills to concentrate on those skills. For example, surgical intensivists could help overwhelmed medical intensivists with ventilator management, and general surgeons could assist with trauma alerts, emergency general surgery procedures, and floor rounds.

Support schedules and team culture that optimize wellness and maintain resilience for team members.

Strategies at point of care

Recommendations for the trauma bay include the following:

  • Do not delay trauma patient evaluation to determine COVID-19 status, but take appropriate precautions.
  • Ensure strict use of PPE for droplet contact precautions for all patients.
  • If a patient has upper respiratory symptoms, immediately place a face mask on the patient.
  • Add questions about fever, upper respiratory symptoms, COVID-19 exposure history, and travel history to the history, and take appropriate isolation measures.
  • Limit the number of personnel at the bedside to those required for direct patient care.
  • Develop policies and procedures for airway management for potential COVID-19 patients requiring emergency intubation.

Recommendations for the OR include the following:

  • Develop a hospital policy for managing patients in the operating room with known or suspected COVID-19 infection and prevent delays in critical operative interventions for unstable patients.
  • Ensure agreements are in place with the anesthesia team for management of these patients.

Recommendations for the ICU include the following:

  • Maintain situational awareness of ICU capacity in the hospital and ensure that critical care needs of trauma patients are considered.
  • Monitor the availability of ventilators and oxygen supply.

Strategies for managing scarce resources

Shortages of PPE and blood products may develop; TMDs and TPMs should support hospital policies and procedures to preserve these resources.

To minimize patient room entries/exits and the need for PPE donning/doffing, cluster the work that needs to be done for a patient.

Restrict nonessential personnel and students from the OR, ICU, and emergency department (ED).

Limit personnel to those essential for patient care during trauma team activation and in the OR.

Support hospital policies for reuse of selected PPE when appropriate.

Monitor the blood supply in the region, and support restrictive transfusion strategies in the ICU when appropriate.

Support messaging to encourage blood donation in the community. There are no data to suggest that COVID-19 can be transmitted via blood transfusion.

Maintenance of essential surgery during pandemic

After the first COVID-19 surge waned, many localities resumed essential surgeries. However, the resurgence of the virus in many regions has many states near or at bed and ICU capacity, and healthcare facilities’ ability to meet the needs of patients presenting for essential surgery may be stressed by new influxes of COVID-19 patients. Healthcare organizations, physicians, and nurses must therefore remain prepared to meet the demands for patients hospitalized with COVID-19 and for patients in need of essential surgery services.  

The following principles and considerations may be used to guide physicians, nurses and local facilities in providing care in ORs and all procedural areas during the ongoing pandemic. [4]

Regional cooperation

Facilities should engage in regional cooperation to address capacity and new patient needs to ensure facilities have appropriate number of ICU and non-ICU beds, PPE, testing reagents and supplies, ventilators, and trained staff to treat all nonelective patients without resorting to a crisis standard of care. Daily forecasting of COVID-19 demand on all resources shall be the baseline for determining the ability to add non-COVID-19 cases.

Facilities policies should account for the following:

  • Local, state, and regional cooperation with public health authorities and state hospital associations for effective management of resources and optimal care for patients in the region.
  • Any provision of essential surgery should be authorized by the appropriate municipal, county and state health authorities.
  • Healthcare capacity should match community prevalence of disease.
  • Facilities in the region/state should be able to safely treat all patients requiring hospitalization without resorting to crisis standards of care.
  • Does the facility have the capability to flex up intensive care across all services, staffing, and specialties?
  • Does the facility have appropriate number of ICU and non-ICU beds, PPE, testing reagents and supplies, ventilators, medications, anesthetics and all medical and surgical supplies?
  • Does the facility have available numbers of trained and educated staff appropriate to the planned surgical procedures, patient population, and facility resources? Can the facilities perform planned procedures without compromising patient safety or staff safety and well-being?

Supply chain

Hospitals, medical professional societies, and government agencies should work together to ensure adequate supplies of vital equipment and medications. Collaboration should involve the following:

  • Collaboration with the FDA and other stakeholders to address drug shortages.
  • Government support for low-margin essential medications.
  • Building of stockpiles of critical equipment, PPE and medications during times of low pandemic activity.
  • Maintenance of distribution of appropriate PPE to healthcare providers for current clinical needs according to CDC recommendations and local needs for PPE conservation and resterilization.
  • Maintenance of an option for healthcare providers to obtain and wear their own facility-approved PPE should critical shortages develop.
  • Facilities and state hospital associations working together to ensure that vital equipment and medicines are shared according to need.
  • Use of mobile field hospitals for postacute and non-COVID care to unburden hospitals.

COVID-19 testing within facilities

Facilities should use available testing to protect staff and patient safety and should implement a policy addressing requirements and frequency for patient and staff testing in accordance with current CDC guidelines. Facility COVID-19 testing policies should account for the following:

  • Availability, accuracy and current evidence regarding tests, including turnaround time for test results
  • Frequency and timing of patient testing (all/selective) - Patient testing policy should include accuracy and timing considerations; if such testing or timely test results are not available, reassessment and implementation of evidence-based infection prevention techniques, access control, workflow, and distancing processes are warranted to create a safe environment for elective surgery; if there is uncertainty about patients’ COVID-19 status, PPE appropriate for the clinical tasks should be provided for the clinical and support team
  • Indications and availability for health care worker testing
  • How a facility will respond to a COVID-19-positive worker, a COVID-19-positive patient (identified preoperative, identified postoperative), a “person under investigation” (PUI) worker, or a PUI patient; patient protocols for the care of a COVID-19-positive patient requiring urgent or essential surgery

Personal protective equipment

Facilities should not provide nonemergency essential surgical services unless they have adequate PPE and medical surgical supplies appropriate to the number and type of procedures to be performed. Facility policies for PPE should account for the following:

  • Adequacy of available PPE
  • Staff training on and proper use of PPE according to non-crisis-level evidence-based standards of care; policies for conservation of PPE should be developed, as well as policies for any extended use or reuse of PPE per CDC and FDA guidance
  • Protocols for any resterilization and decontamination procedures in accordance with CDC and FDA emergency use authorizations

Case prioritization and scheduling

Facilities should establish a prioritization policy committee consisting of surgery, anesthesia, and nursing leadership to develop a prioritization strategy appropriate to immediate patient needs. Prioritization policy committee strategy decisions regarding case scheduling and prioritization should account for the following:

  • List of previously canceled and postponed cases
  • Objective priority scoring (eg, MeNTS instrument)
  • Specialties’ prioritization
  • Strategy for allotting daytime OR/procedural time
  • Identification of essential healthcare professionals and medical device representatives per procedure
  • Strategy for phased opening of ORs - Identify capacity goal before resuming (eg, 25% vs. 50%); outpatient/ambulatory cases start surgery first, followed by inpatient surgeries; all ORs opening simultaneously will require more personnel and material
  • Strategy for increasing OR/procedural time availability (eg, extended hours before weekends)
  • Issues associated with increased OR/procedural volume
  • Potential for expanding procedural capacity by partnering with ambulatory surgery centers (ASCs), including maintenance of waivers allowing ASCs increased average length of stay (ALOS)

COVID-19 issues for five phases of surgical care

Facilities should adopt policies addressing care issues specific to COVID-19 and the postponement of surgical scheduling.

Phase I (preoperative) considerations include the following:

  • Guideline for preoperative assessment process - Patient readiness for surgery can be coordinated by anesthesiology-led preoperative assessment services
  • Guideline for timing of reassessing patient health status - Special attention and reevaluation are needed if patient has had COVID‑19 disease; a recent history and physical examination within 30 days per Centers for Medicare and Medicaid Services (CMS) requirement is necessary for all patients; telemedicine, as well as nurse practitioners and physician assistants, may be considered for components of the preoperative evaluation; some face-to-face components can be scheduled on the day of the procedure, particularly for healthier patients; surgery and anesthesia consents are obtained per facility policy and state requirements; laboratory testing and radiologic imaging should be determined by patient indications and procedure needs; preoperative patient education classes should beassessed against remote instructions
  • Advanced directive discussion with surgeon, especially patients who are older adults, are frail, or have had COVID‑19
  • Assessment of need for post–acute care (PAC) facility stay, to be addressed before the procedure

Phase II (immediate preoperative) considerations include the following:

  • Guideline for preprocedure interval evaluation since COVID-19-related postponement
  • Assess need for revision of nursing, anesthesia, and surgery checklists regarding COVID‑19

Phase III (intraoperative) considerations include the following:

  • Assessment of need for revision of preanesthetic and presurgical timeout components
  • Guideline for who is present during intubation and extubation
  • Guideline for PPE use
  • Guideline for continuing the education of all healthcare students, as feasible
  • Guideline for presence of nonessential personnel

Phase IV (postoperative) considerations include the following:

  • Adherence to standardized care protocols for reliability in light of potential different personnel - Standardized protocols optimize length of stay efficiency and decrease complications
  • ICU capacity, including maintenance of waivers allowing expanded ICU capacity

Phase V (postdischarge care planning) considerations include the following:

  • PAC facility availability
  • PAC facility safety (COVID-19 and non-COVID-19 issues)
  • Home setting - Ideally, patients should be discharged home and not to a nursing home; higher rates of COVID-19 may exist in these facilities

Collection and management of data

Facilities should reevaluate and reassess policies and procedures frequently on the basis of COVID-19 related data, resources, testing, and other clinical information. Facilities should collect and utilize the following relevant facility data, enhanced by data from local authorities and government agencies, as available:

  • COVID-19 numbers (testing, positives, availability of inpatient and ICU beds, intubated, OR/procedural cases, new cases, deaths, healthcare-worker positives, location, tracking, isolation, and quarantine policy)
  • Facility bed, PPE, ICU, and ventilator availability
  • Quality-of-care metrics (mortality, complications, readmission, errors, near misses, etc)

More research is needed regarding the long-term health effects of COVID-19.

COVID-related safety and risk mitigation

Facilities should have and implement a face-covering and social-distancing policy for staff, patients, and patient visitors in nonrestricted areas in the facility that meets current local and national recommendations for community isolation practices. The policy should include the following:

  • Facility policy should require face coverings for all patients, staff, and visitors.
  • Facilities should make hand sanitizer readily available to all patients, staff, and visitors.
  • Facility policy should address whether temperature checks are required for patients, staff and visitors; optimal facility policies will require temperature checks.
  • Each facility’s social-distancing policy should take account for current local and national recommendations, the number of persons that can accompany the procedural patient to the facility, and whether visitors in periprocedural areas should be further restricted.

Additional COVID-19-related issues

Also to be considered are the following:

  • Healthcare worker well-being, including trainees and students if applicable (eg, work hours, posttraumatic stress, burnout, suicide risk)
  • Patient messaging and communication
  • Case scheduling process
  • Facility and OR/procedural safety for patients
  • Preoperative testing process for COVID-19-positive and non-COVID-19-positive patients
  • Environmental cleaning - Before the start of any invasive procedure, all areas should be terminally cleaned according to evidence-based information

In all areas along the five phases of surgical care, regulatory issues must be taken into account, ORs/procedural areas must meet engineering and Facility Guideline Institute standards for air exchanges, and anesthesia machines returned from COVID-19 and non-COVID ICU use must be reengineered, tested, and cleaned as needed.

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Centers for Medicare and Medicaid Services

CMS has recommended that all nonessential planned surgeries and procedures, including dental, be limited until further notice. [5]

Decisions regarding surgery remain the responsibility of local healthcare delivery systems, including health officials, and of surgeons who have direct responsibility to their patients. However, in analyzing the risk and benefit of any planned procedure, not only must the clinical situation be evaluated, but conservation of resources must also be considered, even in areas not currently dealing with COVID-19. While case-by-case evaluations are made, the issue of whether planned surgery should proceed should be considered in the light of the following factors:

  • Current and projected COVID-19 cases in the facility and region - Consider a tiered approach to curtailing elective surgical procedures (see below)
  • Supply of PPE to the facilities in the system
  • Staffing availability
  • Bed availability, especially ICU beds
  • Ventilator availability
  • Health and age of the patient, especially in view of the risks of concurrent COVID-19 infection during recovery
  • Urgency of the procedure

A tiered approach may be applied to decision-making regarding elective surgical procedures, as follows:

  • Tier 1a (low-acuity surgery/healthy patient) – Postpone surgery/procedure
  • Tier 1b (low-acuity surgery/unhealthy patient) – Postpone surgery/procedure
  • Tier 2a (intermediate-acuity surgery/healthy patient) – Consider postponing surgery/procedure
  • Tier 2b (intermediate-acuity surgery/unhealthy patient) – Postpone surgery/procedure if possible
  • Tier 3a (high-acuity surgery/healthy patient) – Do not postpone
  • Tier 3b (high-acuity surgery/unhealthy patient) – Do not postpone

Reopening of facilities to provide nonemergency care

As states and localities begin to stabilize and COVID-19-related healthcare demand decreases, it is important to safely resume care in order to treat ongoing health needs that are currently being postponed. [6] If states or regions have passed the gating criteria announced on April 16, 2020, [15] they may proceed to phase I and subsequently to phase II of reopening. The following recommendations refer only to areas in phase II (states and regions with no evidence of a rebound satisfying the gating criteria).

Optimization of telehealth services, when available and appropriate, continues to be recommended to minimize the need for in-person services. This includes providing individuals with disabilities with tools for effective communication.

All individuals at higher risk for severe COVID-19 illness should continue to shelter in place unless their conditions warrant in-person healthcare.

For care that cannot be provided virtually, these recommendations may guide healthcare systems, providers, and facilities as they consider delivering in-person care to non-COVID-19 patients in regions with lower or declining without-rebound, levels of COVID-19.

Nonemergency non-COVID care (NCC) should be offered to patients as clinically appropriate, in localities or facilities that have the resources to provide such care and the ability to respond quickly to a surge in cases if necessary. Decisions should be consistent with federal, state, and local orders and CDC guidance and should be made in collaboration with state and local public health authorities. Careful planning is required to safely deliver in-person care to patients requiring NCC, including the following:

  • Adequate facilities, workforce, viral testing for SARS-Cov-2, PPE, and supplies across all phases of care in the healthcare system
  • Adequate workforce across all phases of care

General considerations

Healthcare systems and clinicians must preserve the capacity to care for potential surges of COVID-19 patients and ongoing fluctuations of COVID-19 needs, including plans for rapid deployment of alternative care sites through the Hospitals Without Walls program. However, hospitals also must have the flexibility to resume nonemergent but clinically necessary care for patients with non-COVID-19 needs, in accordance with the following general considerations:

  • In coordination with state and local public health officials, evaluate the incidence and trends for COVID-19 in the area where in-person care is being considered, including metrics related to local and regional healthcare system capacity.
  • Evaluate the necessity of the care based on clinical needs: (a) Prioritize services that, if deferred, are most likely to result in patient harm; (b) prioritize at-risk populations who would benefit most from those services.
  • Establish NCC zones where all patients can be screened for symptoms of COVID-19, including temperature checks. Staff should continue to be routinely screened, as should others who work in the facility, including physicians, nurses, housekeeping,delivery, and all people who enter the area.
  • Sufficient resources should be available to the facility across phases of care, including PPE, sufficient healthcare workers, facilities, supplies, and screening and testing capacity, without jeopardizing surge capacity.
  • Participation in a registry or national data collection system (eg, the National Healthcare Safety Network) is strongly encouraged to help track patient outcomes, facility and system impacts, and resource allocation. COVID-19 reporting is required in some facilities (nursing homes).

Facility considerations

When a facility makes the determination to provide in-person nonemergency NCC, it should take steps to reduce the risk of COVID-19 exposure and transmission in any newly created NCC areas. These areas should be separate from COVID-19 care zones, to the extent feasible. Approaches include use of a separate building or of designated rooms or floors with a separate entrance and minimal crossover with COVID-19 care areas.

For in-hospital care and procedures, to the extent feasible, designate space specifically for COVID-19 care or NCC through the use of strategies such as separate floors or dedicated space. Avoid crossover of patients, staff, supplies, and personnel, as feasible.

Within the facility, establish administrative and engineering controls to facilitate social distancing, such as minimizing time in waiting areas, spacing chairs, and maintaining low patient volumes.

Minimize the number of visitors. Actively assess all visitors for COVID-19 symptoms upon entry to the facility; if COVID-19 symptoms are present, the visitor should not be allowed entry and should be referred for care, as appropriate.

Testing for SARS COV-2

For hospitalized patients and those imminently undergoing a procedure or operation, when possible, viral testing should be prioritized and performed 24 hours before the procedure or admission, including for patients in the labor and delivery areas. If testing is not available, patients should self-isolate for 14 days in advance.

For patients who test positive for COVID-19, the clinical team should consider the risks and benefits of proceeding with or postponing the procedure. If care is delivered, it should be done in a COVID-19 care zone with appropriate precautions.

Screening of clinical staff who work in a NCC environment is recommended daily upon arrival. Other staff entering NCC zones should be screened and tested, as appropriate.

Upon entry to the facility, visitors who have symptoms or test positive on screening should be excluded from the NCC zone and encouraged to follow isolation and to seek care as appropriate.

Testing results should be reported appropriately to the state health department, in a manner consistent with state and local requirements.

PPE and supplies

In accordance with the CDC’s infection control recommendations, healthcare providers and staff should wear surgical face masks at all times, unless they are delivering care that would require an N95 respirator.

Procedures on the mucous membranes, including the respiratory tract, with a higher risk of aerosol transmission should be done with great caution, and staff should utilize appropriate respiratory protection (eg, N95 respirators and face shields). If N95 respirators are needed, they must be used in the context of a comprehensive respiratory protection program that complies with the provisions of the Occupational Safety and Health Administration’s (OSHA) Respiratory Protection Standard (29 CFR1910.134).

Patients and visitors should wear cloth face coverings that can be bought or made at home. Facilities should be prepared to provide cloth face coverings or face masks for patients and visitors who do not have one upon entry.

Every effort should be made to conserve PPE, including following protocols for extended use and reuse when necessary.

Adequate supplies of PPE, equipment, medication, and supplies must be ensured to the greatest extent possible, without detracting from the community’s ability to respond to a potential surge in cases.

Workforce availability

Workforce must be sufficient to respond quickly to augment COVID-19 care as necessary.

Facilities should have a plan for screening and potentially testing the workforce for COVID-19, following CDC recommendations.

Staff should be routinely screened for symptoms of COVID-19 daily upon arrival. If symptomatic, staff members should be tested, should not enter the facility, and should follow appropriate care and isolation procedures.

Staff who will be working in NCC zones should be limited to working in those areas and should not rotate into COVID-19 care zones unless absolutely necessary. If required to rotate into COVID-19 carezones, they should be particularly careful to use appropriate PPE and appropriate sanitation protocols.

Staff diagnosed with or suspected of having COVID-19 should follow the CDC return-to-work guidance [16] to the greatest extent possible.

Staffing levels in the community must remain adequate to cover a potential surge in COVID-19 cases.

Sanitation protocols

Ensure that there is an established plan for thorough cleaning and disinfection before using spaces or facilities for patients with NCC needs.

Ensure that equipment (eg, anesthesia machines) used for patients diagnosed positive for COVID-19 are thoroughly decontaminated, following CDC guidelines. [11]  

Populations at higher risk of severe COVID-19 illness

By the CDC's definition, populations at higher risk for severe COVID-19 illness include, but are not limited to, older adults (≥65 years) and people with serious underlying chronic conditions (eg, chronic lung disease, serious heart conditions, diabetes, severe obesity, moderate-to-severe asthma, liver disease, hemoglobin disorders, and compromised immune function). At-risk populations also include people who live or are receiving care in a nursing home or long-term care facility or who require dialysis for chronic kidney disease. Furthermore, individuals with disabilities have a disproportionate rate of underlying health conditions that place them at risk for severe COVID-19 illness.

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Royal College of Surgeons of England

The RCS has made recommendations for surgeons and surgical teams during the COVID-19 pandemic in the following four areas [7] :

  • Adapting surgical services
  • Working in an extended scope of practice
  • Caring for patients at the end of life
  • Protecting the workforce

Adaptation of surgical services

Triage of nonemergency surgery

Hospitals and surgeons should carefully review all scheduled elective procedures with a plan to minimize, postpone, or cancel scheduled operations, endoscopies, and other invasive procedures as necessary and to shift inpatient diagnostic and surgical procedures to outpatient settings when feasible.

Hospitals and surgical units should consider their patients’ surgical needs and their capacity to meet those needs in real time as the impact of the outbreak develops.

The need for surgery should be established by a surgeon with expertise in the relevant specialty.

Logistical capacity for a procedure in a given hospital should be determined by theater managers taking into consideration facility resources and patient safety considerations.

The risk to the surgical patient should include assessment of the real risk of proceeding and the real risk of delay, including the expectation that a delay of 3 months or more may be required.

Plans for triage should avoid blanket policies but rather rely on a day-by-day data-driven assessment of the changing risk-to-benefit analysis.

Provision of surgery in clinical networks

Networking arrangements must have senior clinical and managerial endorsement and be supported by contractual arrangements and agreed, coordinated protocols of care.

Expertise and resources will be drawn from the entire network, enabling patients to be treated at the most appropriate hospital.

Appropriate rapid triage facilities and theaters must be available at short notice, and responsibility for patient care must be clearly delineated. Suitable handover must be viewed as a priority.

Robust handover and transfer arrangements must be agreed on within the network. Protocols and resources must be in place for hospitals less well equipped for rapid patient transfer. Retrieval teams from better-situated or -equipped hospitals must be available at short notice, and ambulance services must be readily available for prehospital care.

Ambulances must be directed to the hospital most suited to the patient’s particular needs.

Initial assessment of patients with suspected surgical pathology can be completed by a senior clinician who is able to determine when surgery may be required and who may then refer to a surgeon for further assessment and decisions regarding postponement of surgery. Decisions to operate should be made jointly with the anesthetic team.

In all cases, emergency surgery should be led by the most experienced surgical team member available. All patients admitted on an emergency basis must be discussed with the responsible consultant if immediate surgery is being considered.

Patients requiring emergency surgical opinion/intervention must be seen at an early stage by a surgeon with the required skills and competencies.

High-risk patients (eg, predicted mortality ≥10%) must be discussed with the consultant anesthetist and reviewed by a consultant surgeon as soon as possible if the management plan remains undefined or the patient is not responding as expected. The operation must be carried out in a timely manner under the direct supervision of a consultant surgeon and a consultant anesthetist.

When predicted mortality exceeds 5%, a consultant surgeon and a consultant anesthetist should be present for the operation, except where adequate experience and the appropriate workforce can be otherwise assured.

For patients not considered high-risk, all emergency surgical admissions should be discussed with the responsible consultant within 12 hours of admission. Active and continued patient monitoring must be carried out, and the consultant should be notified immediately if the patient’s condition deteriorates.

Patients who are admitted but not taken to theater must be seen by a consultant surgeon within 24 hours after admission. The patient must be actively and continuously monitored, and the consultant must be notified immediately if the patient’s condition deteriorates.

Rotas

If the surgical caseload is reduced or sickness reduces the number of surgeons available, individual specialty rotas may not be sustainable, and a generic surgeon rota may become necessary. Surgeons on call should be able to manage initial triage, carry out part of the surgery, and manage postoperative care, with remote support from specialists. Some operations will still require a specialist surgeon when available.

The workforce is likely to break down into torso/cavity surgeons (vascular, general, urology) and extremity surgeons (orthopedics, plastics). Where possible, each site should have both a torso/cavity surgeon and an extremity surgeon present. Having a second consultant on call would be helpful.

Responsibility for ICU patients

Management of patients admitted under a surgeon’s care and then transferred to an ICU is the responsibility of the entire medical team. Responsibility for the various aspects of postoperative care may be shared amongst the various members of the team.

During the COVID-19 pandemic, decision-making should follow the National Institute for Health and Care Excellence (NICE) guidelines for critical care in adults. [17]

When caring for a surgical patient admitted to an ICU, surgeons should work collaboratively with all ICU staff and contribute to the patient management plan as required. A written and verbal handover between the surgical and ICU teams should document postoperative management plans.

Outpatient clinics

For the duration of the COVID-19 outbreak, hospitals and surgical teams should aim to deliver virtual clinics for outpatient appointments to support infection control. For many surgical procedures, virtual clinics can also be used for follow-up appointments.

Face-to-face postoperative review should be done only if clinically necessary and should be done only once unless additional review is clinically indicated. The review should address any adverse outcomes, the pathway followed, and any subsequent actions the patient should take.

Extended practice scope

Working beyond regular scope of practice as team member

Surgeons may be required, on either a regular or an as-needed basis, to extend temporarily the scope of their practice beyond their normal expertise or may be redeployed to support nonsurgical roles. In such circumstances, the following considerations should be taken into account:

  • Identification of local need
  • Appropriate training
  • Teamworking and collaboration

Surgeons may be required to familiarize themselves with relevant World Health Organization (WHO) guidelines [18] ; in such cases, they should ensure they have been adequately updated in airway management and ventilation skills by a senior anesthetist or intensivist.

Retired surgeons and trainees

Doctors, surgeons, and nurses who left the register or gave up their licences in the preceding 3 years, if willing to return to work, will receive temporary registration and be deployed to hospitals and services on the basis of clinical demand.

Trainees may also be asked to work flexibly and provide additional support in other clinical areas/specialties in their trust or in other sites. Trainees working across boundaries must have appropriate induction and training and be closely supervised and appropriately supported.

Postgraduate deans should be informed of plans to redeploy trainees, and arrangements for redeployed trainees should be reviewed weekly with updates provided to the postgraduate dean to ensure that they are adequately supervised and are given tasks appropriate to their stage of training.

Patient care at end of life

For some critically ill and high-risk patients, surgical intervention is appropriate; however, there are cases where surgery will not increase the quantity or improve the quality of life. Surgeons must be able to identify procedures that will be of little or no benefit to a patient and to provide patients with all possible information about alternatives. The following are important:

  • Patients and their carers should be assisted to develop realistic expectations of treatment.
  • The surgical care team should be informed about Advance Care Plans and should encourage and assist patients to put one in place beforehand.
  • The surgeon should discuss the patient’s case with relevant professionals to determine available end-of-life treatment options and should seek to ascertain the patient’s wishes, preferences, and beliefs.
  • The patient’s wishes, as expressed in an Advance Care Plan, should be honored.

When prohibition of visitation by relatives makes nuanced decisions difficult, efforts should be made to contact the family remotely and consult with the multidisciplinary team (including palliative care) to determine the way forward.

Protection of workforce

Infection prevention

All surgeons and teams must familiarize themselves with appropriate infection control practices and ensure that they have access to the right PPE.

PPE advice for higher-risk areas and procedures includes the following:

  • AGPs on a suspected or confirmed case - Disposable gloves; disposable fluid-repellent gown; FFP3 (or, if unavailable, FFP2 or N95) respirator; eye/face protection
  • Suspected or confirmed cases in higher-risk acute care areas where AGPs are regularly performed - Disposable gloves; disposable plastic apron; disposable fluid-resistant gown (sessional use); FFP3 respirator (sessional use); eye/face protection (sessional use)

PPE advice for lesser-risk areas and procedures includes the following:

  • Operating theater with suspected or confirmed cases, no AGPs - Disposable gloves; disposable plastic apron; disposable fluid-resistant gown (risk assess); fluid-resistant mask (type IIR; single or sessional use); eye/face protection
  • Inpatient area with suspected or confirmed cases (direct patient care, ≤2 m) - Disposable gloves; disposable plastic apron; fluid-resistant surgical mask (type IIR; sessional use); eye/face protection (sessional use)
  • Inpatient area with suspected or confirmed cases but not in direct patient care (ie, >2 m) – Fluid-resistant surgical mask (type IIR); eye/face protection (risk assess sessional use)

All PPE above is intended for a single use (disposal after each patient contact) unless otherwise indicated (eg, for sessional use, meaning the period of time during which a healthcare worker is undertaking duties in a specific environment).

Ensuring surgeons’ and surgical teams’ well-being

So as not to neglect self-care, members of the surgical team should make an effort to do the following:

  • Make use of any locally available support systems (eg, mentors, peers, colleagues). Senior clinicians should be prepared and willing to help others who are struggling or distressed.
  • Be mindful of signs and symptoms of stress, fatigue, and burnout (eg, exhaustion, lack of concentration, inability to think clearly).
  • Take breaks to recharge; where possible, allow adequate time off between shifts.

Employers must put in place arrangements to support staff who find themselves under significant pressure when things go wrong (eg, in safety incidents). The following should be considered:

  • Development of structured peer-support programs that include one-to-one discussion with experienced peers following safety incidents
  • Additional arrangements, such as mentoring, providing open opportunities for discussion, and making formal arrangements for operating in pairs where possible
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Society of American Gastrointestinal and Endoscopic Surgeons/European Association for Endoscopic Surgery

SAGES and EAES have made the following recommendations on the basis of the best available evidence and expert opinion from the global surgical community. [8]

Rationing of services

At present, all elective surgical and endoscopic cases should be postponed. Such decisions, however, should be made locally on the basis of COVID-19 burden and in the context of medical, logistical, and organizational considerations. Surgical care should be limited to patients with imminently life-threatening conditions. All others should be delayed until after the peak of the pandemic is seen.

All nonessential hospital or office staff should be allowed to stay home and work remotely. All in-person educational sessions should be canceled. During rounds and other encounters, only the minimum number of providers necessary should enter patient rooms, and adherence to handwashing, antiseptic foaming, and appropriate use of PPE should be strictly enforced. In-person surgical consultation, when necessary, should be performed only by decision-makers.

All nonurgent in-person clinic/office visits should be canceled or postponed unless they are needed for triaging active symptoms or managing wound care. All patient visits should be handled remotely when possible and in person only when absolutely necessary. Where possible, access to clinics should be maintained to keep patients from seeking care in the ED. Only a minimum of required support personnel should be present for these visits, and PPE should be appropriately utilized. When the need is critical, redeployment of OR resources for intensive care needs should be considered.

Multidisciplinary team (MDT) meetings should be held virtually as possible, limited to core team members (surgeon, pathologist, clinical nurse specialist, radiologist, oncologist, coordinator), or both. The MDT is responsible for decision-making and classifying priority level for surgery.

Procedural considerations

With regard to COVID-19 specifically, there is very little evidence regarding the risks of minimally invasive surgery (MIS) relative to those of conventional open surgery.

The possibility of viral contamination during open, laparoscopic, or robotic surgery should be considered, and protective measures should be strictly employed. Although research shows that laparoscopy can lead to aerosolization of bloodborne viruses, no evidence indicates that this effect is seen with COVID-19 or that it would be isolated to MIS procedures. Erring on the side of safety would involve treating the coronavirus as capable of similar aerosolization. For MIS, use of devices to filter released CO2 for aerosolized particles should be strongly considered.

The proven benefits of MIS (reduced length of stay and complications) should be strongly considered in these patients, in addition to the potential for ultrafiltration of the majority or all aerosolized particles. Filtration may be more difficult during open surgery.

Proceduralists and endoscopists may be at greater risk for viral exposure from endoscopy and airway procedures. When such procedures are necessary, strict use of PPE should be considered for the whole team, following CDC (https://www.cdc.gov) or WHO (https://www.who.int) guidelines for droplet or airborne precautions—probably including, at a minimum, N95 masks and face shields.

Practical measures for surgery

Consent discussion with patients must cover the risk of COVID-19 exposure and the potential consequences.

Surgical patients should be tested preoperatively for COVID-19, if testing is readily available and practical.

Intubation and extubation, if needed and possible, should take place within a negative-pressure room.

ORs for patients with presumed, suspected, or confirmed COVID-19 should be appropriately filtered and ventilated and should, if possible, be different from ORs used for other emergency surgical patients. Negative-pressure rooms should be considered, if available.

Only essential staff members should participate in the surgical case. There should be no exchange of room staff unless there is an emergency.

All OR staff members should use PPE (including appropriate gowns and face shields) as recommended by national or international organizations in all surgical procedures during the pandemic, regardless of known or suspected COVID-19 status. PPE should be placed and removed according to CDC guidelines. [11]

Electrosurgery units should be set to the lowest possible settings that will achieve the desired effect. Use of monopolar electrosurgery, ultrasonic dissectors, and advanced bipolar devices should be minimized; these can lead to particle aerosolization. Monopolar diathermy pencils with attached smoke evacuators should be used, if available.

Surgical equipment used during procedures on patients with suspected or known COVID-19 should be cleaned separately from other surgical equipment.

Practical measures for laparoscopy

Port incisions should be as small as possible to minimize leakage around ports.

CO2 insufflation pressure should be kept to a minimum, and an ultrafiltration system should be used, if available.

All pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open surgery.

Practical measures for endoscopy

All staff members in the endoscopy suite or OR should wear appropriate PPE, including gowns and face shields. PPE should be placed and removed according to CDC guidelines. [11]

All emergency endoscopic procedures performed in the current environment should be considered high-risk procedures.

Surgical energy should be minimized.

Endoscopic procedures requiring additional insufflation of CO2 or room air by additional sources (eg, many endoscopic mucosal resection [EMR] and endoluminal procedures) should be avoided until more is known about the aerosolization properties of the novel coronavirus.

Removal of caps on endoscopes should be avoided.

Endoscopic equipment used during procedures with COVID-19–positive patients or PUI should be cleaned separately from other endoscopic equipment.

SAGES has issued recommendations for management of endoscopes, endoscope reprocessing, and storage areas during the COVID-19 pandemic. [19]

Surgical management of specific conditions

SAGES has also made more specific recommendations for surgical management of colorectal cancer, [20] hepatopancreatobiliary cancer, [21] and gastric cancer [22] during the COVID-19 crisis.

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Ambulatory Surgery Center Association

In response to government guidance that hospitals and ASCs postpone elective surgeries during the COVID-19 pandemic, the ASCA has made the following recommendations on how and when facilities should proceed with cases that should not be postponed. [9]

First and foremost, if a procedure can be safely postponed without additional significant risk to the patient, it should be delayed until after the pandemic. The ASCA concurs with the ACS in this regard.

Physicians should engage with patients and families to make care decisions that minimize potential risks to patients while ensuring they receive necessary care that cannot be safely delayed. This includes consideration of postsurgical complications that could place stress on local hospitals lacking transfer capacity. To that end, facilities should establish lines of communication with local hospitals to ensure coordination in managing care during the pandemic.

ASCs should develop explicit controls on how to manage the infection risks of all nonpatient visitors inside the facility and should strictly prohibit all nonessential visitors. Additional social distancing policies should be employed.

Examples of cases where surgery might still have to proceed include the following:

  • Acute infection
  • Acute trauma that would significantly worsen without surgery
  • Potential malignancy
  • Uncontrollable pain that would otherwise necessitate hospital admission
  • A condition for which the prognosis would significantly worsen if treatment were delayed

ASCs must also be prepared for the possibility that the pandemic may eventually strain the system to a point where hospitals will need to shift necessary surgeries to ASCs, ASCs and their resources will be required to serve communities and the healthcare system in a different capacity, or both.

Finally, ASCs must recognize that situations may arise where they may have to suspend services temporarily, such as the following:

  • A patient, staff member, or physician who has been in the ASC is suspected of having or is subsequently diagnosed with COVID-19.
  • A significant shortage of PPE prevents safe practice of surgical cases.

The ASCA has stated that ASCs should resume elective surgeries if two conditions are guaranteed. [23] First, the community must be ready.  The prevalence of COVID-19 in the community must be low or declining, and the community must have sufficient bed capacity and PPE supplies to accommodate the potential needs of patients with COVID-19 infections.

Second, ASCs should open only if the safety of patients and the broader community can be guaranteed. Every ASC must ensure patient health and the prevention of virus spread by applying the following principles [23] :

  • Screening patients before visits and monitoring their health prior to starting surgery as part of the preoperative procedure
  • Requiring staff to self-monitor and screen for viral symptoms daily
  • Continuing to use PPE per the latest CDC recommendations for all procedures
  • Following waiting room spacing guidelines, social distancing, face masking and other recommended procedures for patients and visitors before entry into the facility
  • Ensuring heightened disinfection to prevent and mitigate risk of spread
  • Ensuring that patients have been medically cleared by their primary care physician where applicable

In addition to these cautions, the following factors should be considered [23] :

  • Geographic considerations - Starting in states where the COVID-19 trendline follows gating criteria and expanding to other states as the situation improves
  • Patient prioritization - Starting with patients who have lower co-morbidities and surgical risks
  • Procedure types - Starting with procedures that are lower-risk with regard to airborne transmission and those that carry minimal risk of unintended hospital admissions
  • COVID-19 testing considerations - Consider testing if it is feasible and if it would change the clinical decision to proceed with the procedure
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