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COVID-19 Surgical Resource Page

Page last updated 9/18/2020 at 10:56 AM

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Per updated CDC guidance on July 22, 2020, repeat testing within 90 days of a positive COVID-19 test is not recommended.

Critical Safety and Infection Prevention Principles

  1. Standards are different for elective surgeries and urgent/emergent surgeries and procedures. Thoughtful classification of the procedure is important.
    • Pre-operative/pre-procedural testing is expected for elective cases to allow proper risk stratification (all operative cases and procedures involving an aerosol generating procedure or moderate sedation), and cases should generally be cancelled if testing is not complete. COVID positive patients will be
      rescheduled beyond 30 days.
    • Elective surgeries and procedures must be delayed if a patient is COVID positive or has symptoms suspicious for COVID19.
  2. MedStar Health system standards for PPE use should be followed all times, to ensure safety to associates and patients and to conserve nationally constrained PPE items where possible. Guidance on proper PPE use is located on the PPE Essentials Page on the COVID 19 Resource Site.
  3. Surgical cases on PUI or COVID+ patients should be performed in negative pressure ORs whenever available, and system standards for room cleaning and disinfection should be followed.
  4. Further supporting resources facilities will be available on the COVID19 Resource Site and StarPort.

Elective and Non-Urgent Surgery

Criteria include, but are not limited to:

  • Screening patients: Entities should symptom screen patients 24 hours prior to surgery, working with local departments and physician offices.
  • Screening associates and physicians: Each entity should implement a screening solution for associates and providers, which may include screening at entrances, leveraging screening technology (currently being piloted at select hospitals), screening at the departmental level at the start of each shift, or integrating an “attestation” question in the time-clock system, requiring hourly and exempt associates to attest they are symptom-free upon arrival for shifts.
  • Physical distancing in waiting areas: Physical distancing must be strictly maintained in all settings where patients wait, to minimize direct contact between individuals. Ensure proper staff education, signage, etc., are in place. As practical, entities should implement non-traditional methods (e.g., call-ahead registration, waiting in car until called, etc.) For surgical waiting areas that cannot accommodate physical distancing requirements, consider modifications to MedStar Visitor Policy to allow patient drop off/pick-up or other alternatives. Entities should not begin elective procedures until a solution is implemented.
  • Maintaining supplies: All entities must ensure ample supplies, including PPE (one week’s supply), blood, equipment, medication, and COVID-19 testing equipment and reagents. Each entity is encouraged to designate a Supply Chain representative as an active member of local perioperative teams. All entities must maintain sufficient capacity and supplies to care for COVID-19 patients. 

For more details, please refer to Elective and Non-Urgent Surgeries and Procedures.

Elective Surgical Algorithm

The Elective Surgical Algorithm uses a modified Medically Necessary, Time-Sensitive (MeNTS) Procedures tool. The goal is to ensure real-time review of patients requiring a post-operative bed, blood products, inpatient rehabilitation, skilled nursing facility placement, and advanced care due to co-morbidities. The MeNTS score is to be noted on the surgical posting sheet; scores above the threshold (>10) must be pre-approved prior to posting. Reference the Elective Surgery Decision Worfklow page for more detailed information on testing and scheduling elective procedures for patients who are COVID positive.

Approach for Prioritization of Cases

Each entity president will appoint a perioperative leadership team, consisting of a surgeon, nurse and anesthesiologist. Reporting directly to the entity president, the team will have full authority for implementing the case prioritization protocol and determining the appropriate daily Operating Room volume. The team will collaborate with internal stakeholders (e.g., supplies, PPE, staff, bed availability, etc.). The methodology for the prioritization of cases includes acuity/urgency, service line priority, COVID-19 laboratory testing availability as per system prioritization (if constrained), and daily coordination with the MTO.

  • Emergent and urgent surgeries: procedures deemed time sensitive; delaying the surgery could negatively impact the health of the patient. 
  • Elective and non-urgent surgeries: procedures that can be rescheduled due to the nature of the procedure; delaying the surgery is unlikely to negatively impact the health of the patient. 

Surgical Planning Guidelines

Elective surgeries that can be delayed for 30 days:

  • Postpone surgery 30 days from onset of symptoms or positive COVID test.
  • After 30 days, continue with surgery without COVID isolation precautions.
  • Do not retest patients within 90 days of initial positive COVID test.

Urgent surgeries that cannot be delayed 30 days:

  • If surgery must be performed less than 20 days after initial COVID positive test or onset of symptoms, use COVID isolation precautions.
  • If surgery is performed greater than 20 days after initial COVID positive test or onset of symptoms, proceed without COIVD isolation precautions.
  • Do not retest patients within 90 days of initial positive COVID test.

COVID positive patients’ procedures should be postponed a minimum of 30 days whenever possible.

Pre-Operative Testing and Preparation

Visit the Pre-Operative Testing Page for all information and resources related to pre-op testing.

Effective Tuesday, June 30, at 5PM, the testing tents in Brandywine, Federal Hill and Bethesda will close permanently. Instead pre-operative testing will be available at select hospital-based locations. Reference Pre-Op Covid-19 Testing Hospital, Primary Care, and Urgent Care Locations for a full list of testing locations.

Pre-Operative COVID Testing FAQ

Pre-procedural testing should be completed 72 – 96 hours prior to the procedure. Calculate 72 – 96 hours from the time of the courier pickup to the surgery time. When counting days, count Day 1 as the day of the test, and Day 5 as the day of the surgical procedure.

Pre-Operative Testing Timeline: Refer to the table below for guidance on when to order testing depending on the day of surgery. Click the image for more information.

Pre Operative Testing Timeline. Click the image for more information.

Refer to the MMG Labcorp COVID Testing Algorithm for detailed guidance on when and where to order pre-procedural testing.

All patients are educated about self-quarantining at the time of testing, and are responsible for self-quarantining between the time of the test and when they arrive for surgery. However, findings indicate that MedStar Health has had no conversions to COVID-19 positive status for patients who could not or did not quarantine. Therefore, effective July 10, 2020 the updated pre-operative COVID-19 testing protocol no longer includes the second test requirement or the need to cancel elective surgeries for patients who could not or did not quarantine. Reference this Updated! Pre-Operative COVID-19 Testing Protocol memo for more information.

Common Pre-Op Testing Questions

How close to surgery must patients get tested?

  • Testing should be completed 72 – 96 hours prior to the procedure. Count 72 hours starting from the hour the testing sample is collected. When counting days, count Day 1 as the day of the test, and Day 5 as the day of the surgical procedure. This adherence to protocol is necessary to protect our associates and to conserve PPE.  The only exception to this requirement is a life-threatening emergency procedure.

What if a patient refuses testing?

  • Patients who refuse testing will have their procedure cancelled and will be counselled on the importance of testing for both them and their provider.
  • This patient testing requirement cannot be overridden by the patient’s physician.

What if there are exceptional circumstances for my patient that do not fit the pre-op testing protocol ?

  • Complex patient circumstances that do not fit the standardized protocol will be discussed by the patient’s surgeon and anesthesiologist to determine the optimal testing protocol given the patient’s circumstances.
  • Only the VPMA of the entity can approve proceeding with an urgent/emergent or scheduled case without testing.  Each VPMA will provide a report to us at the end of each week listing the number of testing exceptions and the rationale.

Do patients need to be retested between same day procedures? 

  • No, patients with repetitive procedures in the hospital also do not need to be retested, if they have a negative test within 5 days.

When should I order a rapid test pre-op?

  • Emergency cases do not require testing prior to surgery. Patient care in emergent situations should not be delayed due to testing. Please see the “What PPE should I wear to surgery” section for guidance on appropriate PPE during these cases.
  • All patients are educated about self-quarantining at the time of testing, and are responsible for self-quarantining between the time of the test and when they arrive for surgery. However, findings indicate that MedStar Health has had no conversions to COVID-19 positive status for patients who could not or did not quarantine. Therefore, effective July 10, 2020 the updated pre-operative COVID-19 testing protocol no longer includes the second test requirement or the need to cancel elective surgeries for patients who could not or did not quarantine. Reference this Updated! Pre-Operative COVID-19 Testing Protocol memo for more information.

What if rapid turnaround testing with LabCorp is not available?

  • While the standard protocol is to use LabCorp for pre-operative testing, each entity may prioritize some rapid turnaround testing capacity for pre-operative testing, recognizing the inherent trade-offs for patient flow if this strategy is chosen.

For more details, please refer to the memo on Pre-Operative COVID-19 Testing for Patients.

Antibody tests should not influence clinical management of patients (e.g.: antibody test results should not be incorporated into decision making for surgical planning, testing, PPE use, etc.). Currently, the main benefits of antibody testing are epidemiological. This may change over time as we learn more about prevalence of the disease and the best way of interpreting test results. For more information, refer to the Antibody Testing Provider Guide and the Antibody Testing FAQ page.

Pre-Operative Patient Arrival

Inpatient

  • All consents and pre-procedure paperwork/ lab work should be completed prior to patient’s departure from inpatient unit.
  • Patients should be transported directly to the OR from their inpatient room following standard precautions.

Outpatient

Patient Arrival:

  • Ensure current visitor policies are being followed.
  • Screen all patients and visitors for COVID symptoms at entrance
  • Ensure all visitors and patients are wearing the appropriate mask.

Physical Distancing:

  • Asymptomatic, recovered COVID positive patients:
    • Consider dedicated waiting room area for COVID positive patients.
    • Maintain 6 feet of spacing between patients in waiting, pre-operative, and recovery settings. Physical barriers (such as curtains) should be used when available.
  • Symptomatic COVID positive/PUI patients:
    • Patients should bypass registration and be brought straight to an isolated area for processing.

Preparation for Surgery

  • Place COVID-19/ PUI sign on all exterior entrances to OR.
  • While setting up the room, room staff will wear surgical mask, and shoe covers. Remove unnecessary equipment from the OR.
  • Anesthesia
    • Confirm the presence of a CMAC/Glidescope
    • New HEPA filters on anesthesia circuit should be placed distal to the EtCO2 connector and on the expiratory limb of the circuit. (EtCO2 connector should be placed between the HEPA filter and circuit).
    • Pyxis machines stay in the ORs and ideally should be 6 feet away from the head of the bed during intubation. If the Pyxis machine cannot be moved (against wall or other restriction,) the bed may be moved away from the Pyxis prior to intubation and then returned.
    • If for any reason drawers of a Pyxis machine needs to be accessed, immediate hand hygiene must occur immediately before and after drawer access.
    • Prepare medications needed for induction in standard fashion. Acquire all anticipated narcotics from Pyxis machine prior to patient entering room.
  • Nursing (RN and Tech)
    • Standard OR preparation.
    • Have only necessary supplies and PPE in the room to avoid waste.
    • Repeated exit and entry into the room during the case to retrieve supplies should be avoided.
    • A runner will be assigned to obtain necessary supplies to minimize door openings. The OR door should only be opened to exchange supplies.
  • After patient is transferred to OR table, follow the same steps to clean the bed as for patients under Contact Precautions.

Physical Distancing Guidelines

Prior to Patient Arrival: Consider options for pre-registration and/or touch free registration options to limit contact with admitting personnel on day of surgery.

Patient Arrival

  • Consideration of any person accompanying patient must be made in accordance with the current visitor policy at the care location.
  • Screen all patients and visitors for COVID symptoms.
  • Ensure all associates, visitors and patients are wearing the appropriate mask.

Registration

  • Install proper indicators on floor in waiting areas (6 feet apart) to prohibit congregating or violating physical distancing requirements.
  • Explore possibilities to achieve contactless registration.

Surgical/Procedural Waiting Area

  • Ensure proper physical distancing. Install proper indicators on floor (6 feet apart) to prohibit congregating or violating physical distancing requirements.
  • If waiting room exceeds limits of physical distancing, consider leveraging technology (phone/text/app) to notify visitor of patient’s status so that they may wait in a more open area (e.g. wait in car, outside etc.).

Preoperative/ Preprocedural Holding Area

  • For preoperative/procedural areas without solid walls between patients, ensure physical barrier (such as curtain) is drawn.
  • Install proper indicators on floor to prohibit congregating or violating physical distancing requirements.
  • Follow entity visitor policy.

Recovery Area

  • Ensure physical distancing requirements can be maintained between patients (6 feet apart or separated with a physical barrier).
  • No visitors allowed unless patient has a specific need (e.g. Disability).

Discharge: Recommend alternate solutions to discharge process to achieve physical distancing requirements and limiting contact.

Intraoperative Procedures

One negative pressure room, if available, will be dedicated to COVID and PUI patients.  All efforts, whenever possible, should be made to utilize the dedicated negative pressure OR for COVID patients if available. Efforts should be made with environmental safety and facilities to develop alterations to additional rooms whenever possible. Staff transitions and handoffs should be minimized. Minimum staff to conduct the procedure should be utilized.

Please reference the Room Closure Guidance for COVID-19 Positive and PUI Post-Aerosol Generating Procedures for detailed information.

Follow standard MedStar Health guidelines for use of PPE, donning, doffing, and disinfection of PPE.

Airway Management for Induction (Intubation)

  • Minimize/avoid positive pressure masking.  Ensure deep paralysis prior to intubation.
  • Video laryngoscope recommended for all intubations to position provider farther away from airway and to maximize 1st attempt success.  Intubation should be performed by the most experienced member of the anesthesia team assigned to case.
  • ETT cuff should be inflated immediately after intubation. 
  • Supraglottic Airway Device is the preferred method of rescue ventilation. 
  • Use inline suction systems if suctioning is necessary. 
  • Surgical team will be using N95 respirators and may remain in the room during intubation, minimizing door openings.  Follow CDC guidelines for donning/doffing PPE when exiting/entering room.

Specimen/ Trash Handling

  • Positive COVID status should be indicated on the pathology form.
  • Send specimen direct to pathology in cooler or Oxford Box.  If no box is available, specimen may be placed in a biohazard bag.
  • Trash and waste will be collected in standard trash bags for disposal.
  • All exposed/unused supplies will be discarded.
  • Medications that are removed from the PUI/COVID room Pyxis should be discarded if unused and should not be placed in the return bins. 

SPD/ Case Carts

Airway Management for Emergence (Extubation)

  • Consider strategies to minimize coughing on emergence. 
  • Use of a towel or plastic sheet placed over the airway during extubation (to minimize aerosolized secretions during cough) is encouraged.  Place well-sealed face mask as soon as possible. 

Recovery

  • ICU patients will return to ICU.  For patients remaining intubated, the HEPA filter from the anesthesia circuit will be applied to the bag/mask ventilator for transport. 
  • Non-ICU patients will be recovered in the operating room initially by anesthesia provider and PACU nurse.  Surgical team member will provide handoff report to PACU nurse. 
    • Once patient is stable, an additional PACU nurse is immediately available, and the primary PACU nurse is comfortable with handoff, the anesthesia provider may depart. 
    • Once PACU criteria are met, patient may be transported to the floor wearing a procedural mask.
    • Persons performing transport will wear a surgical or procedural mask.

Room Disinfection

EVS or any personnel disinfecting rooms should refrain from entering the vacated room until sufficient time has elapsed for enough air changes to remove potentially infectious particles. After this time has elapsed, EVS personnel may enter the room and should wear a gown and gloves,
face mask and eye protection when performing terminal cleaning. Please refer to the table below for room closure and turnover times, and visit the Room Closure Guidance for COVID-19 Positive and PUI Post-Aerosol Generating Procedures for the full room disinfection and closure protocol.

Where to Stand During Intubation and Extubation Table

PPE and Disinfection for Surgical Procedures

For comprehensive PPE guidelines, visit the PPE Essentials Page.

Beginning Monday, June 22, there will be a phased rollout of eye protection for all associates. To be consistent with MedStar’s universal eye protection guideline, all associates assisting in surgeries will be required to wear eye protection for all procedures.

To ensure the safety of subsequent patients by allowing airborne particles to clear the environment, extended room closure is required after AGPs are performed on COVID+ patients and PUIs. This principle is applicable to all settings including the operating room, inpatient rooms, and ambulatory exam/procedure rooms. For full protocol information, please reference Room Closure Guidance for COVID-19 Positive and PUI Post-Aerosol Generating Procedures.

Asymptomatic COVID-negative patients NOT undergoing high-risk AGP surgical procedures

Each person in the room during the procedure should use eye protection, a standard surgical mask, and surgical PPE according to their OR role.

During intubation and extubation:

  • Only essential staff should be in the room
  • If required to remain in the room, non-proceduralists should remain >6 feet away from the patient
  • The remaining team can safely return to the room immediately once the intubation is complete

Asymptomatic COVID-negative patients undergoing high-risk AGP surgical procedures

  • Consistent with extended use protocols, one (1) N95 respirator per day will be allocated to each provider performing a high-risk AGP procedure. The N95 should be covered (clean procedure/surgical mask, full-face shield, or surgical mask with face shield) during patient care. Seal check should be performed every time the respirator is donned, as per protocol. 
  • During intubation and extubation, all associates can remain in the room using N95s, maintaining >6 feet of distance from the head of the patient when possible.
  • Limit the number of people participating in procedure to essential staff and minimize associate substitution.  
  • Each person in the room during the procedure should wear eye protection and standard surgical attire according to their role within the OR and an N95 respirator.  

COVID-positive patients or PUIs undergoing any surgical procedure

  • Consistent with extended use protocols, one (1) N95 respirator per day will be allocated to each provider performing a high-risk AGP procedure. The N95 should be covered (clean procedure/surgical mask, full-face shield, or surgical mask with face shield) during patient care. Seal check should be performed every time the respirator is donned, as per protocol. 
  • During intubation and extubation, all associates can remain in the room using N95s, maintaining >6 feet of distance from the head of the patient when possible.  
  • Limit the number of people participating in procedure to essential staff and minimize associate substitution.  
  • Each person in the room during the procedure should wear eye protection and standard surgical attire according to their role within the OR and an N95 respirator.  

All patients undergoing time-critical emergency surgeries

A rapid COVID19 swab should be sent, if feasible. If the results have not returned before the time of induction, the case is treated as follows: 

  • If the patient meets PUI criteria or is undergoing a high-risk AGP procedure:
    •  Use N95, eye protection, and standard surgical attire according to OR role. 
  • If NOT PUI and NOT High-Risk AGP Procedure: N95 is not necessary. Use surgical mask, eye protection, and standard surgical attire according to OR role.

Disinfection Guidelines

Use approved disinfecting products. For updated list of approved disinfecting products for various applications and environments, please reference the EPA Approved Disinfectants List.

  • Registration: After each patient, wipe all non-porous surfaces (including table tops, chairs, pens, clipboards, pin pads, etc.) with an approved disinfectant effective against COVID-19. Follow manufacturer’s instructions for contact time.
    • Alternatively, supplies such as pens and clipboards should be sequestered after use by a patient and periodically disinfected in bulk.
  • Waiting Area: Frequently (including at start and end of day shift), wipe non-porous horizontal and high touch surfaces with an approved disinfectant effective against COVID-19 (at least twice per day).
  • Preoperative and preprocedural areas/PACU: After each patient, wipe all non-porous surfaces (including table tops, chairs, pens, clipboards, pin pads, etc.).
    • Alternatively, supplies such as pens and clipboards can be sequestered after use by a patient and periodically disinfected in bulk.
  • Operating Room: Clean OR utilizing standard OR turnover protocols for non-PUI, non-COVID-19 patients.
    • For asymptomatic, COVID negative patients undergoing an aerosol-generating operative procedure, standard OR procedures should be followed.

For more details, please refer to the document on COVID Pre-op Testing and Use of PPE.

Surgical Practice Guidelines

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Thoracic Surgery Recommendations for COVID-19

Plasma Study

We are seeking plasma donors who tested positive for COVID-19 and are now fully recovered. Patient flyers are provided in English and Spanish.

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