Coronavirus: 10 Considerations for Resuming Elective Surgery

When the crisis level of the coronavirus pandemic passes, healthcare providers will need sophisticated strategies to restart elective surgery.

The American College of Surgeons (ACS) has released recommendations to guide healthcare providers when they resume elective surgery that has been put on hold during the coronavirus pandemic.

To boost resources for treating hospitalized coronavirus disease 2019 (COVID-19) patients, governors across the country have ordered hospitals to delay elective surgery procedures. Last month, ACS released guidance for determining which elective surgeries could be delayed appropriately.

Last week, ACS released a list of 10 issues that should be addressed before a healthcare organization resumes elective surgeries that have been delayed. "Evaluating and addressing each of these 10 issues will help facilities to not only optimally provide safe and high-quality surgical patient care, but also to ensure that surgery resumes and doesn’t stop again," the recommendations say.

The recommendations are highlighted below.

1. Know your community's coronavirus statistics

• The maximum incubation period for the coronavirus is estimated at two weeks. There should be a decrease in incidence of COVID-19 cases for at least two weeks before elective surgery is resumed.
   
• Monitor local COVID-19 statistics such incidence of new cases to detect a resurgence of the virus.
   
• Consider setting a threshold for new cases of COVID-19 that would trigger putting elective surgeries on hold again.

2. Know availability of COVID-19 testing and craft testing policies

• Monitor local COVID-19 testing availability and lab result times.
   
• Craft testing policies for patients such as pre-operative testing of patients scheduled for surgery.
   
• Craft testing policies for healthcare workers such as screening and testing guidance.
   
• With false negative test rates as high as 30%, consider establishing retesting policies for patients and healthcare workers.
   
• With fever and lung complications possible in the postoperative period, consider establishing retesting guidelines for symptomatic patients.

3. Personal protective equipment

• Before elective surgery is resumed, there should be a stored inventory of PPE or a reliable supply chain for at least 30 days of operations.
   
• PPE policies should be in place for COVID-19 positive patients, persons under investigation, and non-COVID-19 patients, including for high-risk procedures such as intubation.
   
• Consider having all healthcare workers and staff wear appropriate PPE outside the operating room and having all patients wear cloth masks.

4. Know key healthcare facility capacities

• A hospital's available resources should include peri-anesthesia units, critical care, diagnostic imaging, and lab services.
   
• Consider new sites for elective surgery such as hospital spaces that were converted for COVID-19 care, including outpatient departments.
   
• OR schedules should be set to accommodate a spike of electives surgeries such as performing procedures at night or on weekends.
   
• Make sure there is sufficient capacity for preoperative, intraoperative, postoperative, and post-acute care.

5. Supplies capacity

• Ensure there are adequate levels of surgical supplies and equipment such as implants and anesthesia-sedation medications.
   
• Ensure a supply chain is in place for traditional or new vendors.
   
• Conduct an inventory of existing supplies and check expiration dates.
   
• There should be adequate cleaning supplies, particularly for areas where care is provided to COVID-19 patients and persons under investigation.

6. Healthcare worker staffing

• There should be adequate multidisciplinary staffing for routine and expanded hours.
   
• Assess coordination of key staff members, including surgeons, anesthesiologists, nurses, and housekeeping.
   
• Have contingencies in place for staff members who test positive for the coronavirus.
   
• Assess the level of stress and fatigue among healthcare workers who have been providing frontline care during surges of COVID-19 patients.
   
• Consider mitigation efforts for workforce shortages such as enlisting retired surgeons to work as first assistants.

7. Create governance committee

• A governance committee can make real-time decisions for several pivotal issues, including PPE, pandemic assessment, patient backlog, and safety and quality.
   
• The governance committee should be multidisciplinary, including surgeons, anesthesiologists, and nurses.
   
• At least during the elective surgery ramp-up period, the governance committee should meet daily.

8. Patient communication

• Consider creating a multidisciplinary committee to manage patient communication.
   
• There are several crucial patient communication topics, including procedure prioritization, coronavirus testing policies, PPE use, and advance directives.

9. Prioritization of surgery

• Key stakeholders such as surgeons, anesthesiologists, and nurses should participate in ramp-up planning, including the collaborative formation of principles and frameworks for surgery prioritization.
   
• The prioritization process should be adjustable to local, regional, and national epidemiological trends and changes in COVID-19 care. The prioritization process should also take a facility's resources, priorities, and patient needs into account.
   
• The prioritization process, principles, and framework should be transparent to hospitals, healthcare workers, and the public. The benefits of transparency include reducing ethical dilemmas.
   
• There are multiple considerations in developing the prioritization process, including a list of canceled and delayed procedures, a strategy for phased opening of ORs, PPE availability, and issues related to increased OR volume.

10. Ensure safety and high value in all five phases of surgical care

• Optimal care in the preoperative phase includes considering the use of telehealth.
   
• Optimal care in the immediate preoperative phase features reviewing surgery, anesthesia, and nursing checklists for possible revisions related to COVID-19 positive patients and other considerations.
   
• Optimal care in the intraoperative phase includes guidelines for staff during intubation.
   
• Optimal care in the postoperative phase includes adherence to standardized care protocols.
   
• Optimal care in the post discharge phase includes post-acute care facility availability and safety.