Purpose: Protocol for treating confirmed or suspected COVID-19 patients and patients testing negative for Covid-19 in the perioperative area

Scope: Perioperative Services

Approved: Perioperative Leadership Team and DOS

Date: 8/17/2020

Definitions:

Confirmed or suspected COVID-19 patient:

o Positive Covid-19 test

-Unless the patient was COVID+ 10 days or more prior to the current positive test (see scheduling document)

o Positive Symptomatic (symptom screening) or

o Unable to obtain history (e.g. trauma patient) plus CXR (or CT chest) findings consistent with Covid-19

General Instructions and Communication:

  • Non-urgent surgical procedures should be postponed or rescheduled until:
    -If symptomatic ≥10 days after symptom-onset AND ≥24 hours after afebrile without fever-reducing medication and respiratory symptoms improving –or- -If asymptomatic, 10 days after first positive test
  • Scheduled patients and urgent patients who are non-emergent should arrive to the PreOp area with a previous Covid test. If not, non-emergent patients should be rapid tested in the PreOp area prior to their procedure[b1] . (See Covid-19 Operating Room Patient Scheduling and Testing)
  • If patient is emergent/trauma the patient should not wait to be tested for Covid to advance to the OR. (These are patients with a case classification of trauma and P1 emergent <1hr.)

-If the patient screens negative (score less than 2), has a reliable health history, and no CXR or CT chest findings consistent with Covid-19 (patients are not required to have a CXR or CT chest), they should be treated as Covid negative.

*All others not fitting this definition should be treated as Covid positive.

-If the patient will be admitted, a surveillance test should have been performed in the ED, if it was not, it should be performed in PreOp (if there is appropriate time to do so) or in the PACU.

  • Inpatients are surveillance tested for Covid upon admission and do not need to be retested prior to their procedure.
    -If a patient has been inpatient, discharged, and returns for a post-discharge procedure, they do not need to be retested unless their Covid result was more than four days old, unless they have had a positive test result within 90 days of their procedure.

Patient Transport:

  • Every effort will be made to transport patients directly to the OR (avoiding PreOp when possible).
    -If patients are unable to be transported directly to the OR, they should be placed in the PreOp isolation bay.
  • Patients should be wearing a surgical mask during transport.
  • Patients will be transported directly to the OR through the main OR hallway. Patients will not be transported through PreOp, PACU, or the OR bridge except in an emergency.

The Operating Room:

  • Whenever possible, the surgery should be scheduled as the last surgery that is performed that day.
  • The air pressure in the OR will remain positive for all cases.
  • The main OR doors will remain closed for these cases except during patient transport.
  • Appropriate isolation signage should be posted on the OR doors to minimize staff exposure.
  • For patient’s that must be intubated / extubated in the operating room, the minimum number of staff necessary to perform the intubation / extubation should be present. Staff members will wear N95 masks and face shields for all covid positive patients and PUI’s and should be ready to assist anesthesia if needed.
  • When intubation / extubation is performed in the OR, the OR doors must remain closed with minimal staff ingress/egress for 10 minutes afterward.
  • Only the equipment needed for that case should be in the room and the gurney or hospital bed should be kept in the room.
  • A clean runner will be assigned to these cases to reduce the need for staff to leave the OR. OR will use a drop zone in the sub-sterile to minimize contamination of the clean runner.
  • Do not use the tube system for covid-19 test specimens (OP or NP swab).

Staff PPE:

  • Only essential staff should be in the OR during the procedure. All OR staff should wear appropriate PPE per the hospital PPE algorithm. Staff should not wear surgical masks over or underneath N-95 masks.
  • NOTE: Staff should not change masks between patients unless visibly soiled or contaminated. Please visit the COVID-19 subsite on the Pulse for more information about extended mask use.
  • After completion of surgery, patients should be transferred immediately to a negative pressure room. All PreOp and PACU isolation bays in Pavilion A are kept at negative pressure. The PACU isolation bay is preferred but if we need an additional isolation recovery room, the PreOp isolation bay will be used.
  • Powered Air-Purifying Respiratory (PAPR) use in the Operating Room (OR) is strongly discouraged at this time as there is a lack of scientific evidence to support safe usage of this type of device and the possible impact (contamination of wearer’s exhaled, unfiltered air) onto the sterile field. Fit tested N95 respirators should be worn by all personnel in the operating room for covid positive patients and PUI’s per the PPE algorithm. A surgical mask can be worn for all covid negative patients.

OR Cleaning:

  • Staff should allow the room to remain empty with all doors closed for 10 minutes after surgery for confirmed or suspected COVID-19. After 10 minutes, staff may perform a terminal clean wearing normal PPE. If the surgical demands keep us from waiting 10 minutes, the employees involved in the terminal clean should don N95 masks.
  • Otherwise, the OR cleaning that is needed for a COVID-19 operating room follows the same standard procedure that is performed for a patient in airborne isolation.

Advanced Scheduled Procedures:

  • The main OR scheduler will note that we have a confirmed or suspected COVID-19 patient when they send out the final schedule to the charge nurses at 1430 the day before surgery.
  • The main OR scheduler will include a 1 hour turnover time between cases.

Aerosol Generating Procedures for Confirmed or Suspected COVID-19 Include:

  • non-invasive ventilation (CPAP and BiPAP)
  • endotracheal intubation
  • airway suctioning
  • high frequency oscillatory ventilation
  • bag-valve mask ventilation
  • chest compressions/ chest physiotherapy
  • nebulizer therapies
  • aerosol humidification
  • bronchoscopy or other upper airway endoscopy
  • tracheotomy
  • open thoracotomy
  • upper airway surgery in which high-speed devices are used
  • Laparoscopic Procedures

In addition to the protocol outlined above:

  • For laparoscopic cases, the OR will use smoke evacuation systems to reduce or eliminate the presence of surgical smoke.

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Instructions for Patients testing negative for COVID-19:

· Surgical masks are recommended for patients with a negative covid test.

· Standard procedures for intubation / extubation should be used.

· OR cleaning for non-suspected COVID-19 operating rooms follows Denver Health’s standard OR cleaning procedures.

· After completion of surgery, patients testing negative for COVID-19 should be transported per normal operating procedures.

· Patients with a prior positive test result should be treated as negative for COVID if:

o symptomatic ≥10 days after symptom-onset AND ≥24 hours after afebrile without fever-reducing medication and respiratory symptoms improving –or-

o asymptomatic, 10 days after first positive test

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