Original Research

You Need a Plan: A Stepwise Protocol for Operating Room Preparedness During an Infectious Pandemic

Fed Pract. 2020 May;37(5):212-218

References

1. Holshue ML, DeBolt C, Lindquist S, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020;382(10):929-936.

2. Siegel S RE, Jackson M, Chiarello L. Healthcare Infection Control Practices Advisory Committee; Guideline for Isolation Precautions. Centers For Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html. Published 2007. Accessed March 28, 2020.

3. American College of Surgeons: COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures. American College of Surgeons. https://www.facs.org/covid-19/clinical-guidance/triage. Published March 17, 2020. Accessed April 19, 2020.

4. American College of Gastroenterology. Gastroenterology professional society Guidance on endoscopic procedures During the covid-19 pandemic. American College of Gastroenterology. https://webfiles.gi.org/links/media/Joint_GI_Society_Guidance_on_Endoscopic_Procedure_During_COVID19_FINAL_impending_3312020.pdf. Published March 31, 2020. Accessed April 19, 2020.

5. Chen X, Liu Y, Gong Y, et al. Perioperative management of patients infected with the novel coronavirus: recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists [published online ahead of print, 2020 Mar 26]. Anesthesiology. 2020;10.1097/ALN.0000000000003301.

6. Zhang HF, Bo L, Lin Y, et al. Response of Chinese anesthesiologists to the COVID-19 outbreak [published online ahead of print, 2020 Mar 30]. Anesthesiology. 2020;10.1097/ALN.0000000000003300.

7. Kamming D, Gardam M, Chung F. Anaesthesia and SARS. Br J Anaesth. 2003;90(6):715-718.

8. Zucco L LN, Ketchandji D, Aziz M, Ramachandran SK. Perioperative considerations for the 2019 novel coronavirus (COVID-19). https://www.apsf.org/news-updatesperioperative-considerations-for-the-2019-novel-coronavirus-covid-19/. Published Feb 12, 2020. Accessed March 30, 2020.

9. Caputo KM, Byrick R, Chapman MG, Orser BJ, Orser BA. Intubation of SARS patients: infection and perspectives of healthcare workers. Can J Anaesth. 2006;53(2):122-129.

10. Judson SD, Munster VJ. Nosocomial transmission of emerging viruses via aerosol-generating medical procedures. Viruses. 2019;11(10):940.

11. Peng PWH, Ho PL, Hota SS. Outbreak of a new coronavirus: what anaesthetists should know. Br J Anaesth. 2020;124(5):497‐501.

12. Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a COVID-19 patient needs an operation: operating room preparation and guidance [published online ahead of print, 2020 Mar 6]. Can J Anaesth. 2020;1‐3.

13. Chow TT, Kwan A, Lin Z, Bai W. Conversion of operating theatre from positive to negative pressure environment. J Hosp Infect. 2006;64(4):371-378.

14. Clark C, Taenzer A, Charette K, Whitty M. Decreasing contamination of the anesthesia environment. Am J Infect Control. 2014;42(11):1223-1225.

15. Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management [published online ahead of print, 2020 Mar 26]. Anesth Analg. 2020;10.1213/ANE.0000000000004829.

16. Jensen PA, Lambert LA, Iademarco MF, Ridzon R, CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005;54(RR-17):1-141.

17. US Environmental Protection Agency. List N: disinfectants for use against SARS-CoV-2. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2. Updated April 16, 2020. Accessed April 19, 2020.

18. Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area [published correction appears in Infect Control Hosp Epidemiol. 2019 Apr;40(4):500]. Infect Control Hosp Epidemiol. 2018;1‐17.

Preoperative Management

In addition to introducing the risk of viral transmission, surgery in the patient with COVID-19 also imposes a large consumption of vital PPE, supplies and can become dangerously low in health care centers coping with an influx of infected patients. Early in the pandemic, to reduce exposure, conserve the medical workforce and lessen the resource strain on the overall health care infrastructure, the American College of Surgeons (ACS), American College of Gastroenterology, and other professional societies recommended cancellation of elective procedures, confining operations to urgent or emergent procedures for high-acuity diseases that would negatively impact morbidity or mortality if delayed.^3,4 In each case, physicians from the surgical and anesthesia services should discuss the rationale for the operation and secure agreement to commit resources to the endeavor prior to reserving the OR. These considerations should be shared with the patient prior to obtaining informed consent.

Preoperatively, the surgical team, consisting of surgeon, anesthesiologist, OR nurse, surgical technician, and assistants to the surgeon, anesthesiologist and nurse, convene for a preoperative “team huddle.” While assistants will aid in patient transport and supplying equipment to the team during the procedure, they should not be in the OR during the case, to minimize personnel exposure and PPE consumption. All members of the surgical team remove their personal effects, including wallets, phones, badges, and jewelry; any pagers are handed to other members of the care team for the duration of the surgery. During this preoperative team huddle, proper setup and accounting of the surgical equipment is confirmed, as well as the availability of all necessary anesthesia equipment and medications.

A specific OR with versatile characteristics was chosen to be the designated OR for procedures in patients with confirmed or suspected COVID-19. The COVID OR is on standby when no such cases are active, and it is not used for surgeries in noninfected patients. This is in accord with published recommendations of anesthesiologists who, throughout the COVID-19 epidemic in China, maintained designated ORs and anesthesia machines for only infected patients.⁵ Strong consideration should be given to performing procedures for which endotracheal intubation is not required in the patient’s own respiratory isolation room, rather than the OR to avoid room contamination and excessive use of PPE.^5,6

The availability of adequate PPE is confirmed during the preoperative team huddle. At a minimum, powered air purifying respirator devices (PAPRs) with hoods must be available for the anesthesia provider, surgeon and surgical technician, recognizing the Anesthesia Patient Safety Foundation (APSF) recommendation that these devices confer superior protection for those with the highest risk and most proximate exposure to the patient throughout the case.^7,8 An N95 respirator, at minimum, must be available for the circulating OR nurse. Patient condition, need for critical care transport, anesthetic plan (monitored anesthesia care or general anesthesia), and availability of negative pressure isolation rooms in the ward vs in the operating suite should help decide patient transport strategies and help determine the most suitable location to secure the airway. In case of an inadvertent tube disconnection, transporting intubated patients carries the risk of disseminating virus laden aerosols into the environment. Risks of pre-OR intubation should be balanced with the potential benefit of securing the airway prior to transport and decreased gross OR contamination with intubation in the operating suite. Airway manipulation and intubation are among the highest risk procedures for nosocomial transmission and performance of these procedures should utilize precautions described in current APSF recommendations.^3,9,10

For patients not requiring critical care transport, and when conditions favor intubation in the OR, patients should be transported in a gurney while wearing a surgical mask. Verification of the operative site, surgical plan, and other components of the WHO universal surgical safety checklist or time out are performed in the OR prior to induction of anesthesia, and a conscious patient can be an active participant.

If critical care transport is deemed necessary and/or a decision is made to intubate the patient outside the OR, preferably in a negative airflow respiratory isolation room, the perioperative team will confirm the availability of the following equipment needed for patient transport: