EXECUTIVE SUMMARY
To meet the challenge of fully reopening surgery centers, leaders will need to focus on infection prevention.
• In April, the Infectious Diseases Society of America published eight recommendations for COVID-19 prevention.
• The Anesthesia Patient Safety Foundation recommends placing a filter between a patient’s airway and the anesthesia machine breathing circuit.
• The Centers for Disease Control and Prevention recommends healthcare facilities know the utilization rate of their personal protective equipment, understand their inventory and supply chain, and stay in communication with local healthcare coalitions and government entities to identify additional supplies.
It is a challenging time for surgery centers as they go through their backlog of patients, whose procedures were put on hold for months during the COVID-19 pandemic.
Infectious disease physicians, surgeons, and others offer advice on how surgery centers can protect against a second wave of viral infections:
• Find out who is carrying the virus. “Screening and testing is absolutely the most important thing right now, not just for patients but also for healthcare workers,” said Joseph A. Dearani, MD, president of the Society of Thoracic Surgeons. Dearani spoke at a Newswise media web conference on May 21 about surgeons and other health professionals during the pandemic’s post-crisis phase.
“You need to know who is carrying the virus, who can wait, and who can’t so that you know how many people are really going to be at risk,” Dearani added.
Surgery centers can screen patients for symptoms and temperature. Also, staff should administer regular tests. “We recommend patients have a real-time PCR COVID test and have it within 48 to 72 hours of the procedure,” says Richard Beers, MD, chair of the American Society of Anesthesiologists Committee on Occupational Health. “If a patient is asymptomatic for COVID — but may develop symptoms — he or she may be at risk for postoperative complications.”
Through testing, surgery centers can prevent an asymptomatic, COVID-19-positive patient from transmitting the virus. Nasal swab and serum testing can be performed right up until the day of surgery, at least until a vaccine is available, notes Beers, professor of anesthesiology at the State University of New York Upstate Medical University.
Obtaining COVID-19 diagnostic kits remains an ongoing issue, but the federal government has approved more labs for this purpose. The Centers for Medicare & Medicaid Services announced on May 8 that pharmacies and other suppliers that are enrolled in Medicare can be classified, temporarily, as independent clinical diagnostic laboratories during the public health emergency. (Learn more here.)
The Infectious Diseases Society of America (IDSA) studied SARS-CoV-2 nucleic acid detection tests, which led to the creation of an evidence-based diagnostic guideline for clinicians and other stakeholders. The IDSA panel made 15 diagnostic recommendations. The recommendations include collecting nasopharyngeal, mid-turbinate, or nasal swabs instead of saliva or oropharyngeal swabs for RNA testing in symptomatic individuals. (Learn more here.)
“The data we had at that time showed that the [saliva test] was less sensitive,” said Angela Caliendo, MD, PhD, FIDSA, member of the IDSA COVID-19 diagnostic guidelines expert panel. Caliendo spoke about the IDSA’s testing guidelines at a media web conference held on May 8. “We did not recommend that saliva be one of the specimens of choice, but this is something we may revisit as more data becomes available,” reported Caliendo, professor of medicine at Brown University.
The IDSA panel also suggested repeating viral RNA testing after an initial negative test in patients with symptoms and who exhibit an intermediate or higher clinical suspicion of COVID-19. Panel members recommended RNA testing in people without symptoms but who are undergoing time-sensitive surgeries.
Testing patients is not a perfect solution, but it is a safety procedure when people are undergoing elective surgery, says Mary Dale Peterson, MD, MSHCA, FACHE, FASA, president of the American Society of Anesthesiologists. Surgery centers have time to test elective surgery patients, but for the test to be effective, they also need to ask patients to self-quarantine until the procedure.
“The question of how often you should test, I think, is up for debate,” Peterson offers. “It’s a challenge because I don’t think we have enough testing supplies to test everybody on a daily basis or weekly basis.”
• Focus on infection prevention. The IDSA offers eight recommendations for COVID-19 prevention. Published in April, an IDSA guidance panel recommends using N95 respirators when involved in aerosol-generating procedures on suspected or known COVID-19 patients.
The IDSA panel also suggested that when a healthcare facility’s area is in contingency or crisis capacity, then a surgical mask or face shield should be used as a cover for the N95 respiratory to allow for extended use. (Learn more about these tips here.)
“Assuming surgery patients test negative and continue to be asymptomatic, they are treated with droplet precautions,” Beers says. “This basically means we do wear surgical face masks, and are very careful about performing hand hygiene.”
Patients and healthcare professionals should wear surgical mask when meeting, he adds. “During aerosol-generating procedures ... we recommend healthcare professionals use airborne precautions and eye protection,” Beers says. “Those procedures would be intubation, extubation, and laryngoscopy.”
Gastrointestinal endoscopies also could be a situation in which there is potential for patients to cough or sneeze and cause aerosolization of droplets, Beers adds.
Instead of only wearing eye protection and surgical masks, staff and physicians should wear N95 respirators that are fitted and can filter tiny droplets. They also can wear a double layer of gloves, Beers offers. “The N95 mask is more restrictive of air flow. They’re difficult to breathe and can be more irritating than face masks, but they’re important for the reasons I’ve mentioned,” Beers explains. One additional infection prevention measure that hospitals have had to use during the pandemic and that surgery centers might need to employ involves disinfecting N95 respirators. No one can assume their supply of N95s will be adequate as the COVID-19 crisis continues. The Centers for Disease Control and Prevention (CDC) has issued techniques for optimizing the supply of personal protective equipment (PPE). (Learn more here.)
One of these techniques calls for decontaminating facepiece respirators, like N95s, when there are shortages. For example, surgeons and other healthcare professionals at Washington University School of Medicine in St. Louis created a disinfection process for N95 respirators. Their method calls for clinicians to wear their N95s for a week and then disinfect. Within a day, the same N95, now clean, is returned to the clinician, explains Shaina R. Eckhouse, MD, FACS, assistant professor of surgery.
“The process we created is to give each N95 [labeled] back to the individual healthcare provider,” she explains. “I’m a small female, and I wear a mask on the bridge of my nose, so if I don’t get the same mask back, I might get one that has a wider area for the nose and it doesn’t fit.”
Also, directing clinicians to use the same N95 helps reduce wear and tear, and it provides them with some comfort, knowing they receive their own mask, Eckhouse adds.
Another infection prevention tactic is to place a filter between a patient’s airway and the anesthesia machine breathing circuit, Beers recommends. The Anesthesia Patient Safety Foundation made the same recommendation. (Learn more here.)
“The Anesthesia Patient Safety Foundation also recommends we have a filter at expiratory, just before expired gas enters the anesthesia machine,” Beers says. “The filter prevents potential contamination of the internal circuit of the anesthesia machine.”
Another precaution is to wait between patients for the room’s air to completely turn over. Many call for waiting at least 15 minutes, but others may wait longer out of an abundance of caution.
“In most ORs [operating rooms], that’s not an issue [air turnover] because it does take time to wipe down, remove the instruments, take out the trash, wipe down all surfaces, and prepare for the next patient,” Beers observes. “By the time the next patient is ready to come in, that air turnover is adequate.”
• Maintain PPE supply and training. Surgery center leaders must assess their supply and access of PPE as surgery cases increase. The CDC recommends understanding the inventory and supply chain as well as use rate. Stay in communication with local healthcare coalitions and government entities to identify additional supplies.
Reduce the numbers of patients going into the setting and limit visits, part of which can include using telemedicine. Finally, train staff on using PPE, and ask them to demonstrate competency.
For instance, a surgery center could review N95 respirator fitting and reuse with OR staff. Employees trained on N95 respirators might have used the device when working with patients who had infections like tuberculosis. However, in those scenarios, employees simply may have discarded the respirator after one use, says Patrick Hughes, DO, MEHP, FACEP, FACOEP, emergency medicine residency assistant program director, assistant professor of integrated medical science, and director of the emergency simulation program for Florida Atlantic University’s Schmidt College of Medicine.
Hughes trains healthcare workers on the proper use of PPE through simulation. Although healthcare employees are trained to use PPE, they often are not prepared to reuse equipment repeatedly, as has occurred during the COVID-19 pandemic.
“Now, people are wearing the N95 respirators for their whole shift,” Hughes says. “Staff need to refresh their skills and get updated on how to put on and take off personal protective equipment.”
Infectious disease physicians, surgeons, and others offer advice on how surgery centers can protect against a second wave of viral infections.
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