key: cord-0880800-pwt453p2
authors: McGee, Morgan; O'Connor, Katherine; Gibson, Mary; Sullivan, Mary Jean; Pennelli, Mary; Alvis, Sarah; Lajoie, Debra
title: Developing an Outpatient Pediatric Pre-Procedure COVID-19 Testing Model
date: 2021-04-18
journal: J Perianesth Nurs
DOI: 10.1016/j.jopan.2021.02.010
sha: 1a9506e229fafe2621c6b0993a6267dc2f39ae0b
doc_id: 880800
cord_uid: pwt453p2

PURPOSE: The purpose of this project was to design, develop, implement, and manage a sustainable process for pediatric pre-operative COVD-19 testing and use the test results to determine the level of personal protective equipment and infection control required for each patient for optimal surgical scheduling and preservation of resources. DESIGN: This quality improvement project used the Plan-Do-Study-Act methodology Multiple cycles of re-evaluation refined this process which was standardized across the enterprise. METHODS: A process for pre-operative testing for all patients undergoing procedures requiring anesthesia was developed and implemented. FINDINGS: A safe, feasible, timely process was developed and piloted to obtain COVID-19 test results to guide individualized interventions. During the pilot, 1707 patients were screened, and five tested positive for COVID-19, eliminating the need to manage 1702 patients as COVID-19 positive. CONCLUSION: To continue to safely re-open, knowledge of the patient's COVID-19 status is imperative to ensure a safe journey through the perioperative area.

The purpose of this quality improvement (QI) project was to design, develop, implement, and manage a pre-operative/pre-procedure COVID-19 testing model for outpatients to support surgical expansion during the re-entry phase after significant care disruption, to provide necessary surgery and procedures to pediatric patients. Specifically, the project aimed to:

1. Develop a sustainable process and workflow to conduct preoperative COVID-19 testing on all patients scheduled for surgery within 24-48 hours of the scheduled surgery.

2. Use the test results to determine the appropriate level of personal protective equipment (PPE) and infection control for each surgical patient to allow for optimal surgical scheduling; and 3. Preserve PPE and mitigate risk of exposure for staff, patients and families.

With the declaration of the novel coronavirus SARS-CoV2 (COVID-19) as a "public health emergency of international concern" by the World Health Organization on January 30, 2020, the care provided to patients in the United States changed dramatically. 1, 2, 3 To contain the global pandemic, guidance was issued leading to a temporary suspension of most face-to-face care including elective and non-emergent surgeries, procedures and routine clinical care limiting exposure to the COVID-19 while expanding surge capacity and preserving PPE. 1, 3 Measures were incorporated to "flatten the curve", designed to reduce the peak incidence of active COVID-19 infections and reduce potentially overburdening already stressed healthcare systems, especially, the availability of critical care beds. [2] [3] [4] COVID-19 has forced healthcare providers and institutions to make complex decisions regarding the provision of surgical care during the pandemic, including weighing the risk and benefits of proceeding versus postponing essential surgeries. 5 Research to date has demonstrated that delayed care during the pandemic has had detrimental effects on the health of children. [6] [7] [8] [9] [10] [11] [12] More children are presenting to the emergency room with acute illness as a result of delayed care due to fear of exposure to COVID-19 in the healthcare setting. Emergency room providers have been reporting increased incidences diabetic ketoacidosis, sepsis, complicated appendicitis, and advanced stage malignancy. [6] [7] [8] [9] [10] [11] [12] Developing a process to provide safe, timely surgical care to pediatric patients is integral to ensuring their ongoing health and development. 13 In the initial phases of the pandemic, reliable serologic testing was lacking to identify COVID-19 positive patients. Healthcare providers, uncertain whether antibodies offered protection to the virus, relied on clinical and epidemiological factors to assess the likelihood of infection. 2, 4 As reliable testing began to emerge in limited quantities, only symptomatic patients were tested. 2 Faced with these challenges, early COVID-19 testing processes and workflows needed to be developed, piloted and rapidly implemented to address this urgent need. 2, 4 However, as reliable tests became more available, including real-time reverse transcription polymerase chain reaction (RT-PCR), it became essential to redefine care processes and develop a sustainable workflow for preoperative/ pre-procedural testing before and during the reentry process. 2, 3, 14 In this setting, pre-operative testing was deemed to be of the utmost importance given the highly contagious nature of COVID-19 and the aerosols that anesthesiologists, surgeons, and perioperative, procedural and intensive care unit staff are exposed to during airway manipulation and intubation. 4, 15 To date, very limited evidence has emerged describing the creation of a preoperative COVID-19 testing process. When we began this process, no evidence could be found describing processes to obtain COVID-19 samples from children scheduled for procedures requiring the administration of anesthesia. Since that time, only one published paper was found describing the development of a pre-operative process for COVID-19 specimen collection for aerosol generating procedures (AGPs) requiring anesthesia. 3 As most of these procedures are AGPs, knowing the patient's COVID-19 status is critical to planning the appropriate level of PPE, procedure times and the appropriate level of precautions necessary as the patient moves through the perioperative units including the perioperative clinic, preoperative holding unit, the operating room (OR) and the post anesthesia recovery unit as well as through procedural areas. 2, 3 Additionally, the patient's COVID -19 status is critical in determining time to allow for room disinfection between procedures. 3 Gupta et al.

(2020) described best practices and developed care algorithms for return to routine endoscopic procedures, indicating that by incorporating point of care testing and accurate clinical assessments, return to elective endoscopy was feasible. 4 A similar literature review provided guidelines for the return of elective, non-urgent procedures and aesthetic surgery that included six specific guideline subsets and algorithms for: surgical risk management and risk stratification; perioperative and anesthesia management; preoperative testing and screening; perioperative pharmacologic prophylaxis; clinical management and contamination control; and patient information and patient consent. 2 Guidance was also developed for orthopedic procedures and otolaryngology. 2, 14, 16, 17 Notably, a joint statement for resuming elective surgery was issued by the American College of Surgeons in collaboration with the American Society of Anesthesiologists, the Association of Perioperative Nurses and the American Hospital Association which described the timing for re-opening aligning with state and national recommendations. 18 This included recommendations for COVID-19 testing, PPE, case prioritization and scheduling, as well as post-COVID-19 processes for the five phases of surgical care, data collection and management. 18 These guidelines recognized that requirements will vary by geographic location and were intended to provide broad guidance to address these regional differences. 18 

This QI project used Plan-Do-Study-Act methodology to design, develop and implement a process for pre-operative testing for all patients undergoing surgical procedures requiring anesthesia. Given the dynamic and fast-paced nature of the evolution of the pandemic, the process was re-evaluated frequently and often. Re-evaluation of the process was done on an hourly and daily basis as needs changed and research/guidelines evolved. This QI project took place in the Perioperative Care Coordination Clinic (PCCC) at a tertiary pediatric academic institution. The PCCC is a multi-disciplinary clinic that provides pre-operative care coordination, clinical evaluation, and education to optimize pediatric patients undergoing general anesthesia for surgical procedures on the hospital's main campus. The PCCC staff consists of patient experience representatives, clinical assistants, nurses, nurse practitioners, and anesthesiologists. At our institution, QI projects are exempt from Institutional Review Board review.

A project management team was developed and consisted of the PCCC nurse manager, two nurses, and three nurse practitioners. The team quickly expanded to include all PCCC nursing and nurse practitioner staff in varying capacities as needs arose. The PCCC team considered the following priorities when developing this process including: utilization of the appropriate levels of PPE to ensure the protection and retention of perioperative/procedural teams; maximizing operational efficiency and mitigation of revenue loss through the effective utilization of limited OR use secondary to COVID-19 state and federal guidelines; reduction of COVID-19 exposure risk to staff, patients and their families; and the reduction of fear and anxiety associated with hospital care. The creation of a process for pre-operative COVID-19 testing would allow for an individualized risk-benefit assessment and the development of a plan of care for each patient related to AGPs.

Given the urgent need for patients to proceed to the operating room safely during the pandemic for essential care, the team rapidly designed and developed an initial framework. The PCCC team frequently adapted the model between April and May 2020, to adhere to the quickly evolving enterprise-wide infection prevention and control guidelines, as well as state and federal guidance in response to rapidly evolving knowledge, and its impact on our institution's operations. The model was updated based on the available support staff, space, and infrastructure.

The PCCC team coordinated pre-operative and pre-procedure COVID-19 testing for extended-stay patients and day surgery patients within 24-48 hours of their scheduled procedure, beginning on April 8 th , 2020. PCCC staff obtained patient information from the OR schedule in advance. The PCCC team scheduled the pre-operative COVID-19 testing appointment and called the patient/family to provide education and appointment details.

The PCCC team coordinated pre-operative/ pre-procedure COVID-19 testing at the entrance to our emergency department (ED) with ED nurses obtaining the COVID-19 specimens. Nucleic acid amplification testing (NAAT) is recommended by the Infectious Disease Society of America as the standard for COVID-19 testing. [19] [20] RT-PCR was the form of NAAT utilized at our institution to process all pre-operative COVID-19 test samples. RT-PCR is considered the gold standard for COVID-19 testing as it is characterized by rapid detection and both high sensitivity and specificity. 21, 22 Oropharyngeal (OP) swabs were collected on patients who were asymptomatic for COVID-19 infection. Per the Infectious Disease Society of America guidelines (2020), all patients with one or more symptom of COVID-19 were tested by nasopharyngeal (NP) swab. 19 This workflow allowed for one patient to be tested every 15 

During April, only urgent, emergent, or time-sensitive procedures were moving forward consistent with enterprise, state and federal guidelines to decrease risk and reduce exposures at the peak of the COVID-19 pandemic. Thus, the volume of patients who required preprocedure/pre-operative COVID-19 testing was low (Figure 1) . The re-opening of multiple hospital departments, planned for May 18 th , 2020, required changes to meet the increased demand. The pre-procedure COVID-19 testing model grew quickly to accommodate preprocedure/pre-operative patients from additional hospital departments, identified as the "affiliates" (e.g., patients undergoing diagnostic imaging, interventional radiology procedures, gastrointestinal procedures, satellite surgeries, and cardiac procedures). As the volume of operating room cases expanded, the model was adapted to meet the institutional needs. We realized we need to quickly increase our capacity to schedule and complete COVID-19 tests. We also needed to address the growing number of patients and families facing hardship coming the hospital 24-48 hours in advance to obtain pre-operative COVID-19 testing.

To address the need for expanded test scheduling capability, we created a centralized scheduling system and developed a novel role, the COVID scheduler, to facilitate testing and communication with multiple clinical teams. Initially, the COVID scheduler was a nurse or nurse practitioner on the PCCC team. As volume grew, this role was transitioned to a patient experience representative.

On May 4, 2020, the pre-procedure COVID-19 testing site was re-located to the Patient Family Garage which could support additional COVID-19 specimen collection. The site was staffed by public relations staff and a pool of nurses to support five COVID-19 tests to be taken simultaneously. The child life services department developed education for patients/families to improve the patient/family experience and minimize patient stress and anxiety. Our behavioral response team nurses also became engaged to develop behavioral plans to facilitate a safe plan for testing for patients with behavioral needs.

In addition to our standardized process, some patients required individualized plans of care to ensure the pre-procedure/pre-operative COVID-19 testing was obtained. This need became particularly pronounced as volume increased. In some instances, pre-procedure testing was facilitated at other clinics using a personalized plan of care to best meet the needs of each patient (e.g. in the infusion, dialysis, or cancer center). To ensure equitable access to care, as some families did not have access to a car, we partnered with our social work team, family relations team and taxi and public transportation companies to secure a vehicle in which the COVID-19

pre-procedure/pre-operative testing could be completed. The team also facilitated walk-up testing and arranged local accommodations for families when needed. As the widespread availability of local COVID-19 testing grew, our program accepted local test results so long as it was processed by NAAT (RT-PCR or transcription-mediated amplification) within 48 hours of the surgical start time. Antigen and antibody test forms of testing have not been proven to be as reliable as standard RT-PCR in detecting the presence of active COVID-19 infection and thus were not accepted. 23, 24 With the expansion of surgical services in May 2020, the number of patients requiring preprocedure/pre-operative testing increased, triggering an increase in requests for preprocedure/pre-operative COVID-19 testing to be completed in the clinic. Our team quickly realized that the clinic did not have the physical space to support safely completing the preprocedure COVID-19 testing which requires COVID-19 isolation precautions and social distancing in the setting of pre-operative visits (which can take up to two hours without testing).

Thus, the PCCC team again adapted the model for patients who required a pre-operative visit, scheduling their visit either before the 24-hour window or having patients receive their COVID-19 testing in the morning in the Patient Family Garage, and then come to the PCCC in the afternoon for their pre-operative visit. The availability of local COVID-19 testing at primary care offices also alleviated the need for day of surgery testing.

As of June 17, 2020, we had screened 1707 patients. Only five COVID-19 tests were positive during this time. During the first week of the screening process, we tested 10 patients.

However, by our second week we saw the demand for testing begin to escalate, screening 45 patients. This escalation continued weekly as local, state and federal guidance evolved. By week 7, we screened 216 patients or between 40-45 patients/day. With this escalation that continued from week 7 on, work was on-going to ensure this process would be transferrable to individual clinics and procedural areas, as well as perioperative services as the re-entry process continued.

By week 10, we screened over 250 patients (Figure 1 ). Historically, nurses have been pivotal to the healthcare response to pandemics and epidemics and this has remained true during the COVID-19 pandemic. 25, 26 Nurses have been providing frontline patient care, advocating for policy changes, and developing innovative processes to keep the healthcare system afloat. [27] [28] [29] [30] [31] As a result of the pandemic, the PCCC team has expanded to include additional pre-operative nurse practitioners and one member of our team is designated daily as the Pre-OP COVID Manager. The Pre-op COVID manager serves as a resource regarding pre-operative COVID-19 testing. In this role, we work closely with our enterprise's Infection Prevention and Control (IPC) colleagues as new COVID-19 research becomes available. We follow guidance from the institution's Emergency Management team especially as it relates to ever-changing policies, procedures, and process changes related to COVID-19 throughout the enterprise. Additionally, we provide guidance and recommendations regarding all questions related to pre-operative COVID-19 testing and precautions for all outpatients scheduled for surgery at our main campus. We provide recommendations to surgical and anesthesia colleagues regarding safe management options especially when a patient receives a positive COVID-19 test result. We guide nurses, schedulers, and various other providers regarding safe practices when potential COVID-19 exposures are discovered for our patients.

We also help determine the need for re-testing following a previously positive COVID-19 test result when procedures are rescheduled. This role has changed as the pandemic has evolved and as pre-operative COVID testing at our institution has continued.

To continue to safely re-open hospital departments and provide healthcare to our pediatric population, knowing the patient's COVID-19 status is imperative to ensure a safe journey through the perioperative area. The PCCC team will continue to facilitate and guide preprocedure COVID-19 testing until COVID-19 is no longer a significant health risk to patients, families, and staff. Innovative methods that we have developed to coordinate pre-procedure 

Rolling updates on coronavirus disease (COVID-19) as they happen

non-urgent procedures and aesthetic surgery in the wake of SARS-COVID-19: Considerations regarding safety, feasibility and impact on clinical management

Pre-operative COVID-19 testing and decolonization

A proposal for the return to routine endoscopy during the COVID-19 pandemic

Scheduling delayed treatment and surgeries post-pandemic: A stakeholder analysis

Delayed access to care and late presentations in children during the COVID-19 pandemic: A snapshot survey of 4075 paediatricians in the UK and Ireland

Delayed access or provision of care in Italy resulting from fear of COVID-19

Reluctance to seek pediatric care during the COVID-19 pandemic and the risks of delayed diagnosis

Has COVID-19 delayed the diagnosis and worsened the presentation of type-1 diabetes in children? Diabetes Care

Delayed diagnosis of paediatric appendicitis during the COVID-19 pandemic

Delayed presentations of pediatric solid tumors at a tertiary care hospital in the Bronx due to COVID-19

Delayed presentation to regular Dutch paediatric care in COVID-19 times: a national survey

Austrian study shows that delays in accessing acute paediatric health care outweighed risks of COVID-19

Guidance for otolaryngology health care workers performing aerosol generating medical procedures during the COVID-19 pandemic

Anesthesia and COVID-19: What we should know and what we should do

Aerosol-generating otolaryngology procedures and the need for enhanced PPE during the COVID-19 pandemic: a literature review

Otolaryngology during COVID-19: Preventive care and precautionary measures

Joint statement: Roadmap for resuming elective surgery after COVID-19 pandemic

Infectious Disease Society of America Guidelines on the Diagnosis of COVID-19

Infectious Disease Society of America. RT-PCR Testing

Recent advances and perspectives of nucleic acid detection for coronavirus

Laboratory diagnosis of COVID-19: Current issues and challenges

Rapid, point-of-care antigen and molecular-based tests for diagnosis of SARS-CoV-2 infection

The role of nursing in the influenza epidemic of 1918-1919

Expanding nursing's role in responding to global pandemics 5/14

Nurse practitioner COVID-19 experience in skilled nursing facilities

Pandemics, crisis conjunctures, and professional practices: What is the role of nursing with regard to COVID-19?

Nurses confronting the coronavirus: Challenges met and lessons learned to date

Utilization of pediatric nurse practitioners as adult critical care providers during the COVID-19 pandemic: A novel approach

Role of anesthesia nurses in the treatment and management of patients with COVID-19