key: cord-0890628-2gagjx4p authors: Lu, Amy C.; Schmiesing, Clifford A.; Mahoney, Megan; Cianfichi, Lisa; Semple, Amy K.; Watt, Dominique; Fischer, Stephen; Wald, Samuel H. title: COVID-19 Preoperative Assessment and Testing: From Surge to Recovery date: 2020-06-01 journal: Ann Surg DOI: 10.1097/sla.0000000000004124 sha: f8e28fd3fa3a3c6303001113dee3281d2d163804 doc_id: 890628 cord_uid: 2gagjx4p nan T he COVID-19 pandemic and post-surge planning highlights the significance of preoperative optimization in a way previously unrecognized in the perioperative period. Published protocols have largely emphasized planning for the intraoperative period 1,2 with less attention afforded to reporting the design, implementation, and scaling of preoperative considerations and testing for long-term safety strategy. We present 2 transformative and sustained changes to our preoperative assessment process initiated during the COVID-19 surge that were pivotal to our success in resuming elective surgeries. These preoperative interventions are the ''overnight'' transition to 100% virtual clinic appointments and the widespread implementation of multiple COVID-19 testing pathways. The improvements were accomplished by redeployment of preoperative clinic staff to a work-at-home model, moving to preoperative video visits, incorporating universal COVID-19 screening, and the development and refinement of previously non-existent preoperative respiratory pathogen testing protocols. In the post-COVID pandemic era, federal, state, and county regulators and national medical societies have established principles to resuming elective surgery. These center around evaluation of timing of reopening based on local cases, availability of COVID-19 testing in the facility, supply of personal protective equipment (PPE), and prioritization of cases and scheduling. 3, 4 When the California ban on elective surgery was lifted on April 23, 2020, Stanford Health Care (SHC) and Lucille Packard Children's Hospital had already drafted preliminary plans for resuming elective procedures. Our health system's thoughtful and preemptive perioperative preparation was based on rapid iterations from multidisciplinary teams that had commenced a month earlier when we ceased performing elective cases in mid-March. Our SHC Interventional Platform (IP) provides the umbrella structure for patients presenting for any surgery or procedure, including out-of-operating room, cardiac catheterization, interventional radiology, and endoscopic procedures. The IP team also works closely with our Anesthesia Preoperative Evaluation Clinic, which consists of patient assessment by nurse practitioners or anesthesiology residents, with medical direction provided by 1 supervising attending anesthesiologist for 6 clinic sites. Before the COVID-19 pandemic, APEC conducted >700 video visits a month through a telehealth platform, comprising 27% of our total preoperative visits. Our shelter-in-place mandate instituted in mid-March provided the impetus to rapidly pivot to an almost total telehealth model and enabled nearly all APEC nurse practitioners to work from remote locations. Within one business day, APEC converted all in-person visits to an entirely virtual platform through completion of remote access training and the delivery of laptop computers for staff to ensure a seamless go-live implementation (Fig. 1a) . Since the transition to accommodate the shelter-in-place mandate, we conducted >3500 telehealth visits. Post implementation, only several patients were seen in person. Reasons to evaluate in person were to auscultate cardiac murmurs and for the inability for a video visit for 1 elderly patient. Preoperative laboratory tests, EKGs, and additional diagnostic tests were coordinated at the patient's primary care offices in some instances, but predominantly deferred until the day of surgery. Staff made every attempt to obtain prior medical records and testing results, limiting the need for new testing. Efforts were also made not to use commercial labs for standard preoperative testing to minimize patient travel and maximize social distancing. Anecdotal reports showed patients and APEC staff felt safer with virtual visits, as this provided reduced exposure to potential transmission and preserved personal protective equipment (PPE). They expressed satisfaction at the opportunity to continue their prescheduled appointments and employment during the shelterin-place mandate. Testing Protocols patients undergoing urgent procedures and outpatients where geographic or physical limitations precluded testing before the day of surgery. All inpatients would undergo testing before any procedures needing monitored anesthesia care, given the possible need for bagmask ventilation. During the pilot, results from the ''routine'' (RT-PCR) test were obtained within 24 to 48 hours, compared to 2 to 6 hours for the ''rapid'' (Cepheid, Xpert) test. At the end of the 2-week pilot, we were able to offer widespread testing availability and a turnaround time of 12 hours for routine tests and <2 hours for the rapid test. We quickly developed multiple preoperative pathways for outpatients, inpatients, day of surgery, and low-risk procedures with moderate sedation (Fig. 1C-F) . Two key decision nodes in the protocols were deciding when to order routine versus rapid tests and whether the results were needed before surgery based on the infectivity risk and procedure urgency. The APEC staff coordinated the outpatient pathway through virtual visits with the patients, communication with the drive-through testing sites, and follow-up with the virology laboratory for all test results (Fig. 1C) . If the screening was positive, APEC staff ordered a COVID-19 test. If the patient was symptomatic or had a positive test, surgery was postponed, and the patient was referred to their primary care physician. Depending on test results, the patient proceeded with the protocol based on risk of infectivity and type of hospital stay postprocedure. If patients were unable to complete drive-through testing due to a physical or geographic limitation or hardship, then day of surgery testing was scheduled. Asymptomatic outpatients presenting for low-risk procedures with nurse administered moderate sedation were not tested unless they had a positive screening (Fig. 1D) . In our inpatient pathway (Fig. 1E ), all patients were tested before procedures. Although patients undergoing emergent and urgent cases received the same day test, procedures were not delayed for test results, and they proceeded with appropriate PPE and precautions. At the time of the pilot, we had a limited supply of Cepheid tests used on our same day pathway, and procedures that could wait 24 hours had routine tests sent. All other inpatient procedures received a same day test. As we transitioned to post-surge planning, we continued to adapt and optimize our COVID-19 preoperative pathways. New Annals of Surgery Volume 272, Number 3, September 2020 operational challenges in this phase included scaling universal preoperative testing and virtual visits to all patients while rescheduling the significant backlog of elective procedures, incorporating new patients, and continuing remote work policies for clinic staff. Multiple improvements were made to efficiently accommodate 150 daily preoperative virtual visits and COVID-19 tests (Fig. 1F) . These enhancements included: prioritization and standardization given to tests drawn for preoperative assessment from drive-through sites, creating small team dedicated to scheduling preoperative COVID-19 tests and follow-up of results, adding COVID-19 testing orders to preoperative order sets (Fig. 1G) , and displaying testing status updates on OR dashboards (Fig. 1H) . These interventions have led to the successful resumption of surgical volume to close to 90% of prepandemic levels within 2 weeks. Thoughtful preoperative assessment has been shown to be cost-effective in reducing case cancellations on the day of surgery and in optimizing perioperative care. [5] [6] [7] We anticipate the unparalleled emergence of COVID-19 will alter the future of perioperative medicine, with increased emphases on preoperative virtual visits and screening and testing pathways for COVID-19 and other possible viral pathogens. Before post-surge planning, preoperative reports were limited to recommending fever screening and using PPE for inperson preoperative visits. 8 Recent medical specialty society recommendations have proposed universal symptom screening and further evaluation and testing based on a population risk assessment. 1, 2, 9 Our multidisciplinary IP team rapidly implemented and expanded an innovative preoperative telehealth platform and widespread testing pathways using an accelerated plan-do-study-act (PDSA) model. Robust preoperative viral respiratory pathogen testing was previously non-existent. Our experiences during the COVID-19 pandemic represent the evolving changes with technology and the strong impetus to develop pragmatic preoperative testing pathways and virtual assessment to provide protection to patients, health care workers, and the community. Several barriers and lessons emerged during implementation. Earlier challenges to video visit adoption became more evident including enrolling patients into our electronic health portal, patients' lack of adequate internet access or usable electronic devices, and access to interpreter services. Patients previously deemed too complex for virtual visits now had no in-person option for preoperative assessment. Vital signs such as blood pressure, oxygen saturation, and heart rate were rarely assessed during the virtual visit. Consistent with published studies on telehealth visits, 10 our patient experience surveys showed strong acceptance for virtual preoperative appointments. Challenges with preoperative testing included resolving demographic and financial hardship in accessing testing sites, increasing access to tests performed outside of SHC, and assessing patient requests for day of surgery rapid testing exceptions. The inability to test certain patients, either due to patient refusal or other contraindication, poses ethical concerns. Clinician agreement on the appropriate preoperative testing windows continues to evolve as testing availability and accuracy improves, best-practice patterns emerge from increased preoperative testing, and as our local prevalence changes over time. Additional considerations in the post-surge COVID-19 era include increasing access to telehealth and testing in underserved areas or for vulnerable patient populations, assessing efficacy of telehealth versus in-person evaluations on clinical outcomes, establishing sustainable reimbursement models for virtual health visits, and expanding options to obtain reliable remote physical examination and vital signs. 11 Our multipronged approach led to successful and widespread implementation at our health system with universal preoperative virtual assessments and accessible COVID-19 testing for all patients presenting for any procedural intervention. These protocols may provide guidance when determining emerging best practice COVID-19 pathways for preoperative optimization during the post-surge era while ensuring patient and health care provider safety. Operationalizing the operating room: ensuring appropriate surgical care in the era of COVID-19 In situ simulation enables operating room agility in the COVID-19 pandemic Local resumption of elective surgery guidance American College of Surgeons. COVID-19: Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement Preoperative clinic visits reduce operating room cancellations and delays Causes of cancellations on the day of surgery at two major university hospitals COVID-19 Infection: Implications for Perioperative and Critical Care Physicians Joint Statement on Perioperative Testing for the COVID-19 To infinity and beyond: the past, present, and future of tele-anesthesia Virtually perfect? Telemedicine for Covid-19 The authors gratefully acknowledge the many faculty and staff at Stanford Health Care, the Lucille Packard Children's Hospital, and the Stanford School of Medicine for their efforts during the COVID-19 pandemic. The authors would also like to acknowledge the efforts of Drs. Mary Hawn, Ronald Pearl, and Denny Lund for their leadership during this time.