key: cord-0963152-mfggwdst
authors: Larsen, Christopher G.; Bub, Christine D.; Schaffler, Benjamin C.; Walden, Timothy; Intravia, Jessica M.
title: The Impact of Confirmed COVID-19 Infection on Ambulatory Procedures and Associated Delays in Care for Asymptomatic Patients
date: 2021-01-20
journal: Surgery
DOI: 10.1016/j.surg.2021.01.005
sha: 340b2d04c9b5a29b4accc77b9738c807fac954e1
doc_id: 963152
cord_uid: mfggwdst

BACKGROUND: Since the reopening of ambulatory centers, minimal data has been reported regarding positive tests among patients undergoing ambulatory procedures, associated delays in care, and outcomes of patients previously positive for Coronavirus-19 (COVID-19). METHODS: A retrospective observational case series of ambulatory procedures was performed. Records since the reopening of ambulatory centers in New York were searched for patients with positive COVID-19 nasal swab results who underwent ambulatory procedures. Chart reviews were conducted to determine COVID history and hospitalizations, demographic information, procedure details, and 30-day admissions. RESULTS: 3762 patients underwent ambulatory procedures. 53 were previously diagnosed with COVID-19, but recovered and tested negative at pre-procedural testing. 37 of 3709 asymptomatic patients (1.00%) tested positive during pre-procedural testing; 21 patients had their procedures delayed on average 28.6 days until testing negative, while 16 had their procedures performed before testing negative due to the time sensitivity of the procedure. There were no major complications or 30-day admissions in any of these asymptomatic patients. Three patients tested positive for COVID after having an ambulatory procedure. CONCLUSIONS: Positive tests in asymptomatic patients led to procedure delays of 28.6 days. No patients who underwent ambulatory procedures after a positive COVID-19 test had any COVID-related complications, regardless of whether or not the procedure was delayed until testing negative. 3 patients tested positive for COVID-19 after having an ambulatory procedure, however at an average of 19.7 days after these cases were likely community acquired making the rate of nosocomial infection negligible.

Records since the reopening of ambulatory centers in New York were searched for patients 24 with positive COVID-19 nasal swab results who underwent ambulatory procedures. Chart 25 reviews were conducted to determine COVID history and hospitalizations, demographic 26 information, procedure details, and 30-day admissions. 27

Results: 3762 patients underwent ambulatory procedures. 53 were previously diagnosed with 28 COVID-19, but recovered and tested negative at pre-procedural testing. 37 of 3709 29 asymptomatic patients (1.00%) tested positive during pre-procedural testing; 21 patients had 30 their procedures delayed on average 28.6 days until testing negative, while 16 had their 31 procedures performed before testing negative due to the time sensitivity of the procedure. 32

There were no major complications or 30-day admissions in any of these asymptomatic 33 positive for COVID-19 after a procedure. The purpose of this study was to determine the impact 66 of COVID-19 on ambulatory procedures since the reopening of ambulatory care centers. 67 68

This study was institutional review board approved. Medical records for patients who 70 underwent an outpatient ambulatory procedure across a large healthcare system, were 71 retrospectively reviewed. The study period spanned May 15, 2020 through July 17, 2020. 72

Electronic medical records were searched for patients with a positive COVID-19 nasal swab 73 polymerase chain reaction (PCR) result. This included patients who had a history of a positive 74 test in the past, patients who tested positive during routine pre-procedural testing, and 75 patients who had a positive test after their ambulatory procedure. 76

For patients with positive tests, chart reviews were conducted of their COVID-19 77 infection courses, including COVID test history, symptomatology, and related hospitalizations. 78

Charts were reviewed for delays in care that resulted from a positive test. Procedure details, 79 including procedure type, anesthesia type and preoperative American Society of 80

Anesthesiologists (ASA) score were evaluated. Patient demographics were also collected 81 including patient age, county of residence, comorbidities, and insurance type. Charlton 82 comorbidity indices (CCI) were calculated for all patients. We reviewed complications and 30-83 day admissions. 84

Most of the data points identified in this study were epidemiological and lacked true 85 comparison groups, therefore it was not possible to run statistical analyses for many of the 86 numbers we report. To determine if there were any factors that may have influenced the 87 J o u r n a l P r e -p r o o f decision to postpone a procedure on asymptomatic COVID-positive patients, we compared 88 factors of age, ASA score, and CCI for asymptomatic patients who had their procedures delayed 89 to patients who had their procedure before re-testing negative using two-tailed heteroscedastic 90 t-tests. Type of anesthesia chosen was compared for these two groups using Chi-squared tests 91 to determine if there were differences in how anesthesiologists chose to manage COVID-92 positive patients. We also used a t-test to compare the time between the first positive test and 93 the first negative test between the group of patients who were known to have been COVID-94 positive prior to pre-procedural testing and patients who had their procedures delayed as the 95 (Table 2) . These patients had an average ASA score of 2.2, and an 112 average CCI of 2.0. Following their procedures, 4 of the 53 patients were admitted within 30 113 days of their procedure, however all admissions were for non-COVID related reasons (Table 3) . 114

Two of the four patients readmitted had major surgical complications requiring intervention. 115

One patient's nephrostomy tube fell out and they required re-insertion of the tube. Another 116 was admitted with fevers and found to have an intra-abdominal collection near the site of a 117 prior splenectomy, which required drainage by interventional radiology (IR). The two other 118 admissions were for uncontrolled hypertension and a urinary tract infection. Specialty 119 breakdowns for the procedures these patients were undergoing was as follows: 18 120 gastroenterology, 15 general surgery, 6 urology, 4 orthopaedic surgery, 3 vascular surgery, 2 121 neurosurgery, 2 obstetrics and gynecology (OB/GYN), 1 plastic surgery, and 1 IR (Table 4) . 122

37 of the patients who tested positive for COVID-19 were asymptomatic and tested 124 positive during pre-procedural testing. Among patients who had not previously tested positive 125 for COVID-19, this was equivalent to an asymptomatic positive test rate of 1.00% (37/3709). 126

Of the asymptomatic positive tests, 21 had their procedures delayed for an average of 127 28.6 days. The average time from a patient's first positive test to their first negative test was 128 significantly shorter than in the group that had recovered from COVID prior to their pre-129 procedural testing (25.5 vs. 56.5 days, p < 0.001) ( Table 1) . 11 patients resided in Queens 130

County (47.8%), 8 in Nassau County (34.8%), 3 in Suffolk County (13%) and 1 in Brooklyn County 131 J o u r n a l P r e -p r o o f (4.3%). The breakdown of insurance types for these patients was as follows: 14 patients (60.9%) 132 had private insurance, 4 patients (17.4%) had Medicare, and 5 (21.7%) had Medicaid (Table 2) . 133

For patients who had their procedures delayed until testing negative, the average age 134 was 42.2 years. ASA score was 2.0 and CCI was 1.2. 17 of these patients (73.9%) had general 135 anesthesia, while 4 (17.4%) had regional anesthesia, 1 patient (4.3%) had local anesthesia, and 136 1 patient (4.3%) was unknown (Table 3) . Patients who had their procedure delayed by a positive 137 test had the following specialty breakdown; 1 gastroenterology, 7 general surgery, 2 urology, 3 138 orthopaedic surgery, 2 OB/GYN, 1 IR, 2 surgical oncology, and 2 Ear, nose and throat (Table 4) . 139

The other 16 asymptomatic COVID-positive patients had their procedures performed 140 before converting to a negative test due to the time-sensitive nature of their procedures and 141 lack of symptomatology. This included 2 patients who had their procedures delayed by 6 and 35 142 days, however after repeat PCR testing was positive the decision was made to undergo the 143 procedure without further delays (Table 1) . 4 patients resided in Queens County (25.0%), 4 in 144 Nassau County (25.0%), 7 in Suffolk County (43.8%) and 1 in Brooklyn County (6.3%). The 145 breakdown of insurance types for these patients was as follows; 11 patients (68.8%) had private 146 insurance, 1 patient (6.3%) had Medicare, and 4 (25.0%) had Medicaid (Table 2) . 147

For the patients who underwent their procedures prior to converting to a negative test, 148 the average age was 44.6 years, ASA was 2.1, and CCI was 1.7. 11 of these patients (68.8%) had 149 general anesthesia, 4 patients (25%) had regional anesthesia, and 1 patient (6.3%) was 150 unknown ( Table 3) . The specialty breakdown was as follows; 3 gastroenterology, 1 urology, 4 151 orthopaedic surgery, 6 OB/GYN, and 2 IR (Table 4) . 152 J o u r n a l P r e -p r o o f There were no significant differences in age, ASA or CCI between asymptomatic patients 153 who had procedures delayed by a positive test and those who underwent their procedures 154 before testing negative (age, p = 0.73; ASA, p = 0.81; CCI, p = 0.51). There were no significant 155 differences in type of anesthesia used for the two groups of asymptomatic patients (p = 0.51). 156

There were no major complications or 30-day admissions in any of these 37 asymptomatic 157 patients, regardless of whether or not their procedure was delayed (Table 3 ). 158

Additionally, there were three patients who tested positive for COVID-19 after their 160 ambulatory procedures. These patients tested positive an average of 19.7 days after their 161 procedure. Two of the three were asymptomatic. One was tested due to known exposure to 162 someone with COVID-19 and the other was having pre-surgical testing for another procedure. 163

The symptomatic patient presented to the emergency room with symptoms of fever and cough 164 36 days after his ambulatory procedure and did not require hospitalization (Table 5) . 165

166 Discussion 167

In this study, we retrospectively identified 93 patients who underwent an ambulatory 168 procedure between May and July 2020 and had a positive COVID-19 nasal swab PCR. 53 of 169 these patients had prior COVID infection and tested negative at pre-procedural testing. Of 170 these patients, 4 required 30-day admission and 2 had major complications requiring a second 171 procedure, however none of these complications were found to be connected to their prior 172 COVID history. 37 patients were asymptomatic and tested positive for COVID-19 during 173 preprocedural testing. 21 of those patients had their procedures delayed for an average of 28.6 174 days until they tested negative, while the other 16 patients had their procedures performed 175 before testing negative. There were no significant differences in age, ASA score, CCI, or type of 176 anesthesia used in asymptomatic patients who had their procedures delayed compared to 177 those who were not delayed. No major complications or 30-day admissions were identified for 178 any of the asymptomatic patients. 3 patients tested positive for COVID-19 an average of 19.7 179 days after their ambulatory procedures. 180

Most hospitals across the US have adopted universal testing of patients undergoing 181 procedures on an inpatient or outpatient basis. However, it is well documented that there are 182 still issues with testing. A positive nasopharyngeal PCR indicates that viral RNA is present, which 183 supports exposure within the past 21 days, however it does not necessarily confirm that a 184 patient is currently infectious or has COVID-19. Additionally, the false negative rate for some 185 tests is known to be up to 30% and false positives also occur due to cross-reactivity with other 186

Coronaviruses. (11) Another interesting aspect of our study that warrants discussion is that we report good 215 outcomes for patients who recently recovered from COVID-19 and then underwent ambulatory 216 procedures. 53 patients recovered from COVID-19 infection prior to pre-procedural COVID 217 testing with 22 of those patients previously requiring hospitalization. Of those 53 patients, 4 218 J o u r n a l P r e -p r o o f required admission after their procedure and 2 required reoperation. However, none of these 219 complications were related to their prior COVID history, but rather were due to known 220 potential risks of the procedures performed. Another 21 patients had their procedures delayed 221 until they tested negative for COVID, but then had their procedures performed without any 222 complications or admissions noted. Overall, 70 of 74 patients who had recovered from COVID-223 19 infection (94.6%) underwent same day ambulatory procedures without any short-term 224 complications. Additionally, we reported an average time of 56.5 days for conversion to a 225 negative test for those patients with prior COVID infection and 25.5 days for those 226 asymptomatic positive patients who had their procedures delayed, which was a significant 227 difference. We feel this difference is explained by two factors: less abundant testing earlier in 228 the pandemic, and more frequent testing of the patients with delayed procedures due to 229 pressure from treating physicians. Regardless, our data suggests that it is relatively safe to 230 perform ambulatory procedures on patients who have recovered from COVID-19, whether their 231 positive test came a few weeks or a few months prior. 232

There were 3 patients in our study who tested positive for COVID-19 after their 233 ambulatory procedure. Even if we assume that their COVID-19 infection was due to nosocomial 234 exposure, it would correspond to a negligible rate of infection (3 of 3672 vulnerable patients, or 235 0.082%). However, one patient was diagnosed 4 days after the procedure and the other two 236 were diagnosed 19 and 36 days after, which implies exposure before the procedure and after 237 the procedure respectively, given the approximately 7-10 day incubation period of Fortunately, only one of these patients was symptomatic and none required hospitalization. The status of the pandemic in the greater NYC area during our study should be 245 mentioned for context. At the start of our study period on May 15 th , there was a 6.8% positive 246 test rate for NYC (which includes Queens and Brooklyn counties) and a 7.1% positive test rate 247 for Long Island (Nassau and Suffolk counties).(16) In contrast, at the end of data collection on 248

July 18 th , the positive test rate for NYC was 1.3% and for Long Island was 0.9%. In comparison, 249 the highest positive test rates during the height of the pandemic were 59.4% in NYC on March 250 29 th and 54.9% in Long Island on March 31 st , while positive test rates reached a low of 0.6% for 251 both regions later in the summer. As we are beginning to experience a "second wave" of cases 252 in NY state, positive test rates of 1.3% to 4.1% for NYC and 1.4% to 4.7% for Long Island were 253 reported in November 2020.(16) This demonstrates that although COVID-transmission rates in 254 the community were far lower during our study period than at the height of the pandemic, the 255 positive test rates experienced in the early summer months are similar to those we are seeing 256 in the late fall in the greater NYC area. 257

Since our data does not capture potential cases of transmission from patients to heath 258 care providers, it is worth mentioning that the safety of the staff at our ambulatory surgery 259 centers is of the utmost importance. In our health system, we recommend that all staff with 260 patient care roles adhere to strict precautions for personal protection, similar to those outlined 261 by Gilat et al.(1) At minimum, all providers with direct patient care roles are advised to wear a 262 surgical mask, gloves, and eye protection at all times when interacting with patients. Social 263 distancing, or maintaining a minimum of 6 feet from patients or coworkers, is encouraged 264 whenever possible. For patients known to have a positive COVID-19 test, N95 respirator masks 265 must be worn at all times by nearby staff and proper airborne precautions should be adhered 266 to. Additionally, people within the operating room should be limited to required staff, 267 especially when aerosol generating procedures such as intubation are required, and anyone 268 present during an aerosol generating procedure should wear an N95 mask and eye protection, 269 regardless of the patient's COVID-19 test results. By adhering to these guidelines, our goal is to 270 ensure the protection both staff and patients from COVID-19 transmission, even in the 271 inevitable setting of a false negative test result. 272

There are certainly limitations to our study. First, it is limited by its retrospective nature. 273

There are other clinical parameters and data points that would have been interesting to 274 evaluate, but they are not routinely collected prior to ambulatory procedures, so they were not 275 available for our retrospective review. Second, we were limited to only data within our health 276 care network's electronic medical record. This means that we could not capture COVID tests 277 performed at facilities outside of our health system and we may have also missed patients who 278

presented to other hospitals with complications and for subsequent care. Third, the data used 279 in this study is largely epidemiological and lacks a comparison group, so our abilities to declare 280 statistical significance is very limited. Lastly, since our database only has records of performed 281 procedures, we were unable to search for COVID-positive patients who had procedures 282 cancelled but not rescheduled. This is why we can only report numbers relative to the number 283 of procedures performed and the 1.00% of asymptomatic patients who tested positive for 284 COVID-19 in our study is not a good surrogate for the general population. Given these major 285 limitations, further studies using larger datasets are needed to validate the findings of our study 286 before the conclusions can be applied clinically. 287

Despite the limitations, we feel our study adds important information to the growing 288 body of COVID-19 literature. To the best of our knowledge, our study is the first to report 289 relative safety of performing ambulatory procedures on patients who previously tested positive 290

for COVID-19. It also reports outcomes that are much more encouraging than the those 291 previously reported for performing procedures on asymptomatic COVID-positive patients, 292 albeit on younger patients undergoing shorter and less complex procedures. Procedures that 293

were delayed for a positive COVID test were delayed for nearly a month, which begs the 294 question, is this delay in care necessary in properly selected patients? Our hope is that the 295 results of this study will stimulate other institutions to study and report similar information so 296 that the medical community can better understand how to manage a growing population of 297 COVID-positive and COVID-recovered patients. 298 299

Positive tests in asymptomatic patients led to significant delays in care, with an average 301 procedure delay of 28.6 days. None of the patients who underwent ambulatory procedures 302 after a positive COVID-19 test had any COVID-related complications, regardless of whether or 303 not the procedure was delayed until testing negative. This suggests that it is relatively safe to 304 perform ambulatory procedures on patients who previously tested positive for COVID-19, as 305 long as they are asymptomatic. The rate of nosocomial spread associated with ambulatory 306 procedures appears to be negligible with the appropriate perioperative testing and precautions. 307

Further studies using larger datasets are needed to validate the findings of our study before 308 these conclusions can be applied clinically. 309 310 Funding/Support: There were no sources of funding or support for this study. 311 COI/Disclosures: None of the authors have any disclosures to report. 312 

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