key: cord-0970649-7y1kh216
authors: Croke, Lisa
title: Protecting perioperative patients and personnel in the era of COVID‐19
date: 2020-11-30
journal: AORN J
DOI: 10.1002/aorn.13311
sha: fdcde1161a8508529ee406d82c970b279ae45327
doc_id: 970649
cord_uid: 7y1kh216

nan

T he COVID-19 pandemic has had a significant effect on patient and health care personnel safety. Nosocomial outbreaks of the virus have occurred among patients; one retrospective study indicated that of 435 inpatients with COVID-19 identified in March and April 2020, 15 percent either definitely or very likely acquired it in a health care facility. 1 Frontline health care workers have an almost 12 times greater risk of COVID-19 viral infection than the general population; this risk is even higher with inadequate availability of personal protective equipment (PPE). 2 In the initial phases of the pandemic, elective surgeries were cancelled, but emergency procedures continued. For these procedures, as well as the elective surgeries that have been resuming, it is important that health care personnel work together to implement strategies that provide protection from virus transmission in the preoperative, intraoperative, and postoperative settings. According to Jeannie Lee, MSN, MBA, RN, CNOR, assistant director of nursing, Johns Hopkins Hospital, Baltimore, when the perioperative teams at her facility were tasked with resuming surgery, it was important to focus on the fact that surgery is a key patient need. "So many of our patients may have significantly different outcomes in a short amount of time without surgery," she said. "We needed the staff to remember this and, subsequently, know that they could operate and work safely, including having adequate protection and guidance to care for their patients."

According to Elena Canacari, BSN, RN, CNOR, associate chief nurse, Beth Israel Deaconess Medical Center, Boston, when resuming surgery, it is essential to acknowledge the difficulty that the pandemic has caused for health care workers and their families and patients, and to continue to communicate the facility's goal to protect the health of staff members while providing safe care to patients. "The challenge of this pandemic has been that policies and practices to protect staff members and patients continue to evolve as we gain knowledge over time; we are fortunate to have a very strong infection control division that has partnered with leaders at the local and system levels to provide the best evidence as it became available," she said. "We have conducted virtual town halls to disseminate the information to our staff members and developed standard practices on caring for patients, including screening and testing, staff member standard attire, masking, and room turnover."

Protocols should be in place to protect patients and personnel from exposure to the COVID-19 virus throughout the care continuum; examples include enacting universal masking, performing active screening of visitors on entry, and requesting that patients come alone. Perioperative personnel should be screened for COVID-19 each day; those who have positive responses to screening questions or increased body temperatures should be isolated and evaluated for their risk of developing COVID-19. 3, 4 All patients should complete a pre-procedure COVID-19 screening checklist within 72 hours of a surgical procedure; each facility should establish a process for preoperative testing, including who to test, the timeframe to conduct testing and receive results, which test to use, and testing location. 3 Lee indicated that the Epidemiology and Infection Control Department was instrumental for developing proper protocols at her facility. "As we implemented new protocols, we had many opportunities to get clarification from them," she said. "If there were questions regarding wording or the guidance, there was an immediate reply; that dynamic response was incredibly important for taking their expert knowledge and translating it into clinical practice."

"Our system performed surveys to find out what was important to our patients and what would make them feel safe to return to our facility," Canacari said. "From that, a safe care program was put into place that combines new processes, standards, and technologies

such as expanded virtual health visits to ensure the safety of patients returning for surgery after the pandemic." Examples of steps implemented include a three-point symptom check, in which patients confirm they are not experiencing symptoms of COVID-19 at scheduling, 24 to 72 hours before arrival, and on arrival; enhanced cleaning and disinfection protocols; universal masking; staff member precautions (e.g., confirmation before each shift that they are not experiencing symptoms, isolation of exposed staff members); redesigned traffic flow patterns; and touchfree check-in and checkout. Use of telemedicine via phone or video calls, text messages, e-mail, and mobile health apps provides an opportunity to prescreen patients and ask them questions before admission while avoiding in-person interactions. 5 All surgical patients should be categorized as not having COVID-19, having COVID-19 without symptoms, or having COVID-19 with symptoms. 4 Any patient whose status is unknown should be treated as positive until proven otherwise. 4, 6 An interdisciplinary team should perform a risk assessment to decide if surgery for a patient with suspected or confirmed COVID-19 can be delayed until the patient is no longer infectious; if not, this team also will identify the type of room (i.e., positive pressure, negative pressure, positive pressure with anteroom) to use for the procedure. 3 Although the use of negative pressure rooms should be considered, 7 the team may decide to use a positive pressure room when the risk for surgical site infection is increased in a negative pressure room or when converting to negative pressure is not possible. 3 One team at a facility in Boston implemented a huddle approach to help align the perioperative care team on requirements for patients with COVID-19 and ensure that guidelines were followed. The huddle was held after the procedure was scheduled and included the OR charge nurse, the anesthesia lead, an OR staff nurse, the attending anesthesia professional and surgeon, and the postanesthesia care unit charge nurse. During the huddle, they discussed COVID-19 status, risk of aerosolization, need for a negative pressure room, and the minimum number of people needed for the procedure; they formed plans to obtain PPE, transport the patient, and determine a recovery location. They found that the huddles were beneficial for talking through concerns and ensuring that they agreed on protocols, and that the huddle approach would be generalizable to other facilities or periprocedural care settings. 8 For patients with suspected or confirmed COVID-19, a sign should be placed on the OR door to indicate airborne and contact precautions and to discourage personnel from unnecessarily entering. A cart with PPE (i.e., N95 respirators, isolation gowns, eye protection, examination gloves) should be placed at the entrance. 3, 6 Only necessary supplies should be in the OR; any unneeded equipment should be removed to decrease the risk of environmental contamination. If any unneeded items must remain in the room, they should be covered with a disposable cover. 3 One step that the teams at Lee's facility took after resuming elective surgeries was to ensure adequate PPE for the perioperative team. "We increased our fleet of PAPRs [powered air-purifying respirators], so that if we have to step away from using N95 masks, we will still have appropriate PPE available for our staff to do the surgeries they need to do," she said. They also perform daily safety audits to ensure that staff members are compliant with different elements of their internal guidance. "We monitor the integrity of certain processes, like cleaning high-touch areas, and compliance with new PPE guidance, such as staff members wearing face shields when they are speaking with patients in the clinical areas."

After the surgery has started, the procedure ideally should be performed using only the instruments and devices available in the OR; however, a dedicated runner also can remain outside the OR to obtain any additional supplies that are requested. 3, 6, 9 Intubation and extubation ideally should be performed in an airborne infection isolation room; however, if they are performed in an OR, a minimal number of personnel should remain in the room, and the OR doors should not be opened until 99 percent of airborne contaminants have been removed. If a door must be opened, one that allows the least amount of airflow distribution should be used. 3 Any team member in the room should move away from the head of the OR bed during intubation.

Because there is a risk of aerosolized particles from intubation settling on the sterile field, protocols should be in place to prevent this from occurring (e.g., covering the sterile field). Skin antisepsis, draping, and the procedure can start immediately after intubation; a minimal number of people should remain in the OR during the procedure. 3 To decrease air contamination, as much time as possible should be allowed to pass after one patient leaves the OR and before performing the next procedure. 6

An interdisciplinary team should establish protocols for patient recovery based on the patient's COVID-19 status and conditions, available resources, patient placement, and recovery room management. Patients with confirmed or suspected COVID-19 should recover in the OR or be transferred to another designated area (e.g., negative pressure airborne infection isolation room). Patients who remain in the OR for recovery, but who are extubated, should be transferred directly to the intensive care unit or patient room. Intubated patients should be transferred directly to the intensive care unit. 3 A minimum number of personnel should provide postoperative care for patients with suspected or confirmed COVID-19 and these patients should be moved only when essential. 3 Personnel should wear PPE and not contact any secretions when completing postoperative rounds, administering medications, and evaluating and treating the incision site. 4 To reduce the risk of exposing other patients, an interdisciplinary team should identify postoperative discharge criteria, including considering same-day discharge when possible. 3

The COVID-19 pandemic has had a significant effect on patient and health care personnel safety. It is important that health care personnel work together to implement strategies to help provide protection from COVID-19 virus transmission in the perioperative setting. Canacari indicated that one benefit that her facility has experienced during the pandemic is even greater teamwork. "We have always had a very collaborative environment, but this pandemic has really put everyone on the same page to protect each other and our patients," she said.

Nosocomial transmission of coronavirus disease 2019: a retrospective study of 66 hospital-acquired cases in a London teaching hospital

Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study

Perioperative Care of the COVID-19 Patient

Surgery during the COVID-19 pandemic: a comprehensive overview and perioperative care

Telemedicine for preoperative assessment during a COVID-19 pandemic: recommendations for clinical care

Surgery in COVID-19 patients: operational directives

American College of Surgeons

Using a pre-procedure COVID-19 huddle to improve operating room safety

Protecting surgical teams during the COVID-19 outbreak: a narrative review and clinical considerations