key: cord-1040733-h4amjqwf authors: Ojan, Assadian; Markus, Golling; Colin M, Krüger; David, Leaper; Nico T, Mutters; Beat, Roth; Axel, Kramer title: Surgical site infections - guidance for elective surgery during the SARS-CoV-2 pandemic - international recommendations and clinical experience date: 2021-02-15 journal: J Hosp Infect DOI: 10.1016/j.jhin.2021.02.011 sha: 98ef180c302457cd166c14f5085f8d41db5c7ce0 doc_id: 1040733 cord_uid: h4amjqwf BACKGROUND: The COVID-19 pandemic not only had an impact on public life and healthcare facilities in general, but also affected established surgical workflows for elective procedures. The strategy to protect patients and healthcare workers from infection by SARS-CoV-2 in surgical departments has needed step-by-step development. Based on the evaluation of international recommendations and guidelines, as well as personal experiences in a clinical “hot spot” and in a 450-bed surgical clinic, an adapted surgical site infection (SSI) prevention checklist was needed to develop concise instructions, which described roles and responsibilities of health care professionals that could be used for wider guidance in pandemic conditions. METHOD: Publications of COVID-19-related recommendations and guidelines, produced by health authorities and organizations, such as WHO, US-CDC, ECDC, the American College of Surgery and the Robert Koch Institute, were retrieved, assessed and referenced up to January 31(st), 2020. Additionally, clinical personal experiences in Germany were evaluated and considered. RESULTS: Part 1 of this guidance summarizes the experience of a tertiary care, surgical centre which utilised redundant hospital buildings for immediate spatial separation in a “hot spot” COVID-19 area. Part 2 outlines the successful screening and isolation strategy in a surgical clinic in a region of Germany with outbreaks in surrounding medical centres. Part 3 provides the synopsis of personal experiences and international recommendations suggested for implementation during the COVID-19 pandemic. CONCLUSION: Understanding of COVID-19, and SARS-CoV-2-related epidemiology, is constantly and rapidly changing, requiring continuous adaptation and re-evaluation of recommendations. Established national and local guidelines for continuation of surgical services and prevention of SSI require ongoing scrutiny and focused implementation. This manuscript presents a core facility checklist to support medical institutions to continue their clinical and surgical work during the COVID-19 pandemic. By February 9 th 2021 accumulated global data indicated that approximately 102 million people had become infected with SARS-CoV-2, approximately 2.2 million had died, and 57 million recovered. A cohort study from Heinsberg, the region with the highest SARS-CoV-2 incidence in Germany, which involved antibody-and swab-PCR-tests of 919 participants in 405 households, showed an infection rate of 15%; 22% of affected individuals were completely asymptomatic, and fatality rate was 0.37% [1] . According to the authors of the COVIDSurg Collaborative [2] , who commented on an international cohort study of mortality and pulmonary complications in patients with perioperative SARS-CoV-2 infection undergoing surgery, an estimated 28.4 million elective operations were cancelled because of the disruption caused by COVID-19. The authors opined that it was the correct decision to postpone operations at a time when patients were at risk of being infected with SARS-CoV-2 perioperatively. Indeed, when a patient developed COVID-19 perioperatively, postoperative pulmonary complications occurred in 51.2% of patients and were associated with a 30-day mortality of 23.8%, with pulmonary complications at 38% [2] . Data from the UK show a clear difference between patients, infected with the virus, who were either conservatively treated and those who had laparoscopic appendicectomy. At 30-day follow-up, complications were significantly higher in the operative group (p < 0.001). Thus COVID-19 may change the management of acute appendicitis to favour non-operative management, which has now been shown to be safe and effective in the short-term [3] . A meta-analysis confirmed a high rate of postoperative mortality among COVID-19 patients of 20% and a postoperative ICU admission rate of 15% [4] . Consequently, it was suggested that there is an urgent need for investigations by governments and health providers into measures that ensure safety of patients and healthcare workers (HCW), as elective surgery restarts. A clear guideline, which has been adapted for this unique epidemiological challenge, is essential for the protection of patients and HCW against infection. A proposal for guidance is presented in this manuscript, which is based on the authors' experience and the evaluation of the current scientific literature. This became relevant in surgery with respect to differentiating between a surgical site infection (SSI) and COVID-19-infection, and in intensive care for decision of early compared with late intubation in critical respiratory conditions, or the need for tracheostomy [27] . In the latter, the discussion is ongoing and a clear decision for or against invasive measures is pending [28] . Furthermore, the hospital management had daily update meetings on current local and regional developments, and the decisions from those meetings were communicated through the public relations office and the intranet to hospital staff. Despite the initial implementation of infection and prevention control measures against COVID-19, 45 (15.2%) of 297 treated patients died, and 47 required ICU care, with 10 (21.3%) deaths. Some patients with respiratory insufficiency were transferred to other hospitals for extracorporeal membrane oxygenation (ECMO). It was initially thought that early intubation was beneficial since prolonged spontaneous breathing, with or without non-invasive assistance, increased respiratory work and worsened the risk of respiratory failure. However, this needed to be balanced against unacceptability of intubating patients too early merely out of concern that the medical staff might be at greater risk of contracting COVID-19 if patients were ventilated non-invasively. A stepwise treatment strategy was later introduced, with appropriate intensive-care monitoring and regulation of all relevant preventive precautions. This depended on the availability of intensive-care beds. In a US single centre comparative cohort study the ventilatory parameters and lung mechanics of consecutive early and late intubated and ventilated patients with COVID-19 ARDS, were measured using descriptive analysis [29] . The authors concluded that larger cohort studies were needed to detect a difference in mortality between early and late intubation. Other studies have found no advantage for early or late intubation [27, 30] . Current mortality data suggest an advantage for patients in whom intubation is completely avoided, but these data may be confounded. Two aspects determined the successful management of COVID-19: the immediate reopening of redundant wards in an old hospital to separate the patients into white, grey or black areas and the continuous evaluation of sometimes contradicting J o u r n a l P r e -p r o o f 6 evidence (e.g. early compared with late intubation, introduction of tracheostomy) as well as the use of digital tools (SOPHIA) for training and decision making. The Immanuel Hospital is a church-backed community hospital that provides care for approximately 300,000 inhabitants in the state of Brandenburg and Berlin. During the early phase of the pandemic in Berlin the main ICU resources of the University Hospitals were occupied by COVID-19 patients and a massive reduction of elective surgery resulted. A strategy was developed around maintaining dedicated ICU and non-ICU areas for COVID-19 patients that also allowed continuation of elective and emergency surgery for as long as possible. The following requirements for the surgical clinic were needed: Admission screening: Prior to elective surgery, patients were asked to record the following symptoms of COVID-19 in a "health diary" starting 5 days prior to admission: fever >37.8 o C, dry cough, shortness of breath, anosmia and loss of taste, sore throat, headache, weakness, fatigue, tachypnoea with breathing frequency ≥ 30, hypotension (systolic BP <90 mmHg or diastolic BP ≤60 mmHg) and pulse oximetry values of <85%. In the admission interview (in a separate screening area of the hospital) contact with COVID-19 patients, recent travel history, occupation, social contacts and contact with a hot spot or cluster were questioned. At this consultation Class II surgical masks were routinely worn by HCW and patients, and a minimum 1.5 metres social distancing was maintained; HCW wore an FFP2 respirator if the patient had respiratory symptoms. Patients with risk factors of symptoms were admitted to the grey area. A COVID-19 test was taken with a combined nose-throat swab (PCR) and, in addition, symptomatic patients underwent a low-dose CT scan of the thorax. If the PCR was positive, the patient was transferred to the black (COVID positive / isolation) area and the decision to operate assessed on the basis of clinical urgency. Acutely symptomatic patients were admitted directly to the black area of the ICU in a single room. If the PCR was negative, patients were transferred to the white area. After the cumulative incidence of COVID-19 rose to >50 patients/100,000 per week, all patients were screened preoperatively using a PCR test. As there was a shortage of nurses in Germany before the pandemic, the clinic has been forced to reduce the number of inpatient beds or carry out short-term personnel rescheduling. This did not increase planning security for patients who require intensive medical monitoring and care in the early post-operative phase. Establishment of isolation care structure: The clinic was separated into a SARS-CoV-2 free ward (white area), wards for suspected infections (grey area) and wards for confirmed infections (black area). In the same way the ICU was divided. All patients and HCW in the white area screened negative for COVID-19; HCW were tested weekly and maintained health diaries with daily documentation of any symptoms. Based on proven efficacy of class II surgical face masks, in combination with social distance [31] , patients and HCW were required to wear class II surgical masks, and alcohol-based hand hygiene was promoted. respirators and 2 pairs of gloves were worn [33] in accordance with the Robert Koch Institute recommendation [34] . The automated OT door activation function was deactivated to reduce the door opening frequency, and the time the patient was in the OT was minimised. Likewise, the number of OT personnel was kept to a minimum , usually one surgeon and one assistant; one physician's assistant and one anaesthetist and one anaesthesia nurse. The work of the circulating nurse in the OT was delegated to the anaesthesia nurse; the J o u r n a l P r e -p r o o f 9 circulating nurse communicated by telephone with the room team for additional requirements. As the risk of exposure to patient-related aerosols was considered to be highest during intubation and extubation, and also during aerosol-generating surgical procedures, the "keep your distance" advice was observed by everyone in the OT, even during surgical procedures. Virucidal gargling was implemented [35] . It is believed that the greatest risk for a COVID-19 outbreak in hospital comes from staff and not patients. Admission of planned, as well as emergency, procedures can be managed and controlled as long as there are sufficient protective materials and adequate facility capacity. It is imperative to reduce the regular number of beds for patient care by 20% of regular bed capacity. Medical and nursing staff leave the hospital every day, with family and other outside contacts, and can introduce the virus into the hospital, from asymptomatic carriers of SARS-CoV-2 in particular. Fixed routines of regular self-testing are required, twice weekly for all asymptomatic staff with a PCR or an antigen rapid test, as well as independent maintenance of a diary of symptoms. Symptomatic staff must remain in quarantine until a negative result is available. Although there may be initial shortages of personal protective equipment (PPE), these need to be available in sufficient quantities. All staff in direct patient contact should wear an FFP2 respirator which provides additional protection for all in the event of an unexpected internal COVID-19 outbreak. • Demand on healthcare organizations (e.g., hospital/clinics) varies. Therefore, recommendations need to be implemented, and standard operating procedures • Following any shortfall of supply or stock, an adaptation of these SOPs may be necessary for a limited amount of time. • The surgical team should, in collaboration with the purchasing department, and based on daily use and consumption, ensure procurement and stock management for personal protection equipment [PPE], together with cleaning and disinfection procedures. The PPE and disinfecting products should have proven or depending on resources definitive efficacy against coronaviruses. • Traceability of internal and external contact points of patients and limited visitors needs to be ensured. • Suspected (potentially infected / incubating) and proven (definitive COVID-19 infections) cases have to be isolated from other patients who are cared for in a designated "white area". Patients with proven COVID-19 infection should be managed in a designated "black area". However, suspected cases must be isolated in a single room until the result of a SARS-CoV-2 PCR is known ("grey area"). Suspected and proven cases need to be reported to local authorities. • A list of contact individuals (contact > 15 min and distance < 1.5 m) and traceability of internal and external contact points of patients and limited visitors needs to be maintained. • Rotating teams (two or more teams with no physical contact separated on an either daily, weekly or fortnight basis). • Monitoring of COVID-19 rates is needed by Health Authority (including basic reproduction rate, and prevalence according to local recommendations). Before arrival to a clinical setting / health diary and tele-triage • It is advisable to implement a tele-triage system, before elective surgery, to implement a risk assessment. Alternatively, a special temporary area can be integrated into the entrance area or prior to hospital admission. Uncontrolled patient access, without triage, has to be prevented by strict control of access. J o u r n a l P r e -p r o o f • If possible, 5 days before admission each patient keeps a health diary to record symptoms suggestive of COVID-19, such as fever >37.8 o C, runny nose, dry cough, shortness of breath, loss of smell and taste, sore throat, headache, weakness, fatigue, tachypnoea with breathing frequency ≥ 30, hypotension (systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg) and pulse oximetry (values <85% are critical). • The most reliable method to assess the current pre-operative SARS-CoV-2 status of a patient is PCR-testing, ideally 48 to 24 hours prior to any surgical procedure. However, the appropriate timeline for preoperative laboratory screening is not known at present. The Dutch Guidelines, [13] for elective surgery on COVID-19 asymptomatic patients, recommend either no pre-operative SARS-CoV-2 screening or within 48 h before elective surgery, depending on the mean of the 3-day average of new infections in the Netherlands (above or below 40 new infections per day). A recent survey among 479 arthroplasty surgeons from 44 countries and 6 continents agreed that "…it would be ideal for all patients to undergo RT-PCR testing for SARS- only high-risk patients should be tested" [14] . • Alternatively, a rapid SARS-CoV-2 antigen test, which takes approximately 15-20 minutes, can be performed at the point of care. It indicates virus excretion with a high degree of certainty (>95%) in patients infected with COVID-19, provided the viral load is sufficiently high (i.e., positivity means infectivity). The positive rapid test enables a rapid decision to be made for immediate transfer to the black area (see below) particularly in symptomatic patients and those with a history of contact with SARS CoV infections, and PCR is unnecessary. However, a negative test does not exclude COVID-19 infection, so in this case the procedure described below is analogous to that for a non-feasible PCR test. • If preoperative PCR testing for each patient is not feasible, then general procedures have to be followed, including a decision about the necessity of PCR testing and the use of PPE by staff before, during and after a surgical procedure. • Triage Step 2a: If patients are not identified as being at risk, they still need to be informed, using an agreed protocol, about the required procedures: such as wearing a mouth-nose protection (class II surgical mask or FFP respirator depending on the classification of the patient on leaving a patient's room), proper hand hygiene, preoperative bathing, stopping smoking [36] , and nutritional management. • Triage Step 2b: If a patient, based on the questionnaire, is assessed as being at risk, PCR-screening should be arranged prior to admission into hospital. • Except for emergency surgery, and cancer surgery that cannot be postponed from a medical perspective, consider the GRADE system [20, 26] mouth-nose-protection as well as proper hand hygiene. Eye protection is also associated with fewer infections [37] . • If tele-triage cannot be executed, as in the case of an emergency, all patients planned for surgery should be submitted for SARS-CoV-2/COVID-19 testing, including temperature and pulse oximetry measurements; an admission can only be allowed into a predefined holding area (grey area) until the screening result is available. • Procedures to separate definitively, and suspected, infected SARS-CoV-2 patients (isolation) from patients who are not considered to be at risk should be established (based on information such as hand and respiratory hygiene, use of PPE and toilet use). Patients with COVID-19-like symptoms should be directed to designated waiting areas and transferred to the grey area. SARS-CoV-2 positive patients need to be transferred to a black area. • In case-positive hospitals which do not possess the potential of spatial separation into these three risk-categories, patients need to be assigned and transferred to a regional tertiary hospital which is able to provide spatial separation [32, 33] . • Diagnostic-based screening for potentially SARS-CoV-2 positive patients depends on the availability of appropriate testing. During the initial phase of the pandemic, the backbone of diagnostic testing was laboratory-based PCR investigation of nasopharyngeal specimens. Currently, there are several laboratory-and point of care-(POC) based diagnostic methods available, which are either molecular biology or antigen detection-based. PCR is highly sensitive and specific, but results are not usually available immediately; antigen testing, although less accurate (see below), can give results within 15 minutes. • The diagnostic efficacy of different commercially-available, antigen lateral-flow POC tests has been evaluated [39] [40] [41] . Depending on the diagnostic antibody test used, J o u r n a l P r e -p r o o f sensitivities of 76.6% (95% CI: 62.8% -86.4%) [40] and 72.6% (95% CI: 64.5% -79.9%) [42] and specificities of 99.3% (95% CI: 98.6% -99.6%) [41] and 99.3% (95% CI: 99.7% -100.00%) [42] have been reported. • If a rapid pre-surgical SARS-CoV-2 assessment is required without time to wait for a PCR result, POC antigen tests may also be considered. However, only validated POC tests with known sensitivity and specificity should be used, and surgical staff trained and informed in the interpretation of results. [42] should reduce the risk further [22] . o In an OT with mixed ventilation, due to the significantly lower ventilation volume with swirling of aerosols, it is questionable whether the FFP3 respirator ensures a seal tight enough to exclude putting the team at risk. In this event, protection of the surgical team can be achieved by wearing overpressure body exhaust suits [43] . o OTs without mechanical ventilation are not acceptable, since released aerosols are not diluted. • Insufflation: Laparoscopic, minimally invasive techniques produce aerosols derived from the induced pneumoperitoneum. The risk of an aerosol carryover is reduced by insufflation-systems equipped with smoke-gas elimination (smoke evacuation) and defined CO 2 feeding and discharge; therefore, these systems are to be preferred. Alternatively, it is recommended that older insufflator-instruments are used which have disposable smoke gas-filters (acc. to ISO 29463 [45]) with a Luer-taper connection to remove smoke-gases by filtering. • Robotic-assisted surgery: This allows further reduction of the number of surgeons and assistants in the high-risk field around the patient. Only the first assistant in the field of intervention is needed to change instruments, or for introducing a suture or swab into the operating field. The operator is working from a console positioned at any distance from the operating area. • Any close contact with patients should include use of appropriate PPE. • Preoperative antibiotic prophylaxis should be given according to accepted local guidelines. Selection and administration of preoperative antibiotic prophylaxis, to prevent SSIs, is not specifically related to SARS-CoV-2. • Surgical face masks should be routinely replaced prior to each operation, if visibly dirty or moist and after 2 hours of surgery. • Observe correct hand hygiene when replacing masks. o Once intubation or extubation are completed, the surgical team should wear class II surgical face masks and, if available, a face shield with a neck cover that wraps around the face with an extension which can be placed inside the gown, head protection and 2 pairs of gloves [48] . Behaviour in the intensive care unit (ICU) • If using aerosol-generating procedures (including intubation, bronchoscopy, cardiopulmonary resuscitation, or suction), pre-procedural virucidal gargling and virucidal nasal antisepsis (spray) is recommended [35] . • Allow entry of essential staff only. • Wear a particulate respirator (filtering face piece, FFP2 or FFP3) if available, together with gown, eye protection and gloves. o It is recommended that members of the hygiene-team should be trained to use the dress/undress code of the PPE [32] . o Dispose of viral-contaminated waste as clinical waste. Prevention of needle stick injury should involve use of suitable containers. After discharge from hospital • Provide instruction and materials to patients and caregivers on the continuous need for respiratory hygiene/cough etiquette, physical distancing as well as hand hygiene and mask-wearing principles. • Provide advice on home isolation if necessary, infection control and limiting social contact, i.e., respect physical/social distancing. • Record patient address and telephone number for traceability. • All patients should wear an approved surgical mask class II postoperatively within the hospital. • Include basic information about maintaining hygiene and monitoring incisional wounds as a routine part of discharge service. All accepted measures for the prevention of SSI (the SSI-bundle approach) need to be undertaken consistently as usual, whether patients with confirmed or questionable COVID-19 infection are involved. This requires the implementation of general recommendations for the prevention of SSI provided by WHO, CDC, NHS and RKI [49] [50] [51] [52] , which are summarized in Figure 2 . The COVID-virus is here to stay. Different vaccines are available, but the protective effect is unclear, especially with the spread of new mutants. At present it is important to: • avoid operating on any patient with COVID-19 (carrier, clinical suspicion or manifestly infected), if the situation allows • prepare hospitals and staff for pandemic situations such as COVID-19 (emergency plans, training of nurses/doctors, establishment of isolated wards, etc.) -it is possible to provide safe surgical care for SARS-CoV-2-positive patients and to minimize nosocomial transmission [53] [54] [55] • learn to live with and deal with COVID-19 without risking dramatic economic upsets. None declared. OA, DL, NTM and AK drafted the manuscript together with BR and MG. MG has included experiences from a clinical "hot spot-centre", CK from a surgical clinic. (COVID- 19) patients. Technical Report. February 26, 2020. Infection fatality rate of SARS-CoV-2 infection in a German community with a super-spreading event. med. medRxiv preprint Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study The management of adult appendicitis during the COVID-19 pandemic: an interim analysis of a UK cohort study Postoperative mortality among surgical patients with COVID-19: a systematic review and meta-analysis Resuming elective orthopaedic surgery during the COVID-19 pandemic: Guidelines developed by the International Consensus Group (ICM) AIOT Alliance of International Organizations of Orthopedics & Traumatology. AIOT Joint Statement -COVID-19 Best Practices OrthoEvidence Best Practices Working Group. Best practices for surgeons -COVOD-19 evidence-based scoping review Options for separate management of COVID-19 suspect cases / cases and other patients in the outpatient and pre-stationary areas American College of Surgeons. Post-COVID-19 readiness checklist for resuming surgery Checklist for hospitals preparing for the reception and Hospital readiness checklist for COVID-19. Regional Office for Europe MedTech Europe COVID-19 Implications for clinical investigations needed for medical device recertification Practice guideline pre-operative work-up for SARS-CoV-2 infection in asymptomatic patients scheduled for surgery under general anesthesia Recommendations for resuming elective hip and knee arthroplasty in the setting of the SARS-CoV-2 pandemic: the European Hip Society and European Knee Associates Survey of Members Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations Interim infection prevention and control recommendations for healthcare personnel during the coronavirus disease 2019 (COVID-19) Pandemic COVID-19: Elective case triage guidelines for surgical care Joint Statement: Roadmap for maintaining essential surgery during COVID-19 pandemic International guidelines and recommendations for surgery during COVID-19 pandemic: A Systematic Review Protecting surgery through a second wave French consensus regarding precautions during tracheostomy and post-tracheostomy care in the context of COVID-19 pandemic Development of clinical care guidelines for faculty and residents in the era of COVID-19 COVID-19 -ESSKA guidelines and recommendations for resuming elective surgery Surgical Infection Society guidance for operative and peri-operative care of adult patients infected by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) Management considerations for the surgical treatment of colorectal cancer during the global Covid-19 Pandemic Clinical significance of timing of intubation in critically ill patients with COVID-19: A multi-center retrospective study Timing, complications, and safety of tracheotomy in critically ill patients with COVID-19 Ventilatory mechanics in early vs late intubation in a cohort of COVID-19 patients with acute respiratory distress syndrome: a single center Timing of intubation and its implications on outcomes in critically ill patients with coronavirus disease 2019 infection Effectiveness of masks and respirators against respiratory infections in healthcare workers: a systematic review and meta-analysis Dealing with the COVID-19 pandemic in orthopaedics: experiences and procedure in Germany Can surgery follow the dictates of the pandemic "keep your distance"? Requirements with COVID-19 for hygiene, resources and the team Empfehlungen des RKI zu Hygienemaßnahmen im Rahmen der Behandlung und Pflege von Patienten mit einer Infektion durch SARS-CoV-2 Virucidal gargling and virucidal nasal spray Wound healing and infection in surgery. The clinical impact of smoking and smoking cessation: a systematic review and meta-analysis on behalf of the COVID-19 Systematic Urgent Review Group Effort (SURGE) study authors. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis Comparison of seven commercial SARS-CoV-2 rapid Point-of-Care Antigen tests Evaluation of the accuracy, ease of use and limit of detection of novel, rapid, antigendetecting point-of-care diagnostics for SARS-CoV-22020 Real-life validation of the Panbio COVID-19 Antigen Rapid Test (Abbott) in community-dwelling subjects with symptoms of potential SARS-CoV Risk assessment of mixed and displacement ventilation (LAF) during orthopedic and trauma surgery on COVID-19 patients with increased release of infectious aerosols Surgeon personal protection: an underappreciated benefit of positive-pressure exhaust suits High-efficiency filters and filter media for removing particles in air -Part 2: Aerosol production, measuring equipment and particle-counting statistics World Health Organization. WHO COVID-19. Experimental Treatments. Classification of treatment types. World Health Organization 2020: R&D Blue-print Povidone-iodine demonstrates rapid in vitro virucidal activity against SARS-CoV-2, the virus causing COVID-19 disease Effect of single-versus double gloving on virus transfer to health care workers' skin and clothing during removal of personal protective equipment Global guidelines for the prevention of surgical site infection. 2. Aufl, WHO Centers for Disease Control and Prevention guideline for the prevention of surgical site infection Surveillance of surgical site infections in NHS hospitals in England Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut Emergency surgery during covid-19 pandemic; what has changed in practice COVID infection and sentinel lymph node procedure for melanoma: Management in a dermato