How can operating rooms resuming elective surgeries maintain safety and maximize efficiency

Posted on May 12, 2020 by Tomas Rapaport

Summary

Main recommendations involve manipulating basic Hierarchy of Controls to best protect patients and staff. These focus on addressing engineering controls, administrative controls, and PPE, as well as certain other recommendations. Assessing risk of the patient being infected with SARS-COV-2 is paramount. See below for sample risk assessment forms and screening algorithms. 

I.   Safe Surgical Care: Strategies

All of the following was taken from the UBC Continuing Professional Development Safe Surgical Care: Strategies during a pandemic free online course (1) with supplementation from the British Columbia Infection Prevention and Control (IPC) Protocol for Surgical Procedures during COVID-19 (2): 

 

Basic Hierarchy of Controls that can be used are seen in the image below:

 

II.   Engineering Controls

Reduce or eliminate all high risk exposures to infected patients via different avenues

  1. Cohort suspected/confirmed cases separate from non infected patients at every step of the patient flow
  2. Create a closed circuit with separate entrances and exits for suspected and confirmed cases
  3. Create a dedicated operating room for infected patients. If possible, convert the operating room to a negative pressure room to prevent potentially displacing airborne particles out of the room
  4. Increase the relative humidity in the operating room and post-operative areas to around 45%  as this causes more rapid fallout of particles, helps clear respiratory secretions and hydrates mucous membrane with associated improved outcomes. This decreases virus survival and can decrease aerosol spread (2)
  5. Only perform elective surgeries that have a clear positive benefit-to-risk ratio (e.g. performing an elective tracheostomy may benefit the patient greatly, however; it may risk exposure due to prolonged intubation, tracheal aspiration, and excessive patient coughing if the airway circuit is not fully closed)
  6. Limit the number of personnel in the room during intubation and extubation

III.   Administrative Controls

  1. Allow for leave of absence for staff returning from affected areas
  2. Support sick-pay and sick-leave
  3. Limit staff mobility between health care facilities
  4. Limit number of staff present in an area or operating room
  5. Conduct a pre-surgical patient assessment of all patients undergoing a surgery with a questionnaire and a PCR swab. Sample Surgical Patient Assessment form can be found in Appendix 1 of the IPC Protocol for Surgical Procedures during COVID-19 (2).  A negative PCR test may not change your approach, but a positive test will likely dramatically change your plans. Especially since the specificity of the current PCR swabs is close to 100%. Below is an example of one possible screening model used at St. Paul’s Hospital in Vancouver, BC

 

St. Paul’s Hospital Pre-Operative Screening Algorithm

What do the different levels of PPE mean?

Note: The BC IPC (2) does not indicate the use of double gowns, water impermeable gowns, neck protection, face shield, or double gloves. They state that any patient in the yellow or red zone should be treated with a fit-tested N95 respirator, goggles, gown, and gloves. See Protocol for Management of Surgical Patients – Adults (2)

6. Conduct a pre-surgical procedure huddle with the entire team as this is one of the best determinants for achieving high standards of safety. Make sure everyone agrees on the patient risk category and PPE being used (2)

7. Procedures performed under local or regional anesthesia, including spinal and epidural, can be performed using only contact and droplet precautions (2)

IV.   Proper PPE

  1. Wash your hands! Coronaviruses are enveloped viruses, meaning they are very easy to kill with typically hand washing practices
  2. Improper PPE use is the #1 cause of healthcare worker infection. Usually due to improper donning and doffing of PPE. Establish a buddy system. 
  3. Vancouver General Hospital began recycling N95 masks by decontaminating, steam sterilizing, and storing them appropriately

V.   Other

  1. Workers should change into scrubs as soon as they arrive and put them in the laundry hampers when leaving their shift, clothes worn to the hospital should be washed as soon as you arrive to your home
  2. Staff should shower if operating on a patient with suspected or confirmed infection and change into clean scrubs before seeing other patients or going home
  3. Cell phones and other personal items should be kept in a ziploc bag at all times and cleaned with >60% alcohol solution
  4. If all of the above things are done, the risk of contamination to members of a staff’s household is very low, however; consideration should be given to limiting physical contact with other household members if staff feel that they were unacceptably exposed

VI.   Additional Resources:

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Safe Surgical Care: Strategies During a Pandemic | UBC CPD [Internet]. Ubccpd.ca. 2014 [cited 2020 May 12]. Available from: https://ubccpd.ca/course/safe-surgical-care
  2. Infection Prevention and Control (IPC) Protocol for Surgical Procedures During COVID-19: Adult [Internet]. 2020 [cited 2020 May 13]. Available from: http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID19_IPCProtocolSurgicalProceduresAdult.pdf 

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.