Local Resumption of Elective Surgery Guidance
Local Resumption of Elective Surgery Guidance
Local Resumption of Elective Surgery Guidance
Introduction
In order to focus local resources on managing the new coronavirus (COVID-19) pandemic,
“elective” surgery has been largely postponed and stopped. As the COVID-19 rates have already
reached their peaks, or will do so over the next week or two (depending on location), the
current focus for an increasing number of facilities is toward “ramping up” to prepare for
elective operations.
The current document offers a set of principles and issues to help local facilities plan for
resumption of elective surgical care.
While the effect of the COVID-19 pandemic on local communities or facilities is a spectrum,
we suggest facilities use this checklist as a guide to ensure issues have at least been
considered. Understanding both the local facility capabilities (e.g., beds, testing, operating
rooms [ORs]) as well as potential constraints (e.g., workforce, supply chain), while keeping an
eye on potential subsequent waves of COVID-19 will continue to be important.
Within the categories of I. COVID-19 Awareness, II. Preparedness, III. Patient Issues, and IV.
Delivery of Safe High-Quality Care, there are 10 distinct issues to be addressed locally before
elective surgery may be safely reinstituted. Evaluating and addressing each of these 10 issues
will help facilities to not only optimally provide safe and high-quality surgical patient care, but
also to ensure that surgery resumes, and doesn’t stop again.
Document Sections
I. COVID-19 AWARENESS
1. Know your community’s COVID-19 numbers, including prevalence, incidence, and
isolation mandates
2. Know your COVID-19 diagnostic testing availability and policies for patients and
health care workers
II. PREPAREDNESS
3. Promulgate personal protection equipment (PPE) policies for your health care
workers
4. Know your health care facility capacity (beds, intensive care units (ICUs),
ventilators), including expansion plans (e.g., weekends)
5. Ensure OR supply chain/support areas
6. Address workforce staffing issues
7. Assign a governance committee
III. PATIENT ISSUES
8. Patient communication
9. Prioritization protocol/plan
IV. DELIVERY OF SAFE AND HIGH-QUALITY CARE
10. Ensuring safe, high-quality, high-value care of the surgical patient across the Five
Phases of Care continuum
I. COVID-19 AWARENESS
1. KNOW YOUR RATES: Knowing your community’s COVID-19 numbers, including
prevalence and incidence rates, as well as local isolation mandates, will help dictate
timing of ramp up.
• The 75th percentile of the incubation period prior to developing symptoms of
COVID-19 is seven days, and the maximum estimated incubation period is
approximately 14 days. Thus, it has been recommended that a decrease in measures
of COVID-19 incidence for at least 14 days should be considered before
transitioning to provide surgical services for patients without immediately life- or
limb-threatening conditions. A Roadmap to Reopening reference is provided.
• Once the COVID-19 crisis has been mitigated locally, it is still vital to continually
know the latest local COVID-19 rates (such as incidence rates of new cases, as well
as hospitalizations), particularly as there is a threat of subsequent waves of COVID-
19 infection regardless of whether isolation/physical distancing mandates are
reversed.
• Consider defining specific criteria and/or a threshold COVID-19 incidence rate for a
re-entering mitigation phase in the facility if COVID-19 rates locally resurge.
• Ensure compliance with state or local community executive orders and regulations.
II. Preparedness
3. PERSONAL PROTECTIVE EQUIPMENT: Know your local PPE availability and developing
policies for your health care workers and procedures.
• Sustaining a productive workforce while ramping-up surgical cases requires
adequate PPE availability and the continued adherence to protocols established to
protect workers from virus exposure.
• PPE supplies: Stored inventory—or a reliable supply chain—of PPE for both
airborne/aerosol and droplet/contact precautions optimally for at least 30 days of
operations should exist in a hospital prior to relaxing restrictions on surgical activity.
• A Centers for Disease Control (CDC) PPE calculator is provided as an example for
determining supply needs.
• PPE guidelines should include PPE recommendations for COVID-19+, PUI, and non-
COVID-19 patients for all patient care, including high-risk procedures (e.g.,
intubation, chest tubes, tracheostomy).
• Consistent with CDC and Centers for Medicare & Medicaid (CMS) recommendations
for PPEs outside the OR, facilities may consider having all health care workers and
staff wear appropriate-level PPE, while patients wear cloth masks during the ramp-
up period, and possibly beyond.
4. LOCAL FACILITY CAPACITY: Know your health care facility capacity (e.g., beds, ICUs,
ventilators), including capacity in expansion strategies (e.g., weekends).
• The approach to restoring the elective surgery caseload depends greatly on the
hospital's available resources, including OR capacity and alternative sites of care.
Sufficient facility capacity for providing care to surgical patients must be present in
the system, including—in addition to ORs and peri-anesthesia units—critical care,
emergency, diagnostic imaging, and laboratory services.
• Consider potential sites for resuming elective surgery, including those facility areas
that were converted or closed during the surge, such as ORs, ambulatory surgery
centers, and hospital outpatient departments.
• Facility cleaning policies in context of COVID-19 should be considered. Cleaning—in
all areas—along the continuum of care should be addressed (e.g., clinic,
preoperative, ORs, workrooms, path-frozen, recovery room, wards, ICUs, ventilators,
scopes, etc.).
• Certain select procedures may be appropriate for the office setting as long as safety
concerns are identified and addressed.
• Collaboration and coordination of timing and site designation among clinically
integrated networks, Accountable Care Organizations, and other key partners may
accelerate the scaling of surgical activity.
• The OR schedules should change to accommodate the rapid influx of cases.
Modifications may include limiting block time assignments to increase open time
and extending hours of elective operations later into the evening and on the
weekends. Rooms may be outfitted with new equipment to expand the capacity for
specific procedures. Scheduling cases according to priority and grouping like cases
together may increase scheduling efficiency.
• Ensure that a post-corona elective surgery surge will not overwhelm the local facility
throughout preoperative, intraoperative, postoperative, and post-acute care phases.
• Other areas of the hospital that support perioperative services must be ready to
commence operations, including the clinical laboratory, diagnostic imaging, and
sterile processing. If these areas are not ready, it may be feasible to consider
engaging outside partners in providing temporary support, such as national
laboratory services.
• Facility capacity and expansion should include estimating the anticipated demand.
• Need to consider numbers of canceled/postponed patients.
• Need to consider facility capacity for usual levels of emergency care, trauma care,
and others.
• Engineering issues (e.g., reversing negative flow ORs for COVID-19 to positive flow
ORs for surgery).