Introduction
The COVID-19 pandemic has certainly been an unprecedented time. We have had to halt
and modify our lives on a local, national, and international level and cooperate to
fight this “invisible enemy” in every sector (medical, governmental, industrial, economic,
educational, and social). Our immediate action in AAGL has been to organize weekly
webinars on subjects related to the pandemic and unite with 8 other professional women's
health care societies to provide joint statements that guide our membership and others
to expand their knowledge and optimize patient care during the COVID-19 crisis. This
international and multidisciplinary collaboration with surgeons and medical specialists
at the leading edge of the pandemic course has been an invaluable resource for global
health care providers who are at earlier points on the COVID curve.
COVID-19 preparedness has required flexibility due to lack of diagnostic tools to
accurately detect all viral carriers and absence of effective viral therapy. Most
gynecologists have halted the majority of “non-essential” office and surgical procedures
in an effort to protect and mitigate risk for all patients and caregivers, preserve
personal protective equipment (PPE), and maintain facility capacity for a surge in
COVID-19 cases. Joint statements from the American College of Surgeons and the consortium
of 9 women's health care societies have provided guidance for resuming surgical practice
and reintroducing elective procedures [1-2]. This special article provides further
detailed information necessary for successful surgical and clinical reactivation for
elective procedures during the COVID Era while the SARS-CoV-2 virus remains a viable
threat.
Economic Impact of COVID-19 in Healthcare
Financial issues impact the reopening of elective surgical services during the COVID-19
pandemic. Decreased surgical volume has led to a widespread and immediate revenue
loss on physicians and surgeons in private practice. The loss of volume has a projected
longer-term impact on physicians employed by larger groups or institutions and on
the facilities themselves.
Disruption of the supply chain also limits return to normalcy. PPE is in high demand,
and some small centers are unable to order supplies due to allocation of PPE to large
hospitals and to areas with higher infection density. Long-term ventilator use has
created a national shortage on medications such as opiates and paralytic agents. While
hospitals and ambulatory surgical centers are slowly booking surgical cases, the limited
supplies, longer room turnover times, and backlogs of cases are projected to lead
to salary reductions, layoffs, and financial distress.
Timing for Reactivation of Non-essential Office and Surgical Procedures
Multiple factors influence the timing of reactivation for non-essential surgery. The
burden on the healthcare system and reserve capacity limit reactivation of non-essential
office and surgical procedures. Chinese data suggest that an appropriate level of
hospital resources must be preserved to care for patients with COVID-19 related illness.
The mortality of COVID-19 in Wuhan, where preparedness was not feasible for obvious
reasons, was five times higher than in the rest of continental China, where advanced
planning made resources more widely available and the hospital systems were not overwhelmed
[3].
Social distancing of patients and health care workers to limit viral transmission
is another factor in determining the timing of re-entry. Primary care consults increase
the proximity and circulation of healthcare professionals and patients, which in turn
facilitates viral spread. Such visits have, so far, been deferred for being seen as
non-essential in the short term in order to decrease the dissemination of the virus[4].
Conversely, empty hospitals risk bankruptcy before demand comes; furloughed healthcare
professionals are already the second most in need of unemployment insurance in some
areas[4]. Therefore, a precise modelling method for the pandemic progression is urgently
needed. Real time modelling of the COVID instantaneous reproduction rate [3] is essential
to predict the curve in the short term and anticipate the need for healthcare resources,
preparing for a likely second wave [5]. Adequate modeling and widespread testing allowed
for Germany to minimize COVID-19 mortality rates and its impact on the economy [6].
Likewise, with good strategy, institutions have the ability to increase non-COVID
care and reactivate elective surgical practice and office procedures. In that sense,
timing for resuming elective surgical and clinical care should be determined and monitored
by a committee of local authorities, clinical leaders, and hospital administration
to assess local viral prevalence, regional success of “flattening the curve,” testing
capability, non-COVID care capacity, and PPE supply chain.
Experience in continental China shows that a second wave is almost inevitable [3,5].
Consequently, careful planning of healthcare resources should take into account a
good safety margin for institutional functional reserve. Therefore, local medical
and governmental authorities must collaborate to continuously monitor the pandemic's
local reproduction rate, determine the hospital's reserve capacity, and develop modelling
strategies to continually guide opening, closing, accelerating, or reducing elective
clinical and surgical activity.
Case prioritization and scheduling
Surgery is considered "elective" or “non-essential” in patients with chronic problems
when the procedure can be delayed without significant harm to the patient and without
significant change in the prognosis. Although the need for surgery is debatable when
pain or functional impairment detracts from quality of life, the determining principle
for non-essential surgery is that delay of treatment does not significantly impact
clinical outcomes [7].With this in mind, successful reactivation requires clear prioritization
criteria aimed to ensure resource optimization and service to the most patients possible.
Therefore, during re-entry, outpatient or same-day procedures should be favored over
more complex cases in order to preserve hospital resources and decrease the risk of
patient exposure. Table 1
summarizes our suggested prioritization scoring system, adapted from Prachand [8].
In this system, the lower the score the higher the priority.
Table 1-
Suggested prioritization criteria (adapted from Prachand et al, 2020)
Table 1-
Procedure Factors
Score
1
2
3
4
5
OR time (min)
<30
31-30
61-120
121-180
≥180
Estimated LOS
Outpatient
<24h
24-48h
2-3d
≥4d
Risk of Postoperative ICU
Very unlikely
<5%
5%-10%
>10%-25%
>25%
Anticipated blood loss (mL)
<100
100-250
250-500
500-750
>750
Surgical team size (n)
1
2
3
4
>4
Intubation probability (%)
<
1-5
6-10
11-25
>25
Surgical site/access
None of the following
Abdominopelvic MIS
Abdominopelvic open surgery, infraumbilical
Abdominopelvic open surgery, supraumbilical
OHNS/upper GI/thoracic
Disease Factors
Nonoperative option effectiveness
None available
Available, <40% as effective as surgery
Available, 40% to 60% as effective as surgery
Available, 61% to 95% as effective as surgery.
Available, 96% to ass effective as surgery
Nonoperative treatment option resource/ exposure risk
Significantly worse/not applicable
Somewhat worse
Equivalent
Somewhat better
Significantly better
Impact of 2-wk delay in treatment outcome
Significantly worse
Worse
Moderately worse
Slightly worse
No worse
Impact of 2-wk delay in surgical difficulty/risk
Significantly worse
Worse
Moderately worse
Slightly worse
No worse
Impact of 6-wk delay in treatment outcome
Significantly worse
Worse
Moderately worse
Slightly worse
No worse
Impact of 6-wk delay in surgical difficulty/risk
Significantly worse
Worse
Moderately worse
Slightly worse
No worse
Patient Factors
Age (yrs)
≤20
21-40
41-50
51-65
>65
Lung disease (asthma, COPD, CF)
None
–
–
Minimal (rare inhaler)
> Minimal
Obstructive sleep apnea
Not present
–
–
Mild/Moderate (no CPAP)
On CPAP
CV Disease (HTN, CHF, CAD)
None
Minimal (no meds)
Mild (1 med)
Moderate (2 meds)
Severe (≥3 meds)
Diabetes
None
–
Mild (no meds)
Moderate (PO meds only)
> Moderate (insulin)
Immunocompromised*
No
–
–
Moderate
Severe
ILI symptoms (fever, cough, sore throat, body aches, diarrhea)
None (Asymptomatic)
–
–
–
Yes
Exposure to known COVID-19 positive person in past 14 days
No
Probably not
Possibly
Probably
Yes
⁎
Hematologic malignancy, stem cell transplant, solid organ transplant, active/recent
cytotoxic chemotherapy, anti-TNFa or other immunosuppressants, >20 mg prednisone equivalent/day,
congenital immunodeficiency, hypogammaglobulinemia on intravenous immunoglobulin,
AIDS. CAD, coronary artery disease; CF, cystic fibrosis; CHF, congestive heart failure;
COVID-19, novel coronavirus; CPAP, continuous positive airway pressure; CV, cardiovascular;
HTN, hypertension; ILI, influenza-like illness; med, medication; PO, by mouth;GI,gastrointestinal;LOS,lengthofstay;MIS,minimallyinvasivesurgery;OHNS,otolaryngology,head&necksurgery;OR,operatingroom
Surgical expertise also contributes to mitigation of risk, with shorter operating
times, fewer complications, and fewer readmissions observed in high volume centers
[9,10,11]. Therefore, the ideal prioritization for allocation of operating room resources
involves high volume surgical teams with limited learners performing primarily minimally
invasive outpatient procedures [12]. Conservative management and postponement of surgery,
when applicable, should be mandatory during the reactivation process, in order to
allow for prioritized surgical treatment of those who have already failed non-surgical
alternatives.
Recommendations for Phases of Surgical Care
All caregivers and healthcare systems will have to learn how to co-exist with COVID
once the decision is made to resume clinical and surgical practice. Therefore, specific
considerations apply to each phase of perioperative care.
Preoperative Phase
All patients who decide to proceed with surgery must be informed that there is a risk
of contracting COVID-19 as a nosocomial infection, resulting in greater morbidity
and mortality (see below). Advanced directives and post-surgery rehabilitation should
be discussed virtually so that the appropriate forms, paperwork, and pre-authorizations
are completed. Institutions can consider electronic signatures and verbal consents,
and all details should be documented in the electronic medical record. In institutions
that require signature by written paper consent, signatures should be obtained upon
admission to avoid non-essential in-person visits.
Processes to minimize interpersonal contact are essential during preoperative care.
Only strictly essential in-person interactions should be permitted in order to mitigate
risks for both patients and caregivers. Preoperative requirements should be streamlined
so that the majority of steps are accomplished by physician extenders using distance
healthcare or online tools. Preoperative education should not require face-to-face
interaction. While local guidelines may vary, US federal guidelines allow the preoperative
history to be performed virtually within 30 days of a procedure, and an updated physical
examination can be performed at the time of pre-anesthesia care unit admission.
When in-person consultations are unavoidable, patient care areas should be disinfected
immediately after use. Thorough disinfection is important because the SARS CoV-2 virus
can be transmitted by respiratory aerosol droplets, close contact, and fecal-oral
transmission. Therefore, extra time should be allotted per visit to allow for sanitizing
work areas and patient rooms after each patient visit. The facility waiting rooms
and examination rooms should be reorganized to optimize social distancing. Patient
check-in should be done by smartphone, smart devices, or kiosks that are far from
the person assisting at the front desk, and appropriate PPE and/or aerosolization
barriers should be used to separate health care personnel and patients. Screening
questions should be routinely utilized to identify COVID-19 symptoms.
If a patient screens positive for COVID-19 symptoms, she is directed to local COVID-specific
clinics (see section on recommended testing below). Laboratory testing should be consolidated
to decrease unnecessary patient exposure during lab visits, and preoperative laboratory
tests can be drawn at the time of COVID-specific testing. If available, patient-administered
tests to rule out COVID can be obtained at home so that the patient's COVID status
is known prior to obtaining preoperative labs [13]. A useful algorithm for preoperative
decision making is demonstrated in Figure 1
. [14]
Figure 1
– COVID-19 Preoperative Surgery Decision Tree (Courtesy of Cleveland Clinic[14])
Figure 1
Immediate Preoperative and Intraoperative Phases
After preoperative procedures have ruled out COVID just prior to surgery (see below),
the patient may proceed to scheduled surgery. The number of support people accompanying
the patient should be limited to one individual if institutional policy allows. This
support individual is required to wear a mask and maintain social distancing etiquette.
In certain hospitals where patient support people are forbidden, patient status updates
are reported by phone or another telecommunication process.
Enhanced Recovery after Surgery (ERAS) [15] protocols should be utilized to optimize
intraoperative and postoperative courses. Preoperative and intraoperative surgical
checklists should be modified using COVID-19 precautions.
Providers should employ the equipment deemed appropriate by their respective institutions.
It is recommended that anyone working in the operating room utilize full PPE, which
includes shoe covers, impermeable gowns, surgical or N-95 masks, protective head covering,
gloves, and eye protection. [16]
In the operating room and during surgery, considerations should include air flow and
containment or reduction of personnel exposure to respiratory droplets during intubation
and extubation. Considerations include using the “intubation box” originally designed
by Dr. Hsien Yung Lai in Taiwan [17]; the design is now available in the US [18] and
was recently been shown to be a viable solution for reduction of respiratory droplet
exposure [19].
In addition, movement of personnel in and out of the operating room should be strictly
limited, with efforts made to limit staff breaks mid-case when possible. Trainee participation
should be limited and include only personnel essential to the safe performance of
the operation in order to avoid exposure and preserve PPE resources [12].
Theoretical concerns pertain to operative technique and relate to viral contamination
in the operative field from the smoke plume generated by electrosurgery. Viral particles
have been reported in the aerosolized smoke plume created in electrosurgery and the
tools and techniques used in surgery can create particles of various sizes [20-23].
While smoke filtration and evacuation are highly recommended during surgery as part
of risk mitigation technique, most smoke evacuators remove up to 88% of small particles.
To further reduce the aerosolization risk of viral particles (20-360nm), use of active
suction is recommended prior to tissue removal, port exchange, and for desufflation
at the conclusion of laparoscopic surgery. In addition, electrostatic charging of
the peritoneal cavity can precipitate over 99% of particulate matter ranging from
7nm-10um in diameter. Such systems deliver a negative electrostatic charge from an
ion wand to generate precipitation (e.g. Ultravision®, Alesi Surgical®). This combination
of techniques may be considered for maximum risk mitigation.
Postoperative and Post-discharge Phases
Optimal facility design incorporates separation of recovery areas for COVID-positive
and COVID-negative patients. ERAS protocols should be carried out to optimize same
day discharge. A follow up plan should include standardized surveillance and use of
distance health, or telemedicine. Patients should not require a face to face visit
unless there are complications that require physical examination. COVID home monitoring
programs should be used as deemed appropriate; these include: automated thermometers,
blood pressure monitors, oximeters, and/or smart device innovations [24]. Patients
who have COVID-positive family members should quarantine themselves in local facilities.
Some institutions provide such housing opportunities for patients and/or caregivers.
Recommended COVID 19 testing within various facilities based on timing of procedures
Data from apparent COVID-negative patients after elective surgery suggests that advanced
age, comorbidities, surgical time, and surgical complexity may be risk factors for
poor prognosis in the event of postoperative development of SARS-CoV2. Such patients
are at greater risk of ICU admission (44% vs 26%) than paired patients who did not
undergo surgery [25]. Therefore, adequate preoperative screening and diagnosis of
COVID-19 infection is essential for the success of any surgical reactivation program.
In areas with more than 40 active cases / 100 thousand inhabitants * (see observation
at the end of chapter), we suggest that all patients planning to undergo surgery should
have a diagnostic test for COVID-19 up to 72 hours before surgery and be quarantined
until the time of hospital admission.
The RT-PCR test is considered the gold standard for the diagnosis of COVID-19. In
clinical practice its specificity varies between 93% and 98%, but sensitivity can
vary significantly from 63% to almost 100%, depending on the prevalence, onset of
symptoms, viral dynamics, collection method of the clinical specimen, and transport
media [26, 27]. Therefore, the positive and negative predictive value of RT-PCR is
high for symptomatic patients, but its accuracy may be limited in asymptomatic patients.
Other methods that can be used for the diagnosis of COVID-19 include detection of
IgA, IgG, and IgM antibodies by enzyme-linked immunosorbent assay (ELISA) and immunochromatography.
Initial validation demonstrates a high positive predictive value. The presence of
IgG antibodies confirms previous COVID-19 disease [28], suggesting that serological
IgG testing may be useful for screening, but not triage for surgery. To date, no data
exist that positive IgG antibodies confer lasting immunity to SARS CoV-2.
There is no formal indication for chest tomography (CT) as a screening method in asymptomatic
patients. However, some COVID-free institutions in Europe and China recommend its
use in exceptional situations in high prevalence areas, based on the capability for
diagnosis in 54% of asymptomatic cases [29]. Chest CT performed up to 24 hours prior
to hospitalization is therefore considered an option when more accurate tests are
not available.
If surgery is considered mandatory and diagnostic tests are neither available nor
reliable, the patient may be quarantined for 14 days prior to surgery (if possible).
This recommendation is based on the CDC statement that the incubation period of SARS-CoV-2
and other coronaviruses ranges from 2–14 days[30]. For this strategy to work, patients
need to comply with self-isolation and be instructed regarding development of symptoms.
If the patient is asymptomatic and tests negative for COVID-19, surgery can be performed
with the use of conventional PPE by the surgical team[31]. Guidelines for protection
should follow individual institutional standards developed in conjunction with the
infection control team. If the patient is symptomatic or has a positive RT-PCR, IgM
antibody, or chest CT findings consistent with COVID, the procedure must be postponed,
and the patient should be referred based on institutional COVID diagnostic and treatment
protocols. Surgical rescheduling should require clinical improvement, normalization
of chest CT scan, and two negative RT-PCR tests to confirm resolution[32]. Finally,
if RT-PCR, rapid serological testing, or chest CT are not available, elective surgery
should only be considered if regional prevalence is less than 40 active cases / 100
thousand inhabitants. In this case, guidelines for the use of PPE should be the same
as for COVID-19 positive patients.
Regarding concerns about a resurgence of COVID-19, it is imperative that a centralized
monitoring system collects data on the number of COVID-positive, asymptomatic patients
in a large healthcare system or defined geographical area. Any rise in the number
of asymptomatic COVID-positive individuals among elective surgery patients could be
a sign of an impending second wave of COVID-19. It is well known that asymptomatic
and pre-symptomatic patients are a major source of community transmission. [34,35]
According to Robert Redfield, the director of the Centers for Disease Control and
Prevention, 25 percent of people infected with SARS CoV-2 are asymptomatic; however,
they can still transmit the illness to others.[36]
Control of COVID-19 is a dynamic and fluid process. Institutions must be flexible
in responding and implementing changes in strategies based on the most current assessment
of disease prevalence in the community. As we resume non-essential surgeries, we must
be cognizant of the need to adjust and adapt according to the disease burden in the
community. As prevalence of COVID-19 decreases in the community, a standardized epidemiological
screening questionnaire should be conducted at a minimum. If the epidemiological questionnaire
is positive, a RT-PCR and a chest CT can be performed.[29,31] Some countries are employing
novel population-based techniques, such as QR code scanning, to facilitate detection
of patient exposure to COVID and contact tracing [37].
Financial support to mitigate the impact of reduced surgical volumes
Despite the strategies summarized above, the revenue generated by healthcare systems
is anticipated to remain at much lower levels than usual due to the mandated halting
of non-essential procedures. While reactivation will achieve some normalcy, a second
or third wave of viral infection may further decrease revenue generation. Therefore,
knowledge of available financial support programs is paramount to ensuring the survival
of surgical services.
In the United States, the Coronavirus Aid, Relief, and Economic Securities (CARES)
Act includes multiple lending programs for physicians and businesses treating patients.
These lending programs include the Small Business Association (SBA) Payroll Protection
Plan (PPP), Economic Injury Disaster Loans (EIDL), and Department of Health and Human
Services (HHS) relief. These programs are summarized on the American Medical Association's
website[38].
Businesses with under 500 employees can apply for relief in a forgivable interest-free
loan when the funds are used per SBA guidelines. Many physicians in private practice,
small group settings, and large group settings qualify for such relief [39].
As surgeons and facilities move toward the “new normal” of pandemic recovery, the
number of unemployed workers in the US and abroad will undoubtedly have an impact
on insurance coverage. Insurance companies and hospitals will be looking for relief
and will be forced to find ways to offset the profound economic implications brought
on by the costs associated with COVID-19. It is imperative for physicians everywhere
to gain an awareness of these issues and prepare for potential impact on revenue,
salary, and job security.
Conclusion
In our lifetime, the practice of medicine has never been altered to the extent imposed
by the COVID-19 pandemic. We, as surgeons, have had to rise up to many challenges
in order to meet the needs of our patients while mitigating risk to all those involved
in their care. The postponement of non-essential surgical procedures in order to preserve
resources has created back logs in our practices that we must address as we co-exist
with COVID. The AAGL has forged important collaborations among national and international
experts and societies to educate caregivers worldwide during this unprecedented time.
This article should serve as a supplemental guide for effective reactivation to clinical
and surgical practice to optimize care for the women whom we serve.
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