American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Introduction

What we are currently facing...
The Coronavirus Disease 2019 (COVID-19) outbreak continues to challenge our nation. Expert projections estimate that despite social distancing being practiced (albeit suboptimally in certain places), we have yet to feel the full impact of COVID-19. We as surgeons need to help prepare locally for the potential increase in COVID-19 patients.

Things are changing daily. In the coming weeks, COVID-19 rates are expected to begin skyrocketing and hit a peak in late April/May/June given lessons learned from China, Italy, and others. There will be variability in rates, peaks, and timing, and while at this time we cannot accurately predict many aspects, we all should be preparing.

In this regard, we continue to recommend that surgeons curtail the performance of “elective” surgical procedures. The ACS is receiving reports that most surgeons are in the process of or have already stopped performing elective operations. Thank you.

The goal of these twice-weekly ACS newsletters is to iteratively update information, data, and recommendations. A common issue with which many are confronted is identifying which procedures should be curtailed. To this end, we are including guidelines from various specialties, facilities, and thought leaders to help inform the decision making occurring at the local level.

The guidelines include

Some overarching principles for all cases include the following:

  1. Be aware that while some of the following triaging guidelines include a “Level 1” (e.g., lowest level of COVID-19 acuity) in the recommendations, one must be aware that the rates of COVID-19 are predicted to skyrocket in the next few weeks, and the overarching recommendation is to prepare for markedly increased rates when triaging elective cases at present.
  2. Patients should receive appropriate and timely surgical care, including operative management, based on sound surgical judgment and availability of resources.
  3. Consider nonoperative management whenever it is clinically appropriate for the patient.
  4. Consider waiting on results of COVID-19 testing in patients who may be infected.
  5. Avoid emergency surgical procedures at night when possible due to limited team staffing.
  6. Aerosol generating procedures (AGPs) increase risk to the health care worker but may not be avoidable. For patients who are or may be infected, AGPs should only be performed while wearing full PPE including an N95 mask or powered, air-purifying respirator (PAPR) that has been designed for the OR. Examples of known and possible AGPs include:
    1. Intubation, extubation, bag masking, bronchoscopy, chest tubes
    2. Electrocautery of blood, gastrointestinal tissue, any body fluids
    3. Laparoscopy/endoscopy
  7. There are insufficient data to recommend for/against an open versus laparoscopy approach; however, the surgical team should choose an approach that minimizes OR time and maximizes safety for both patients and healthcare staff. Refer to to Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines for these patients.

Also view: Create a Surgical Review Committee for COVID-19-Related Surgical Triage Decision Making