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

Clinical Issues and Guidance

Collection of Elective Case Triage Guidelines

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.

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

Developed by the American College of Surgeons, American Society of Anesthesiologists, and Association of periOperative Registered Nurses.

The COVID-19 crisis is requiring hospitals and ambulatory surgery centers throughout the country to defer nonessential surgery to preserve personal protective equipment (PPE), protect the safety of health care professionals, and allocate potentially scarce resources for the care of the COVID-19 patient. In the past week, the American College of Surgeons (ACS) and the U.S. Department of Health and Human Services have promulgated guidance for postponement of elective, nonessential surgery. Implementation has varied from community to community based on health care resources, disease spread in the community, and patient need. National guidance is needed.

To serve as a resource for decision making, the ACS, in conjunction with the surgical specialty societies has prepared triage criteria. The ACS and the American Society of Anesthesiologists (ASA) recommend that decisions on surgery cases be made on a daily basis, no later than the day before surgery, by a leadership team representing surgery, anesthesiology, and nursing.

A Surgical Review Committee, composed of surgery, anesthesiology, and nursing personnel is essential to provide defined, transparent, and responsive oversight. This committee can lead the development and implementation of guidelines that are fair, transparent, and equitable for the hospital or system in consideration of rapidly evolving local and regional issues.

Recommendations for Managing GI Endoscopy During the COVID-19 Pandemic

An article in Gastrointestinal Endoscopy focuses on a methodology developed at a single academic medical center in Milan, Italy, which supplements other recommendations published by the American College of Surgeons (ACS). Careful management of resources is necessary to ensure that patients’ needs are met while simultaneously protecting surgeons and valuable health care professionals who make successful patient care possible. Optimal use of resources will require an understanding of the COVID-19 threat level in the community, the supply of resources available in the community and the health care facility, and the risk for COVID-19 infection in patients who need surgical care.

The ACS has developed several documents that provide valuable information on managing surgical resources in these challenging times. Suggestions that may prove useful for surgeons and health care facility administrators are as follows:

  • Prepare for the medical needs of a COVID-19 pandemic with an understanding of the community’s incidence and prevalence rate of infection.
  • Map the care pathway for patients with mitigation strategies and early detection for isolation and quarantine. Patients with greater needs should be triaged and appropriately isolated with supportive care. The personnel and bed management require repurposing many of the surgical assets in a delivery system to support patients in extreme need. Ventilation personnel, therapists, intensivists, and others are precious contributors to the success of supportive care. All these efforts for COVID-19 will tap into the assets often used in surgical care. Routine surgical care involves a team of providers across a care continuum. These highly specialized providers may prove crucial to the COVID-19 care team. Surgical assets to consider include preoperative support, perioperative nurses, post-anesthesia care units (PACU), intensive care unit (ICU) care teams, anesthesia, and surgeons.
  • Set local policies/guidelines for minimizing elective cases. Communication and leadership are paramount. Having a multi-perspective, organized approach with an identified leader(s) or management leadership team to adjudicate decisions may prove helpful.

The article emphasizes that human-to-human transmission of COVID-19 often occurs through contact with aerosol droplets and can be recovered from feces. These observations confirm that gastrointestinal endoscopy units will be areas where the risk of infection transmission is significant. Data cited in the article show an increased risk for droplet deposits on the faces of health care personnel during endoscopic procedures. These data support the use of personal protective equipment as recommended by the World Health Organization and the Centers for Disease Control and Prevention.

The authors present a summary of the definition of COVID-19 contacts and stress the importance of a telephone interview with the patient the day before the procedure to determine the presence of symptoms that may warrant testing for infection. A description of the types of protective equipment that will be worn by all personnel in the endoscopy examination area is provided.

The Use of Hydroxychloroquine to Treat or Prevent COVID-19

Infectious disease specialists and pharmacists at Penn Medicine, Philadelphia, are developing prescribing recommendations for the use of hydroxychloroquine and azithromycin for the treatment of COVID-19. They have found limited evidence to suggest that it is an effective treatment, and no scientific evidence supports using hydroxychloroquine and azithromycin for prevention. The American College of Surgeons advises against prescribing or self-prescribing hydroxychloroquine for prevention or personal use. There is a national shortage, and hospitals need to maintain their supply for treating patients with lupus. Remember, the best prevention is frequent handwashing, avoiding touching your face, covering coughs and sneezes, social distancing of at least six feet, and cleaning and disinfecting surfaces at work and home. For additional discussion of this topic, see the CDC’s information on therapeutic options. 

CDC Issues Guidelines Regarding Health Care Professional Exposure to COVID-19

The Centers for Disease Control and Prevention (CDC) has issued guidelines regarding health care professional exposure to COVID-19. The key elements that affect surgeons are the definitions of close contact, whether the patient was wearing a facemask, whether the patient has tested positive for COVID-19, and the personal protective equipment (PPE) that the health care professional is wearing. The site provides definitions of close contact, but pertinent to surgeons is the possibility of aerosolization during an event in which the surgeon might have been exposed (cardiopulmonary resuscitation, intubation, extubation, bronchoscopy, nebulizer treatments, sputum production).

The next question is how long the professional needs to be isolated and what type of monitoring (self or active) is required. These are determined by risk level of the exposure (high, medium, or low). High-level and some medium-level exposures require 14 days restriction from work with active monitoring. Low-level exposures may only require restriction for 14 days with self-monitoring.

For patients under investigation (PUI), exposure requires restriction from work until the COVID-19 status of the patient is determined—usually 24–72 hours.

Use of PPE recommended is gown, gloves, N-95 mask, and eye protection. Although N-95 masks are recommended, even non-N-95 masks lower the risk of exposure, according to the CDC guidelines.

Despite all such precautions, community exposure and travel remain a possible cause of health care worker exposure. Therefore, all health care professionals should be self-monitoring for early symptoms, immediately report symptoms, and stay home if such symptoms arise.

Two Studies Under Way to Inform Management of COVID-19 Patients

CovidSurg, an international collaboration of surgeons and anesthetists who are capturing real-world data and sharing international experience to support the management of surgical patients during the COVID-19 pandemic, has undertaken two new studies.

The CovidSurg Hospital Resource Study focuses on rates of cancellation of elective surgery because of COVID-19 and shifts in the management of patients with appendicitis. Responses will used to estimate likely numbers of canceled elective procedures, by specialty, for each country in the world and to inform future surgical policy and practice as the pandemic evolves.

The CovidSurg-Cancer study is designed to determine the frequency of hospital-acquired COVID-19 infection in elective surgery, the impact of COVID-19 infection on outcomes, and delays to elective cancer surgery caused by the pandemic and consequent impact on oncological outcomes. Participating centers will be able to choose to collect data on one or more of the following patient groups: breast cancer, colorectal cancer, and gastric cancer. Join the CovidSurg platform.

Royal Colleges of Surgeons Issue Guidance for Managing COVID-19 Patients

The surgical royal colleges of the U.K. and Ireland have published guidance for surgeons working during the COVID-19 pandemic, which offers advice on how to plan, train, and prepare for the challenge of treating patients who may have or have tested positive for the virus. The surgical royal colleges have stated that the overarching principles should be to triage and deliver health care to patients for maximal benefit, as in a mass casualty scenario, and to protect and preserve the surgical workforce.

The guidance sets out the following key priorities for surgery during the pandemic:

  • Maintain emergency surgery capabilities
  • Protect and preserve the surgical workforce
  • Fulfill alternate surgical roles
  • Fulfill alternate non-surgical roles

The guidance is jointly issued by the Royal College of Surgeons of England, the Royal College of Surgeons of Edinburgh, the Royal College of Physicians and Surgeons of Glasgow, and the Royal College of Surgeons in Ireland.