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

Clinical Issues and Guidance

Updated Emergency General Surgery Guidelines Released

The American College of Surgeons has posted updated COVID-19 Guidelines for Triage of Emergency General Surgery Patients. The goal of the guidelines is to provide timely surgical care to patients presenting with urgent and emergent surgical conditions while optimizing patient care resources (such as hospital and intensive care unit beds, personal protective equipment, ventilators) and preserving the health of caregivers.

CAGS Issues Recommendations to Reduce the Risk of Aerosolization During Laparoscopy

The Canadian Association of General Surgeons (CAGS) Minimally Invasive Surgery Committee has developed a directive to prevent the risk of aerosolization of viruses during laparoscopy. The CAGS committee recommends that surgeons use a closed filtration system during laparoscopy and for evacuation of the pneumoperitoneum at the end of the case as resources and availability allow. Many commercial filtration systems reportedly can filter more than 99.9 percent of particles as small as 0.08 to 0.1 microns in diameter. These particles exceed the N95 designation, which requires that at least 95 percent of small particles (0.3 microns) be filtered. The use of laparoscopy should be based on local current standards of practice and are outside the scope of these recommendations.

CAGS further recommends that laparoscopic ports should be inspected for adequate seal prior to use and reassessed frequently for leak while in use. If ports do develop a leak, the seals/ports should be changed immediately when it is safe to do so. The procedural pneumoperitoneum should be set at the lowest pressure that facilitates safe and efficient operative conduct.

Smoke evacuators should be attached to ports that allow for efficient laparoscopy in terms of allowing a clear view of the operator at a rate that minimizes resource/carbon dioxide (CO2) use. If insufflation or evacuator tubing needs to be moved from one port to another, the ports should be set to the closed position before detaching and reattaching the tubing. All ports should remain in situ and closed while desuflation is occurring.

To facilitate efficient desuflation, evacuator tubing should be moved to the most nondependent port, and the patient should be repositioned to allow CO2 removal. Extraction of surgical specimens should occur after the desuflation technique described here is completed. The ports may be left in place and the desuflation procedure repeated If the operating surgeon decides to ‘look back in’ after specimen extraction.

ACS Blue Book Offers Guidance on Management of COVID-19 Hospital Patients

The penetration and rapid spread of COVID-19 throughout the U.S. has presented significant challenges to the day-to-day management of patients infected with this virus, as well as the organization and structure of the health care system needed to manage this pandemic. It's clear that the existing hospital infrastructure is insufficient to deal with the potential number of patients, particularly individuals who require intensive care and ventilator support. The civilian hospital infrastructure will need to develop creative methods to manage these patients as well as the patients who are already in hospitals.

A 1,000-bed hospital has been established in New York, NY, and other portable hospitals are being established in other states and cities. A number of these portable hospitals have been constructed by the Department of Defense (DoD), the Federal Emergency Management Agency, or the National Guard. The operation of the hospital falls under the purview of the state where it is located and the hospital or hospital system that will provide care in the facility. It is possible that there will be military and civilian collaboration in providing care in these hospitals. A portable military facility staffed with a combination of military and civilian medical personnel could offload large civilian trauma centers, making available staff, beds and equipment in those civilian hospital for the care of victims of COVID-19. For such a program to succeed, criteria outlined in the American College of Surgeons (ACS) “Blue Book,” scheduled for release in May, need to be considered. The Blue Book: Military-Civilian Partnerships for Trauma Training, Sustainment, and Readiness, provides guidance on important topics such as institutional commitment, governance and administration, human resources, physical resources, education, and evaluation.

The Blue Book was created under the aegis of the Military Health System Surgery Partnership ACS (MHSSPACS), established in 2014 as collaborative effort between the College and the DoD. The 2017 National Defense Authorization Act established military-civilian partnerships to develop training and sustain essential trauma knowledge and skills to ensure a ready medical and surgical workforce. The MHSSPACS has developed the criteria for the selection and evaluation of military civilian partnerships to effectively provide this training. These criteria are outlined in the Blue Book, which is designed for military readiness and can be easily adapted for the collaboration of civilian and military teams in response to any disaster, including the COVID-19 pandemic. The DoD has approved this document, which will be fully released in May. If you would like to access an advance copy, please reply to this email. If you have any questions, contact Margaret “Peggy” Knudson, MD, FACS, Medical Director, MHSSPACS, at pknudson@facs.org.

DoD Develops COVID-19 Practice Management Guide

A multidisciplinary group of 60 Department of Defense experts has developed the COVID-19 Practice Management Guide to combat the COVID-19 pandemic. The guide consolidates resources and optimizes patient management for clinicians and hospitals, based on the DoD’s latest best practices evidence. Contents of the management guide include planning and preparation, screening and triage, collecting specimens, and managing of the three stages of the COVID-19 virus—mild, severe, and critical. Also included are protocols on treatment and intubation, surgical considerations for special populations, and ethical concerns during COVID-19 patient care. To ensure that the COVID-19 information is timely and accurate, the DoD has been working closely with the U.S. Department of Health and Human Services and State Department to provide support in dealing with the pandemic.

Medical Liability

Many efforts are under way at the state and federal level to provide immunity from liability for health care professionals using telemedicine in response to the COVID-19 federal emergency. New York Gov. Andrew Cuomo issued an Executive Order on the issue. The U.S. Department of Health and Human Services Office of Civil Rights has agreed to exempt the use of telemedicine from Health Insurance Portability and Accountability Act violations providers who use this technology in good faith during the COVID-19 nationwide public health emergency. For more information from the Doctor’s Company click here, and from The Center for Connected Health Policy click here.

Workforce Redeployment

A major concern is redeployment of surgeons and other health care personnel to intensive care units to care for COVID-19 patients. How should surgeons prepare to redeploy given COVID-19, will that happen, and what should they know? Of special concern would be redeployment of pregnant and immunocompromised personnel. Key issues related to redeployment include addressing the backlog of elective surgeries as the virus transmission wanes, financial support, resident education, and staff payroll. 

The Society of Critical Care Medicine offers recommendations for non-critical care specialists who are called upon to care for patients in the ICU, accessible here and here.

Update on Promising Therapeutics

The Food and Drug Administration (FDA) has announced availability of use of convalescent plasma as a single patient emergency investigational new drug application in patients with serious or life-threatening COVID-19 infections. This investigational treatment is based on the use of convalescent plasma collected from recovered COVID-19 patients. It is possible that convalescent plasma contains antibodies to the SARS-Co-V-2 virus that may be effective against established infections. This has been studied in previous outbreaks of other respiratory infections such as H1N1, SARS-CoV-1 and MERS-CoV, though not with uniform effectiveness. This will not be considered for use in prevention of infection.

There is interest in clinical trials in the treatment of COVID-19 infections, as well as in prophylaxis for infection. The National Institutes of Health now has 17 open clinical trials available. Two trials are investigating the use of hydroxychloroquine and three are investigating remdesivir.

One of the pathways thought to be very important in the etiology of the severe and critical stages of COVID-19 is the cytokine storm or cytokine release syndrome mediated through interleukin release. Three approved medicines for the treatment of these storms, which are frequent complications of CAR-T cell therapies for malignancy and work through blockade of IL-6 release, are Actemra (tocilizumab), Kevzara (sarilumab) and Sylvant (siltuximab). The use of tocilizumab has been reported in a small Chinese study to benefit patients with severe manifestations of COVID-19. Clinical trials for the use of these agents for severe disease manifestations are being developed. See Clinical Trials.gov for additional information.

Guide for Protecting Yourself in the OR and Ensuring Your Family’s Well-Being

Increasing information is becoming available regarding protection of health care professionals, including the operation room (OR) team. The American College of Surgeons (ACS) has developed a guide that brings together the latest information, data, and recommendations for personnel in the OR, as well as how to minimize risk of COVID infection afterwards. Of note is a video developed by a physician at Weill-Cornell Medical Center with practical information for frontline healthcare workers. The following topics are covered:

  1. Use of personal protective equipment in the OR, including donning/doffing of the PPE
  2. Intubation risks
  3. Specific operative risk issues
  4. After operation: leaving the OR and leaving the facility

Rural Surgeons Provide Report to ACS Regents

A recently formed task force of the ACS Advisory Council for Rural Surgery has identified areas of concern for rural surgeons and has drafted a report to the Board of Regents. Like all hospitals, the lack of adequate PPE supplies and test kits was at the top of the list. There were accounts of small facilities that were forced to send their already insufficient numbers of masks, gowns and face shields to larger facilities within their system to help with urban surges of COVID-19 patients. Additionally, as the national blood supply dwindles, due to collection delays, rural facilities will feel that shortage the most.

Rural hospitals that have strong physician input are clearly ahead of the curve in preparation compared with facilities where administrators monopolize the planning strategies and actions. Fellows of the ACS have taken the lead in rural America in terms of preparing for the COVID-19 crisis. The flow of information from the College very early in this process facilitated the ability of surgeons to take the lead, even at the expense of limiting their own elective surgical procedures and office visits.

Transfer of patients to larger medical facilities may become very difficult. Rural hospitals will then become “islands” where COVID-19 as well as trauma and complex surgical cases will need to be cared for with very limited resources. Difficult ethical decisions will need to be made in those facilities to determine which patients receive the already limited resources.

Transition to telemedicine for office and clinic visits has been much easier in urban centers than in rural locations with limited access to broadband Internet and elderly populations with little digital experience.

Preparing for a large surge of COVID-19 patients, while still having to care for other acute medical issues, is a real problem in small community facilities. Many critical access hospitals have only one or two ventilators or the only ones might be the ones used in the operating room. Critical care beds and experienced nursing and respiratory technicians to staff them are in very short supply in rural areas and would not be able to cover very ill patients on a 24/7 basis, especially if these key team members become ill with the virus. Conceivably, one physician could be the sole provider for a facility with a full census leaving the entire facility at risk if that physician becomes ill. To read the full report, click here.

Tracheotomy Recommendations During the COVID-19 Pandemic

The Airway and Swallowing Committee of the American Academy of Otolaryngology-Head and Neck Surgery issued recommendations that focus on patient and health care team well-being during the COVID-19 pandemic with minimization of risk, viral exposure, and PPE depletion. View the recommendations.

ASPS Issues Statement on Breast Reconstruction

The American Society of Plastic Surgeons (ASPS) has issued a Statement on Breast Reconstruction in the Face of COVID-19 Pandemic. The statement calls for postponement of delayed breast reconstruction and planned secondary or revision breast reconstruction until the system in your area can accommodate elective surgery. To help conserve reserve resources, immediate reconstruction procedures should be performed with the informed consent of the patient and should be delayed whenever possible. If breast operations are medically necessary to ensure a positive outcome, the ASPS recommends the use of regional blocks to facilitate same-day discharge and minimizing the number of people in the operating room to decrease risk of exposure as well as decrease personal protective equipment use.

Royal Colleges of Surgeons Issue Updated Guidance

The royal colleges of surgeons of the U.K. and in Ireland have updated the guidance on surgical care during the COVID-19 pandemic mentioned in the last of issue of this newsletter. This current document features new directives as further information has now emerged from the U.K. and Ireland government, Italy and China. The new guidance stresses that surgeons must follow guidelines, apply common sense to at-risk clinical environments, and consider COVID-19 infection possible in every patient.

AAO-HNS Launches Tool for Anosmia Reporting

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) has developed a reporting tool—COVID-19 Anosmia Reporting Tool for Clinicians—to allow health care providers around the world to submit data on anosmia and dysgeusia related to COVID-19. Although the evidence of a potential connection between loss of smell or taste and COVID-19 patients remains in its early stages, reports from South Korea, China, and Italy indicate a significant increase in the number of patients presenting with anosmia. As more anecdotal evidence accumulates about anosmia, particularly in patients who test positive for the coronavirus, the AAO-HNS Infectious Disease and Patient Safety Quality Improvement Committees created the reporting tool to gather helpful data about the reported symptoms. Since most COVID-19 patients are seen by non-otolaryngologists, AAO-HNS is soliciting help in gathering this data. The AAO-HNS hopes that these data will help define Centers for Disease Control and Prevention policy for specific subgroups with no other obvious symptoms. To report data about anosmia and dysgeusia, fill out the online-only form.

Critical Care Resources in ICU

Various hospitals have developed protocols for the care and management of COVID-19 in the intensive care unit (ICU). An example from Massachusetts General Hospital, Boston, follows. We will be posting more examples as they become available.

MGH Treatment Guide for Critically Ill Patients with COVID-19

Importance of Ongoing Communication with Families

Because many hospitals and health care facilities deny families the opportunity to visit patients with COVID-19, it is critical that physicians keep in close contact with patient families during treatment. They should find time to call or video conference with families, carefully explain the status of the patient, and reassure families that proper care is being provided. These conversations would be similar to those physicians would have in person but should be provided through telecommunications to avoid potential exposure to infection.

Advances In Surgery Webinar and COVID-19 Resources

The March 27 AIS Channel global interactive free online educational platform broadcast "New Strategies in Colorectal Management During the COVID-19 Pandemic" included more than 34,000 participants from around the world. This archived program can be viewed at here. The next live COVID-19 program will be held on April 9.

ACS Cancer Programs Kicks Off Webinars for Triage and Management of Cancer Patients

To support the guidance documents issued earlier this week on multidisciplinary management of colorectal cancer, breast cancer, and thoracic cancer during the COVID-19 pandemic, the American College of Surgeons hosted two webinars this week. These webinars were recorded and are available on the ACS Cancer Programs web page within 24 hours following the event. The colorectal webinar is scheduled to be posted Friday, March 27. The breast and thoracic webinars will be available Saturday, March 28.

ASCRS Presents Webinar on COVID-19 Lessons

The American Society of Colon and Rectal Surgeons (ASCRS) will host a webinar at 8:00 pm Sunday, March 29, which will bring together panelists to discuss their experiences in treating patients during the COVID-19 pandemic and the lessons they’ve learned. From operating on patients with COVID-19 to shifting schedules, panelists will discuss the impact of the pandemic and what you can do to ensure the safety of your patients, your staff, and yourselves.

The Orthopedic Trauma Association Panel Discussion Webinar

The Orthopaedic Trauma Association (OTA) is holding a webinar panel discussion on COVID-19: Preparedness in Orthopaedic Trauma. Part 1 will be held on March 27 at 8:00 pm ET, and Part 2 on April 2 at 8:00 pm ET. Access additional information here.

New Online Portal from the European Medical Journal

The European Medical Journal is creating an online portal to link physicians, hospitals, device manufacturers, drug companies, medical experts, and philanthropists to ensure the timely delivery of goods and equipment necessary to provide care during the COVID-19 pandemic. To learn more, contact covid19@emjreviews.com.