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

Clinical Issues and Guidance

Military Health System Postpones Elective Operations

All U.S. military health and dental treatment facilities will postpone elective operations and procedures for 60 days starting March 31, according to an announcement issued by the U.S. Department of Defense (DoD). This policy includes aerosol-producing procedures such as endoscopies, bronchoscopies, pulmonary function tests, and sleep continuous positive airway pressure titrations.

This action is being taken to ensure the safety of military medical staff, conserve health care resources including personal protective equipment, and protect patients from further exposure and transmission of COVID-19.

This policy—including exceptions regarding maintaining the deployment and readiness of active duty service members—is available here.

This announcement follows a March 16 surgical response letter also issued by the DoD in which the agency reaffirmed its commitment to the role of surgeons in meeting the challenges of the pandemic, including the DoD’s response to surge capacity, and the DoD’s support of resident education and research activities during the pandemic.

For additional guidance, the Military Health Service Strategic Partnership American College of Surgeons has made an electronic version of the Blue Book, described in Issue 3 of this newsletter, available online ahead of print. Access it here.

Promising Therapeutics

A great deal of promising news about therapeutics emerged over the weekend. Highlights include:

  • The Journal of the American Medical Association published a study on treatment of five severely ill COVID-19 patients treated with convalescent plasma with good outcome. There is an accompanying editorial that is quite thoughtful about this tentative but promising use.
  • The French clinical community has reported promising results using hydroxychloroquine (HCQ) and azithromycin in COVID-19 patients and now has a follow up article on short-term outcomes in their small sample with encouraging results.
  • Medscape has an excellent short editorial analysis of the pitfalls of assigning significance to small sample articles, focusing on the COVID papers.
  • The World Health Organization has announced the initiation of a multi-arm trial of HCQ or chloroquine, remdesivir, lopinavir plus ritonavir, and interferon beta.

Hydroxychloroquine Sulfate and Chloroquine Phosphate Available for Use in COVID-19 Patients

The U.S. Department of Health and Human Services (HHS) has accepted donations of 30 million doses of hydroxychloroquine sulfate and one million doses of chloroquine phosphate to be distributed and prescribed by physicians to hospitalized teen and adult patients with COVID-19, as appropriate, when a clinical trial is not viable. This action is the result of an Emergency Use Authorization (EAU) submitted by the U.S. Food and Drug Administration (FDA) to the Biomedical Advanced Research and Development Authority (an office of the HHS) on March 28.

The chloroquine phosphate and hydroxychloroquine sulfate products were donated to the Strategic National Stockpile, which is managed by the Assistant Secretary for Preparedness and Response (ASPR). This agency will work with the Federal Emergency Management Agency to ship donated doses to the states.

The EUA requires that fact sheets be available to health care providers and patients outlining key information about using chloroquine phosphate and hydroxychloroquine sulfate in treating COVID-19, including the known risks and drug interactions.

Deployment of Surgeons for Out-of-Specialty Patient Care

The COVID-19 pandemic has inflicted unprecedented stresses upon health care institutions and the caregivers who provide the frontline services needed to maximize the chances of survival and return to normalcy for patients who are infected and develop clinical symptoms. In this challenging time, it will be necessary to deploy surgeons to work outside of their usual specialty to maximize effectiveness of available clinicians. The solutions chosen for individual patient care units will need to be based on patient needs, availability of trained critical care surgeons, residents, physicians’ assistants, advanced practice nurses and medical students. Once the need has been assessed, deployment of surgeons to provide out-of-specialty care can be determined.

Suggested resources for surgeons who redeploy to critical care areas during the COVID-19 pandemic are listed below. These materials should be valuable for older surgeons and out-of-specialty surgeons. Early resources that will be valuable at the time of entry into the intensive care unit care activities include the Society of Critical Care teaching modules for noncritical care clinicians, the Advanced Trauma Life Support (ATLS®) video modules, and the Surviving Sepsis Campaign practice guidelines for management of critically ill COVID-19 patients.

The ACS Committee on Trauma has made available teaching videos from the Advanced Trauma Life Support® course that cover the topic areas listed here:

Orthopedics This Week
How to Deploy Residents During COVID-19

Society of Critical Care Medicine
Teaching Modules for Non-Critical Care Practitioners
Disaster Response Recommendations

Surviving Sepsis Campaign
Surviving Sepsis Campaign Website
Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019

University of Pennsylvania
Suggested Health Care System Response to Needs for Personnel Deployment during the COVID-19 Pandemic

COVID-19 and Surgical Procedures: A Guide for Patients

For patient safety and to ensure that resources, hospital beds, and equipment are available to patients critically ill with COVID-19, the American College of Surgeons (ACS) and the U.S. Centers for Disease Control and Prevention recommend that non-emergency procedures be delayed. A new Patient Education resource from the ACS explains the following: why patients might experience delays in surgery, why operations are being postponed, the rescheduling process, what to do about follow-up visits, how to address medical emergencies,  and what to expect when at the hospital experiencing COVID-19 symptoms. The guide also outlines visitation and follow-up care for COVID-19 patients. Access the resource.