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

Clinical Issues and Guidance

ACS Issues Guidance on Ramp Up of Elective Operations

In an effort to focus local resources on managing the COVID-19 pandemic, health care institutions and surgeons have been triaging or halting “elective” procedures. As the COVID-19 rates peak over the next week or two (depending on location), many providers are turning their focus to ramping up elective operations. The American College of Surgeons (ACS) has developed a guidance document that offers a set of principles and issues that local facilities can apply as they prepare for resumption of elective surgical care. The ACS suggests facilities use this checklist to ensure they have given due consideration to the relevant issues. Understanding both the local facility’s capabilities as well as potential constraints, while keeping an eye on potential subsequent waves of COVID-19 patients will continue to be important.

The document centers on four major areas of concern: COVID-19 Awareness, Preparedness, Patient Issues, and Delivery of Safe and High-Quality Care. It provides guidance on 10 distinct issues that should be addressed locally before elective surgery can safely resume. They are as follows:

  • Know your COVID-19 numbers.
  • Know your COVID-19 diagnostic testing availability and develop operational testing policies for patients and health care workers.
  • Know your personal protective equipment availability and develop policies for your health care workers and procedures.
  • Know your health care facility capacity.
  • Know your resources and supplies.
  • Know your workforce staffing issues.
  • Assign a governance committee.
  • Respond to patient questions and concerns regarding ramp up.
  • Develop a prioritization protocol/plan.
  • Ensure safe, high-quality, high-value care of the surgical patient across the Five Phases of surgical care continuum.

Evaluating and addressing each of these 10 issues will help facilities to not only optimally provide safe and high-quality surgical patient care, but also to ensure that surgery resumes, and doesn’t stop again. Click here to read more.

New ACS COVID-19 Patient Registry

The American College of Surgeons (ACS) has developed the ACS COVID-19 Registry, which is now available to all hospitals seeking to capture meaningful data about the COVID-19 patients they treat. The overarching priority of this registry is to collect important clinical patient data for a disease about which little is known.

The registry will collect data on COVID-19 patients who did not undergo surgery as well as COVID-19 patients who did. 

The ACS COVID-19 Registry was developed with the input of several experts who are currently treating COVID-19 patients. They have advised the ACS as to what key variables should be collected. The final set of variables is based on the expected availability of relevant information and ease of data collection, as well as other factors.

Included data variables cover demographics, severity predictors, admission information, hospitalization information, therapies used, and discharge information. Participating hospitals will be able to capture all patients ages 18 and older and tracked from hospital admission through discharge.

The ACS has a long history of developing and maintaining clinical data registries for trauma, cancer, surgical quality improvement for adult and pediatric hospitals, and bariatric surgery. Relying on the decades of experience the ACS has with data collection and improving patient care, we also acknowledge the registry was created in an expedited time frame because of the immediate crisis. We will continue to monitor the variables that are collected, the definitions of the variables, and reiterate as needed. We are using REDCap as the data collection platform for the ACS COVID-19 Registry since it is a known system and easily accessible to all hospitals.

All hospitals can contribute. We ask that you help to advance our collective knowledge and understanding by participating in this important initiative. There is no fee to participate. We only request your commitment to collecting and submitting data.  Please contact COVID19Registry@facs.org or Amy Sachs, Senior Manager, ACS Registry Operations, at asachs@facs.org to request more information and a copy of the participation form.  Learn more about the ACS COVID-19 Registry.

ACS Guidelines for Triage and Management of Elective Cancer Operations during Ramp Up

Although the entire population appears to be at risk for COVID-19 infection, certain subgroups of patients are at increased risk of experiencing significant morbidity and mortality if they become infected. One high-risk group includes patients with cancer. To help reduce morbidity and mortality in these vulnerable patients, the American College of Surgeons (ACS) has developed guidelines for triage and management of elective cancer operations as hospitals prepare to resume offering these services. The guidelines organize decision-making into three acute phases and two recovery phases. Hospitals will likely progress through these phases over the next several weeks to months. Access the guidelines.

Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic

The American College of Surgeons (ACS), American Society of Anesthesiologists, Association of periOperative Registered Nurses, and American Hospital Association have developed a Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic. This guidance document is intended to help surgeons and other members of the surgical team respond to the pent-up patient demand for surgical and procedural care that has developed over the course of the first wave of this pandemic. The road map includes a list of principles and considerations to guide physicians, nurses, and local facilities preparing operating rooms and all procedural areas for the resumption of elective surgery. These guidelines are aligned with the protocols that the ACS issued today.

Lessons Learned About Ramp Up in New York, NY

As the rest of the nation prepares for the number of COVID-19 cases to peak this month, trauma directors from New York, NY, hospitals and members of the American College of Surgeons Greater New York Chapter Committee on Trauma have developed an outline of the lessons learned from the experience and offer recommendations for ramping up intensive care unit (ICU) capacity. Specifically, the authors recommend prompt review of existing emergency department/trauma bay protocols, reallocation of staff and physical resources to the ICUs, and an integrated regional response plan. Read the full report here.

COVID-19 and Telemedicine: No Turning Back

COVID-19 has fundamentally promulgated the use of telemedicine, and most likely telemedicine will be part of our surgical careers ever after the outbreak. This pandemic has forced people around the world to rethink how we interact socially and surgeons to reevaluate how we practice. The currency for health care traditionally was a face-to-face visit; now many surgeons have rapidly turned to telemedicine for their nonoperative work. This change happened in one month—March 2020. Once this sad time passes and we enter the new era of our society and health care, a large portion of our surgical practices, if not the majority, will be based on telemedicine. Surgeons have been through rapid technological change before, especially with the advent of minimally invasive surgery that radically transformed—for the better—patient outcomes and our ability to operate.

It is critical that we embrace telemedicine and make sure that we craft the future of telemedicine to enable surgeons and the American College of Surgeons in providing safe surgical care. Read more about telemedicine from Andrew Watson, MLitt, MD, FACS, University of Pittsburgh Medical Center, Presbyterian Shadyside Hospital, PA.

Additional Telehealth Resources

Healthline’s Best Telemedicine Apps of 2019

Software Advice: Telemedicine Software

Mundaii, a web-based free-market platform for health care opinions and services

AAMC Releases New Guidance on Medical Student Participation in Direct Patient Contact Activities

The Association of American Medical Colleges (AAMC) on April 14 released updated guidance on the participation of medical students in patient care activities. The overall message remains the same as in previous guidance – for medical schools within areas that have significant active or anticipated community spread of COVID-19, and/or limited availability of personal protective equipment (PPE), and/or limited availability of COVID-19 testing, the AAMC recommends that medical students not be involved in direct patient care activities, unless an institution is experiencing a critical workforce shortage.

The updated guidance provides specific additional recommendations for medical schools that are experiencing a critical workforce shortage to keep their volunteer medical students as safe as possible. These new recommendations include reviewing medical students’ health insurance information to ensure that volunteering to serve during the pandemic does not preclude them from coverage, making certain that sufficient PPE is available for the medical student volunteers to have consistent access, and ensuring COVID-19 testing is readily available to students and that any increase in positive tests among trainees is monitored and reacted to accordingly.

Early Data Show that COVID-19 Wreaks Havoc on Multiple Organs

Clinicians and researchers are finding that COVID-19 not only kills by inflaming and clogging the tiny air sacs in the lungs, thereby choking off the body’s oxygen supply, but it also can cause heart inflammation, acute kidney disease, neurological malfunction, blood clots, intestinal damage, and liver problems.

That development has complicated the treatment of the most severe cases of COVID-19, the illness caused by the virus, and makes the course of recovery less certain, physicians  say in an article published this week in The Washington Post. The prevalence of these effects is too great to attribute solely to the “cytokine storm.” For example, early data show that 14 to 30 percent of intensive care patients in New York, NY, and Wuhan, China, lose kidney function and require dialysis or continuous renal replacement therapy.

Society of Gynecologic Oncology Reassignment Recommendations

Because of the rising burden of COVID-19 on institutions throughout the country, the Society of Gynecologic Oncology (SGO) is offering guidance to their members to help them discuss their potential reassignment outside the practice of obstetrics and gynecology.

Whereas SGO members have responsibilities that preclude their reassignment—such as obligations to see new urgent and emergent cancer cases, overseeing ongoing chemotherapy and radiation of patients, and assisting gynecology colleagues with surgical emergencies—the SGO has recommendations regarding where gynecologic oncologists can be used to assist other medical and surgical staff. Read about the back-up and support recommendations here.

Guidance on Tracheostomy during the COVID-19 Pandemic

As the COVID-19 pandemic evolves, acute care surgeons, intensivists, and other surgical specialists increasingly may be asked to perform a tracheostomy in patients with known or suspected coronavirus-19 infection. To help surgeons prepare for this inevitability, the Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma (AAST) have developed guidance and recommendations on how to perform the procedure safely in altered or suboptimal conditions and protect themselves and other health care personnel from undue risk of exposure and infection.

The guidance documents are published in Trauma Surgery and Acute Care Open, with leaders of the AAST and the Committee on Trauma of the American College of Surgeons as authors. The authors note that tracheostomy has many known benefits in critically ill and injured patients, but its utility in the recovery of patients with COVID-19 is unknown. Furthermore, the procedure poses a significant risk of viral transmission because it is an aerosol-generating procedure. The document recommends that surgeons consider both short- and long-term outcomes of tracheostomy along with the risks of exposure of the clinical team.

Association of Coloproctology of Great Britain and Ireland Releases Guidance on Surgery for IBD during the COVID-19 Pandemic

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) has released guidance on surgery for patients with irritable bowel disorder (IBD) during the COVID-19 pandemic. The guidance document notes that surgery is recognized as the treatment of choice for some specific complications of IBD in order to save lives and improve quality of life. The document encourages the use of multidisciplinary teams in clinical decision making, consideration of the severity of patients’ illness, and strong stewardship of hospital resources during the pandemic. The guidance document can be accessed here.

Spanish-Language Video Demonstrates How to Manage the Airway

Clinica Universidad de los Andes has produced a short Spanish-language video on airway management in COVID-19 patients. The techniques used in this simulated demonstration are based on those outlined in the American College of Surgeons Committee on Trauma’s Advanced Trauma Life Support® course.