American College of Surgeons Post-COVID-19 Readiness Checklist for Resuming Surgery

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As hospitals are preparing for the resumption of elective surgery, research shows that patients have many questions and specific uncertainties about the safety of undergoing elective operations in hospitals, regardless of whether COVID-19 patients are being concurrently treated in the same facility.

Patients are increasingly requesting information about their facility's readiness for safely performing surgery, and they trust their surgeon to deliver safe and high-quality care, as well as provide information on how they will do so. To address this, the ACS has developed this checklist to help surgeons ultimately communicate to their patients the important items they want to know.

How should this checklist be used? First, surgeons should verify which of the checklist items are present in their facility. Some items won't be needed or appropriate to your facility. On the other hand, some items might need to be developed. The final list, of course, will be individualized to a facility's local resources, prevalence rates, etc.

Second, surgeons can consider communicating to their patients some of the checklist items (e.g. resources, protocols, and policies) in the form of a personal letter, email, or other. In the coming days, the American College of Surgeons will provide a tool kit of materials to help you communicate with patients regarding how they can safely return for surgery they need.

The American College of Surgeons supports our surgical community and patients as we return to surgical care. There are many aspects to building patient trust in post-pandemic care, including assuring that staff are ready, that proper resources are available, and that the facility is safe for delivering high quality patient care. Having these elements in place and transparently and frequently (given the constantly growing knowledge-base) communicating this information to patients will help to support surgical safety during the COVID-19 pandemic and post-pandemic periods. Reportedly, surgeons communicating the content to their patients will help to create an important level of patient-public assurance.

The checklist is organized into two parts: Part I addresses the "Core" facility items. Part II addresses the "surgery specific" items.

Patient-related COVID-19 policies for the facility

• Screening and testing for patients entering facility
  • Meet patients with a greeter to buffer concerns and answer questions
  • Screening policy in place for all people entering your facility
  • Screening policy includes protocol for people who screen positive
• Mitigation with masks
  • Patient/visitor mask policy in place and supply on hand for patients without one
• COVID-19 informed patient program
  • COVID informed patient program,¹ which educates patients about conduct they should undertake to avoid complications for needed care in a post-pandemic environment

Health care worker and PPE policies for the facility

• Policies/Protocols in place for health care workers² to keep patients safe
• Policies/Protocols in place for safe protection of medical first line teams (e.g. Emergency Department)
• Policies in place for health care workers and includes Level of PPE required/recommended
• Patient policy to "STOP THE LINE" if concerns raised with genuine interest in addressing patient concerns

Facility infection control

• Pandemic COVID-19 policies in place
  • Universal precaution protocols
  • Patient isolation/physical distancing
  • Handwashing protocol
  • Facility cleaning
  • Equipment sterilization
  • Air circulation/filtration processes

COVID-19 rate tracking

• Rates of COVID-19 new cases and COVID-19 related deaths in local area (city, county, or state)
• Rates of COVID-19 in local hospital—new cases, COVID-related deaths.
• Patient outcomes with morbidity and mortality tracking for COVID-related events

Publicly available hospital information and data

Building trust through informed public and patients is paramount. In a recent survey, no amount of information is "too much" for the consumer at present. Sharing information on a hospital website, for example, would serve to inform patients of local hospital COVID-19 related policies and processes, data, etc., as would individual discussions between each patient and their surgeon to ensure they are informed about all protective steps being taken. This discussion is one of the most effective way to restore patient trust by facilities and surgeons resuming surgery.

• Publicly available hospital information is available for the following items
  • Patient-need driven policy on resuming surgery, which considers both medical need and appropriate considerations for patients who may have experienced insurance coverage loss
  • Daily surgery resumption multidisciplinary team to review COVID-19 metrics and update COVID-19 daily progress as this impact readiness status
  • Visitor policy
  • Entrance screening processes
  • Patient mask policy within the facility
  • Cleaning policies of key facility areas, including patient rooms
  • Physical distancing
  • Waiting room policy
  • Use of telehealth options
  • Staff testing policy
  • Scripted staff introduction and badging policy for patients to know who the individuals are behind masks, gowns, gloves etc. and what role the person plays on the team
  • Policy for Patient centered verbal query on daily basis to access patient experience regarding COVID-19 safety concerns
  • Food preparation and service policy
  • Family update policy
  • Elevator policy
  • Separate staff policy for treating non-COVID19 patients

Video presentation and policies to assure implementation are suggested^3,4

Process- and facility-related policies

• Preoperative processes for COVID-19 testing or screening (or both) for surgical patients
• Protocol/Policy for consent (with or without advance directive) with COVID-19 related information and discussion of triage criteria and condition specific priorities to have surgery if treatment is at risk due to prolonged delay
• Protocol/Policy for patient readiness for surgery with specific screening questions identified for readiness evaluation (e.g. consider isolation 1-2 weeks prior to operation
• Protocol/Policy for patient PPE (e.g. mask) during inpatient stay
• Cleaning Processes within key areas for the surgical patient—operating room, intensive care units, emergency rooms, hospital rooms, imaging centers, anesthesia services, waiting rooms, etc.
• Cleaning processes for equipment related to surgery including anesthesia.

Publicly available surgery-related information and data

In a recent survey, no amount of information is "too much" for the consumer at present. Sharing information on a hospital website, for example, would serve to inform patients of local hospital COVID-19-related policies and processes, data, etc.

• Publicly available surgery specific information is available for the following items
  • Preoperative testing/screening processes for surgical patients
  • Surgery/Operating room staff testing/screening
  • Policy/recommendation for patient isolation prior to operation
  • Patient mask policy during day of operation, and postoperatively
  • Cleaning policies
  • Surgery Consent policy with informed risks related to COVID-19
  • Advance directive before surgery discussions
  • Options for telehealth options
  • Post-acute care discussions/options as related to surgery
  • Prehabilitation discussions/options as related to surgery and post-acute care
  • Enhanced Recovery protocols in place to optimize postoperative care and outcomes

1. COVID Informed patient program is intended to inform the patient about avoiding complications for needed care in a post pandemic environment. The program should inform them about their conduct while undergoing care in a clinic or hospital during a pandemic. It includes the why's and how's about handwashing for 20 seconds, wearing a mask, social distancing, family visitation during procedures and waiting rooms. It informs patients about quarantine, how to seek more information and so forth.
2. Health care worker policies in COVID setting: These policies exist to keep patients safe and outline expectations for employees for strict handwashing, self-policing, mask protocols, PPE gown and glove protocols. Also, expectations are set for HCW self-monitoring for testing (when available), personal temperature monitoring, self-imposed quarantine for symptoms (and what should be the possible for COVID related illness when/if their partner becomes infected with COVID).
3. Video Tours for Patients It is suggested that a video tour of the hospital experience from the front door to the entire process of surgical care be developed to demonstrate visually for the patient what to expect, how people will look, how they will be communicated with and how to raise concerns, ask for clarification or stop the line as needed.
4. Pace of Care Policy It is recommended that an overarching policy is in place to pace care deliberately and slow down processes (i.e., six second rule) to assure disciplined following of new policies and avoid errors (tracked and compliance tested).