A QUESTION ABOUT REOPENING SURGERY. IS IT SAFE FOR PATIENTS?

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An important question for many Americans is, “Is it safe for me to have surgery during the COVID pandemic?” Is it safe to reopen surgery?

It depends. 

In the San Francisco Bay Area where I work, the answer as of today, June 4th, 2020, is “yes.”

This is a key point: Healthcare professionals are more concerned with catching COVID-19 from you, the patient, than you should be concerned with catching COVID-19 within the healthcare facility. Read on to learn why.

The main questions as to whether a hospital or an ambulatory surgery center can resume elective surgery as of May 2020 are:

  1. What is the incidence of COVID-19 in your geographic area?
  2. Is testing for the virus that causes COVID-19 available in your area?
  3. Is there adequate personal protective equipment (PPE) at the facility?
  4. If you are having a major surgery in a hospital, will there be an adequate number of ICU and non-ICU beds, ventilators, medications, anesthetics and medical surgical supplies at the facility?

Your state health department will have statistics regarding the incidence of COVID-19 in your area. In Palo Alto, California, where I work at Stanford, the percentage of asymptomatic patients who have a positive COVID posterior nasal swab is quite low at 0.4%, or only 1 out of 250 people. The incidence of positive COVID antibody tests, indicating a prior exposure to the disease, is only 3%. Our county and state health administrations have noted a decline in the incidence of COVID cases, and have authorized a reopening of elective surgery. 

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The American College of Surgeons, the American Society of Anesthesiologists, the American Association of periOperative Registered Nurses, and the American Hospital Association issued a joint statement on April 17th2020, stating that for reopening to occur, “there should be a sustained reduction in the rate of new COVID-19 cases in the relevant geographic area for at least 14 days and the facility shall have appropriate number of intensive care unit (ICU) and non-ICU beds.”

The joint statement also said that “facilities should use available testing to protect staff and patient safety whenever possible and should implement a policy addressing requirements and frequency for patient and staff testing.” Most facilities are interpreting this to mean that patients should have a negative COVID virus screening test prior to surgery. Most of these swab specimens are taken from the posterior aspect of the nose, although some tests only require an anterior nasal swab or a sputum/saliva sample. 

When you enter the healthcare facility, a nurse will question you regarding virus symptoms, and will screen you by taking your temperature. The inside of the healthcare facility will be cleaned prior to any patient care, and will be recleaned after each patient leaves an operating room. Everyone in the healthcare facility will be wearing masks. Everyone will be practicing social distancing of 6 feet unless they need to be closer to you to do their duty. All the precautions you’ve heard about multiple times from TV news reporters over the past weeks are strictly practiced inside healthcare facilities. When I’m at Stanford Hospital or the surgery centers in our area I’m confident the environment is safe.

Changes in the care of surgical patients during the time of COVID are best discussed in terms of preoperative care, intraoperative care, and postoperative care:

Preoperative care: No visitors are allowed into the perioperative region. At Stanford, if you have not had a COVID test prior to elective surgery, a nasal swab is taken on admission, and a rapid COVID test is done with the result available within about 2 hours. Healthcare workers take respiratory precautions with all patients as if that patient was COVID positive, whether the COVID test result has come back yet or not. You will wear a mask in the preoperative room, and that mask will remain on your face until just prior to the induction of anesthesia.

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Intraoperative care: The American Society of Anesthesiologists states that “virus-carrying droplet particles become aerosolized into finer particles by airway procedures such as laryngoscopy, intubation, extubation, suctioning, and bronchoscopy, as well as by coughing and sneezing. These airway procedures and exposures carry a higher risk of infection for anesthesia professionals and other healthcare workers and require the use of rigorous PPE and environmental protection.” This means that when you are going to sleep or when you are waking up, airway procedures such as placing and removing a breathing tube are high-risk times for you to cough and project virus-carrying droplets into the atmosphere around you. The anesthesiologist wears full PPE (N95 mask, face shield, gown, two pair of gloves) during these times, and all other healthcare professionals (surgeons, nurses, techs) are to be at least 6 feet away or preferably outside of the operating room entirely. This is what your anesthesiologist will be wearing immediately prior to the time you go to sleep:

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Postoperative care: When you awaken and your breathing tube is removed, the anesthesiologist once again places a paper surgical facemask over your mouth and nose to prevent you from coughing virus-containing droplets into the atmosphere of the operating room or the post-anesthesia care unit (PACU). If the procedure was an outpatient surgery, you will leave the facility and return home after you’ve recovered from anesthesia. Outpatient surgeries have the advantage of not requiring a hospital bed or an ICU bed/ventilator, which leaves these supplies available if a resurgence of COVID occurs in the community.

Which surgeries are commonly done as of May 13th, 2020? 

Each hospital or ambulatory surgery center is supposed to establish a prioritization policy committee consisting of surgery, anesthesia and nursing leadership, to develop a strategy to screen which surgical cases are appropriate to proceed with or not.

What do you, the patient, do with all this information? 

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The timing of scheduling a surgery is always a balance of benefits and risks. Your surgeon will perform an essential surgery for you whenever a delay could cause harm. Your surgeon will weigh the risk of delay against the benefit that can be achieved by moving forward with your surgery. If your surgeon says your surgery is appropriate at this time, and you are willing to consent to the surgery, then you can move forward with the procedure. 

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Healthcare professionals will adhere to the high quality standards as outline above, and surgery and anesthesia should be safe for you. 

References: 

Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic. (The American College of Surgeons, the American Society of Anesthesiologists, the American Association of periOperative Registered Nurses, and the American Hospital Association) 

Anesthesia Patient Safety Foundation, COVID-19 and Anesthesia FAQs

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