Original Research

You Need a Plan: A Stepwise Protocol for Operating Room Preparedness During an Infectious Pandemic

Fed Pract. 2020 May;37(5):212-218

References

1. Holshue ML, DeBolt C, Lindquist S, et al. First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020;382(10):929-936.

2. Siegel S RE, Jackson M, Chiarello L. Healthcare Infection Control Practices Advisory Committee; Guideline for Isolation Precautions. Centers For Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html. Published 2007. Accessed March 28, 2020.

3. American College of Surgeons: COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures. American College of Surgeons. https://www.facs.org/covid-19/clinical-guidance/triage. Published March 17, 2020. Accessed April 19, 2020.

4. American College of Gastroenterology. Gastroenterology professional society Guidance on endoscopic procedures During the covid-19 pandemic. American College of Gastroenterology. https://webfiles.gi.org/links/media/Joint_GI_Society_Guidance_on_Endoscopic_Procedure_During_COVID19_FINAL_impending_3312020.pdf. Published March 31, 2020. Accessed April 19, 2020.

5. Chen X, Liu Y, Gong Y, et al. Perioperative management of patients infected with the novel coronavirus: recommendation from the Joint Task Force of the Chinese Society of Anesthesiology and the Chinese Association of Anesthesiologists [published online ahead of print, 2020 Mar 26]. Anesthesiology. 2020;10.1097/ALN.0000000000003301.

6. Zhang HF, Bo L, Lin Y, et al. Response of Chinese anesthesiologists to the COVID-19 outbreak [published online ahead of print, 2020 Mar 30]. Anesthesiology. 2020;10.1097/ALN.0000000000003300.

7. Kamming D, Gardam M, Chung F. Anaesthesia and SARS. Br J Anaesth. 2003;90(6):715-718.

8. Zucco L LN, Ketchandji D, Aziz M, Ramachandran SK. Perioperative considerations for the 2019 novel coronavirus (COVID-19). https://www.apsf.org/news-updatesperioperative-considerations-for-the-2019-novel-coronavirus-covid-19/. Published Feb 12, 2020. Accessed March 30, 2020.

9. Caputo KM, Byrick R, Chapman MG, Orser BJ, Orser BA. Intubation of SARS patients: infection and perspectives of healthcare workers. Can J Anaesth. 2006;53(2):122-129.

10. Judson SD, Munster VJ. Nosocomial transmission of emerging viruses via aerosol-generating medical procedures. Viruses. 2019;11(10):940.

11. Peng PWH, Ho PL, Hota SS. Outbreak of a new coronavirus: what anaesthetists should know. Br J Anaesth. 2020;124(5):497‐501.

12. Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a COVID-19 patient needs an operation: operating room preparation and guidance [published online ahead of print, 2020 Mar 6]. Can J Anaesth. 2020;1‐3.

13. Chow TT, Kwan A, Lin Z, Bai W. Conversion of operating theatre from positive to negative pressure environment. J Hosp Infect. 2006;64(4):371-378.

14. Clark C, Taenzer A, Charette K, Whitty M. Decreasing contamination of the anesthesia environment. Am J Infect Control. 2014;42(11):1223-1225.

15. Dexter F, Parra MC, Brown JR, Loftus RW. Perioperative COVID-19 defense: an evidence-based approach for optimization of infection control and operating room management [published online ahead of print, 2020 Mar 26]. Anesth Analg. 2020;10.1213/ANE.0000000000004829.

16. Jensen PA, Lambert LA, Iademarco MF, Ridzon R, CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005;54(RR-17):1-141.

17. US Environmental Protection Agency. List N: disinfectants for use against SARS-CoV-2. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2. Updated April 16, 2020. Accessed April 19, 2020.

18. Munoz-Price LS, Bowdle A, Johnston BL, et al. Infection prevention in the operating room anesthesia work area [published correction appears in Infect Control Hosp Epidemiol. 2019 Apr;40(4):500]. Infect Control Hosp Epidemiol. 2018;1‐17.

Portable transport monitor;
Video laryngoscope;
Airway supplies and medications for induction of general anesthesia;
Self-inflating bag-mask apparatus attached to an oxygen source;
High-quality HMEF (heat and moisture exchanging filter) rated to remove at least 99.97% of airborne particles ≥ 0.3 microns to filter out viral particles attached to the expiratory outlet; and
PPE including impermeable disposable gowns, gloves, and shoe covers.

While the surgical technician remains in the OR, the rest of the team will proceed to the patient’s location with these supplies, along with the necessary number of PAPRs and N95 respirators.

Outside the patient room, the team consisting of surgeon, anesthesia provider, OR nurse, and the assistant to each of these health care providers, gathers for the first time out, confirming the patient’s identification, intended procedure, surgical site, laterality, and informed consent. If the patient is verbal and has decision-making capacity, they confirm their identification, understanding of the planned procedure, and consent with the team over the phone from the confines of their room. If a patient lacks decision making capacity standard organization policies should be adhered to, most of which do not require direct patient contact and do not pose any unique infection control challenges. The anesthesia provider and surgeon don their PPE including PAPR devices with the aid of their assistants. Using a PPE checklist, the surgical team member dons with the assistance of a PPE partner, who is charged with reading the instructions on the checklist to the surgical team member step by step and inspecting the adequacy of the full PPE attire (Figure 1). A similar secondary check of appropriate PPE by an assistant during high risk encounters has also been advocated by other authors.⁶

Consideration should be given to intubating the patient prior to transport to the OR particularly if the patient originates in a respiratory isolation room with negative pressure airflow, being mindful that most operating suites are ventilated with positive airflow that could help disperse virus laden aerosols in the procedure area. It may also be beneficial to have a secure airway in a patient who is actively coughing, sneezing, and dispersing respiratory droplets to the surrounding environment prior to leaving respiratory isolation. When intubation prior to OR transport is chosen, the fully attired anesthesiologist enters the patient room first, with a video laryngoscope, medication, and other supplies needed to successfully induce general endotracheal tube anesthesia. The anesthesia and surgery assistants don droplet precaution PPE and remain outside the patient room. Whenever possible, a rapid sequence induction is performed with minimization of bag-mask ventilation. Video laryngoscopy is preferred over direct laryngoscopy in patients with COVID-19 as it enables a greater distance between the health care provider and the airway.^5,6 The surgeon and OR nurse then enter the room, wearing PPE including PAPR, and assist with attaching the transport monitor and moving the patient bed out of the room. The OR nurse wipes the front face shield and PAPR hood of the anesthesia provider after intubation, to clean these presumably contaminated components prior to exiting the room. A second, clean disposable gown covers the one worn during intubation to minimize environmental contamination during transport.^11,12

The patient is intubated, anesthetized, and, transported to the OR, with a self-inflating bag mask apparatus attached to an oxygen source and a second high-quality HMEF rated to remove at least 99.97% of airborne particles ≥ 0.3 microns is attached to the expiratory outlet, or a transport ventilator with HEPA filter attached to the expiratory limb. In the OR, the anesthesia provider, surgical technician, and OR nurse assist with moving the patient to the operating gurney and attaching the monitor. The surgeon remains outside the room in order to doff the gown and gloves worn during transport, disinfect their hands (preoperative scrubbing), and don sterile attire, all while continuing to wear the same PAPR and hood.