In that circumstance, the patient remains in the OR for 30 minutes after extubation to allow for turnover of air in the room prior to the doors opening for patient transport to the ICU.16 A surgical mask is placed over the patient’s oxygenating face mask to reduce droplet spread during transport. Patients who are not intubated for the anesthetic may be first recovered in the operating room or transported under droplet precautions directly back to a negative pressure isolation room.
Prior to transport, the patient’s gurney is thoroughly cleaned with Environmental Protection Agency-approved disinfectant wipes, and a clean sheet is placed over the patient’s body below the head.17 The front face shield of the surgeon’s and anesthesiologist’s PAPR hood should be wiped down with an alcohol-based disinfectant. Both health care providers don a clean disposable gown as an outer layer to minimize contamination by their used attire during transport. Once the patient is transported out of the OR, all disposable items are discarded. Reusable medical equipment are cleaned and disinfected according to a thorough application of local environmental services standard operating procedures.18 The surgeon and anesthesia providers aid in transporting the patient to the ICU, along with their outside OR assistants. All personnel remaining in the OR exit and doff their PPE according to the doffing protocol, which is similar to the donning protocol, utilizes a PPE partner tasked with providing instructions to the surgical team member step by step (Figure 5).
After leaving the OR, terminal cleaning must be performed by environmental services (EVS) personnel, but they should delay entry into the room until a sufficient amount of time has elapsed after the last aerosol-generating procedure in the OR. Time determination will depend on the air change per hour (ACH) in the OR that will achieve 99.9% removal of airborne contaminates. For example, ventilation in our operating rooms operate at approximately 15 to 20 ACH, which should attain that level of air clearance in 21 to 28 minutes.16 Once the stipulated time has elapsed EVS personnel may enter the room but should wear a gown and gloves when performing terminal cleaning. A face mask and eye protection should be added if splashes or sprays during cleaning and disinfection activities are anticipated, or otherwise required based on the selected cleaning products. Anesthesia technicians can now also enter the room to disinfect the anesthesia machines and set up all disposable supplies for any potential following case.
Conclusions
The outbreak of COVID-19 has resulted in an unprecedented modern health care crisis across the globe. Perioperative management of patients with COVID-19 pose unique challenges to all personnel working in the OR, where the risk of nosocomial transmission of infection is ever present. It is essential that hospitals consider their local resources, infrastructure and capabilities when devising policies to respond to the COVID-19 emergency. In all perioperative situations, meticulous attention should be given to both donning and doffing of PPE, crucial for the safety of everyone involved in the care of patients with COVID-19.