COVID-19 – Restarting Elective Surgery

FIGO Statement about resuming elective surgery at the current point of the COVID-19 health crisis

Elective surgery is designed to improve the quality of life and optimise clinical outcomes in patients who have a surgical management indication for non-urgent conditions. The public health crisis associated with the SARS-CoV-2 pandemic forced physicians and health care systems to postpone such scheduled surgeries to ensure both the availability of resources and patient safety for those affected by COVID-19.

Now, given the regional evolution of the epidemiological curves associated with the pandemic, measures can be taken to allow elective surgery to be safely resumed. This process must be implemented in an incremental fashion to avoid negative impact on local health care resources, the needs of urgent and emergency patients, and the access to medical care required by those affected by COVID-19.

  1. Local Epidemiological Considerations

To make the decision to restart elective surgery in a given location it is important to determine that the population in question is in one of two circumstances:

  1. The expected peak of SARS-CoV-2 infection will not occur in the 14-day period following an elective procedure.

OR

  1. The rate of new cases has been steadily decreasing for the last 14 days (3 Day rollover mean).

To make safe healthcare choices for the entire population, it is important to formulate the decision to restart elective surgery based on local epidemiological evidence.

  1. Installed Capacity and Supply Chain

Each institution must ensure that the availability of hospital beds is not adversely impacted by a decision to resume elective surgery. Consequently, it is necessary to have continuing access to data regarding occupancy of beds for COVID 19 affected patients, including intensive care unit (ICU) beds both locally and regionally.

Adequate supply chain access must also be ensured so that resources (including Personal Protective Equipment - PPE) used when performing elective surgery do not adversely affect those needed for the rest of the hospital population and their providers, who will also be caring for patients affected with COVID-19. When considering available resources, calculations must also consider the spectrum of health providers necessary for care of acute patients both with and without the infection

  • Each medical facility must be able to define its occupancy limits to authorize or restrict the performance of elective surgery based on local and national regulations and WHO guidance for allocating services between COVID and Non-COVID patients.
  • Total hospital occupancy rates under 50% provide a reasonably safe buffer that should allow for the reactivation of elective surgery services
  • Hospital occupancy rates above 75% mandate suspension of all elective activity.
  • When the occupation rates are between 50 and 75%, a more cautious approach to restarting elective surgery must be followed and will depend on a number of local factors including surgical complexity, facilities available, and the individual possibility of COVID-19 resolution.

 

  1. Categorisation of Procedures

When considering elective surgery delayed by the pandemic, each institution must design implementation strategies that consider the risk to benefit ratio for the patient in the context of the general effect on public health.

  • Urgent operations, which have occurred since the beginning of the crisis, should be performed without restriction.
    • Each institution should establish a “prioritisation policy committee” that includes health personnel leaders who will develop appropriate objective criteria and consider the immediate needs of both patients and the institution. Furthermore, this committee should monitor the ongoing capacity and the local and regional epidemiological behavior of SARS-CoV-2 and COVID-19 disease.
    • There exist several published risk scores designed to guide resumption of elective surgery by categorising patients according to both specific conditions and procedure characteristics.
    • The final decision should favor surgeries that use fewer resources and pose lower risk for both patients and medical personnel.
    • Priority should also be given to patients who are undergoing low morbidity procedures and who are likely to make the most rapid recovery with less resource use.
    • Preference should be given to minimally invasive procedures that are ambulatory or have a short hospital stay.
    • Enhanced recovery protocols should be implemented, whenever possible, after surgery.
  • Suspected or known SARS-CoV-2 positive patients should not undergo elective surgery, as they may have higher post-surgical morbidity.
  • Clinical pre-surgical screening policies for both patients and all health providers (including, but not restricted to, universal completion of a symptom questionnaires, measuring body temperature, instituting contagion follow-up protocols, and evaluating evidence of local and regional travel) are appropriate where testing is not an accessible and available strategy. Current tests for SARS-CoV-2 have a sensitivity that is as low as 70%, are not universally available and lack accuracy in infected asymptomatic patients.

 

  1. Risk Reduction
    1. The personal protection of patients, companions and caregivers must be ensured, according to local and national guidelines and following WHO recommendations.
    2. Emphasis should be placed on a number of measures including contact control, social distancing, frequent handwashing, and general care for both patients and health care providers during all aspects of clinical care.
    3. Access to, and availability of, the appropriate individual PPE must be ensured in all cases and for all members of the surgical team.

 

  1. Informed Consent

Each institution must ensure that patients have received complete and adequate information regarding the particular characteristics of this public health emergency, the risks inherent in performing elective surgeries during the COVID-19 crisis and the special considerations of its evolution, both intra and post-operative.

 

  1. Special Considerations Regarding the Phases of Surgical Care

In all cases, each institution must ensure adequate post-surgical follow-up that includes unimpeded access to health services for the patients in the event of a known or suspected adverse outcome.

 

The rapid evolution of the situation forces us to periodically review the measures taken on a regular basis and analyze the clinical, social, and economic impact as well as reviewing the safety for both patients and staff.

 

  1. References:
  1. Weber Lebrun EE, Moawad NS, Rosenberg EI, Morey TE, Davies L, Collins WO, Smulian JC. COVID-19 Pandemic: Staged Management of Surgical Services for Gynecology and Obstetrics. Am J Obstet Gynecol. 2020 Apr 3;S0002-9378(20)30389-6.  doi: 10.1016/j.ajog.2020.03.038. Online ahead of print.
  2. American College of Surgeons Local Resumption of Elective Surgery Guidance. Released April 17, 2020. https://www.facs.org/covid-19/clinical-guidance/resuming-elective-surgery
  3. Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic.  American College of Surgeons. American Society of Anesthesiologists. Association of periOperative Registered Nurses. American Hospital Association. Online April 17, 2020. https://www.facs.org/covid-19/clinical-guidance/roadmap-elective-surgery
  4. COVIDSurg Collaborative. Global Guidance for Surgical Care During the COVID-19 Pandemic. Br J Surg. 2020 Apr 15.  doi: 10.1002/bjs.11646. Online ahead of print.
  5. Akladios C, Azais H, Ballester M, et al.  Recommendations for the Surgical Management of Gynecological Cancers During the COVID-19 Pandemic - FRANCOGYN Group for the CNGOF J Gynecol Obstet Hum Reprod. 2020 Apr 1;101729.  doi: 10.1016/j.jogoh.2020.101729. Online ahead of print.
  6. FIGO Minimally Access surgery committee statement on Elective surgery and COVID-19. https://www.figo.org/elective-surgery-and-covid-19
  7. AAGL webinar. Resuming Elective Surgeries After COVID-19: Global Perspectives. https://www.aagl.org/news/new-webinar-restarting-elective-surgeries-during-and-after-covid-19/
  8. COVID-19: Joint Statement on Minimally Invasive Gynecologic Surgery. Issued:  3/27/2020 – by AAGL. https://www.aagl.org/news/covid-19-joint-statement-on-minimally-invasive-gynecologic-surgery/
  9. COVID-19: Joint Statement on Re-introduction of Hospital and Office-Based Procedures. Issued:  4/29/2020 by AAGL. https://www.aagl.org/news/covid-19-joint-statement-on-re-introduction-of-hospital-and-office-based-procedures/
  10. Prachand VN, Milner R, Angelos P, Posner MC, Fung JJ, Agrawal N, Jeevanandam V, Matthews JB. Medically Necessary, Time-Sensitive Procedures: Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic. J Am Coll Surg. 2020 Apr 9. pii: S1072-7515(20)30317-3. doi: 10.1016/j.jamcollsurg.2020.04.011. [Epub ahead of print]
  11. Recomendaciones para la reactivación de la cirugía ginecológica electiva durante la pandemia en Colombia. Federacion colombiana de obstetricia y ginecología – FECOLSOG. Comité de cirugia minimamente invasiva. Mayo 7 de 2020. https://www.fecolsog.org/wp-content/uploads/2013/04/REACTIVACION-CIRUGIA-GINECOLOGICA-EN-PANDEMIA-COLOMBIA-2020-POSICION-FECOLSOG-1.pdf
  12. AAGL webinar. Flattening the Curve – Re-entry and More. Issued:  4/19/2020 – by AAGL. https://surgeryu.com/public/covid194232020
  13. WHO. Updated Country Preparedness and Response Status for COVID-19 as of 7 May 2020. https://www.who.int/who-documents-detail/updated-country-preparedness-and-response-status-for-covid-19-as-of-7-may-2020
  14. Barrios Parra A, Prieto Ortiz RG, Torregrosa Almonacid L, Álvarez Tamayo CA, Hernández-Restrepo JD, González Higuera LG, Valencia Ceballos Álvaro, Ospina Londoño JO, Herrera Chaparro JA, Moore Perea JH, Ayala Acosta JC, Zurita Medrano N, Vargas Barato FE, Coba Barrios HJ, Fajardo Gómez R, Borraez Segura BA, Moros Vera ME, Mendivelso Duarte FO, Aristizabal OL, Guevara Pulido FO, Cabrera-Vargas LF, Petrone P. Volver a empezar: cirugía electiva durante la pandemia del SARS-CoV2. Recomendaciones desde la Asociación Colombiana de Cirugía. Rev Colomb Cir . 11 de mayo de 2020;35(2):302-21. https://www.revistacirugia.org/index.php/cirugia/article/view/656
  15. https://apps.who.int/iris/bitstream/handle/10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2-eng.pdf
  16. Stahel PF. How to Risk-Stratify Elective Surgery During the COVID-19 Pandemic?

Patient Saf Surg 2020 Mar 31;14:8.  doi: 10.1186/s13037-020-00235-9. eCollection 2020.

  1. https://openwho.org/courses/UNCT-COVID19-preparedness-and-response-EN?locale=fr