COVID-19 FAQs

Reviewed/Updated February 1, 2021
AORN is here to support the entire perioperative community during this novel coronavirus (COVID-19) pandemic. We will continue to update this page as issues and questions arise.

PPE

No, a cloth mask is not recommended to prolong the use of N95 respirators. Healthcare facilities should establish policies for management of PPE based on current and projected number of Covid-19 cases, and availability of resources such as surgical masks and N95 respirators. Refer to the chart on this FAQ page to assist in making decisions regarding mask use in times of shortage. Additionally, the CDC website contains guidance for HCP regarding facemask use.

To assist with preserving N95 respirators during extended use, utilize a cleanable face shield that extends down over the respirator or use other fluid-resistant protection such as surgical mask. Available research found no significant impact on breathing effort or gas exchange when a surgical mask was used to cover a N95 respirator. A cloth mask would not provide fluid-resistant protection, therefore should not be used.

Whenever using an N95 respirator, the user should always thoroughly inspect and perform a self-fit check to be sure the seal between the mask and face is tight. Discomfort or difficulty breathing are indicators that the respirator should be changed.

Resources:

Updated December 22, 2020.

Reuse of N95 respirators is not safe nor commensurate with standards of care, and should only be considered in a crisis situation when other strategizes to optimize respirator use have failed. The CDC provides guidance on the reuse of N95 respirators. N95 respirator materials degrade when they are worn and can degrade more quickly in the presence of increased moisture. Information about duration of safe mask wear can be obtained from the manufacturer of the mask. If no manufacturer guidance is available, limit the number of reuses to no more than five donnings per device by the same HCP to ensure an adequate respirator performance. Use of a cleanable face shield over the N95 is preferred over a surgical mask to reduce surface contamination. Between uses, respirators should be hung in designated storage area or kept in clean breathable container such as a paper bag. Clean non-sterile gloves should be used when redonning used N95 respirator and performing a user seal check.

Resources:

Updated December 22, 2020.

When manually moving a patient with known or suspected COVID-19, health care personnel should follow standard, contact, and airborne precautions. Health care personnel who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator or facemask, gown, gloves, and eye protection. When available, respirators (instead of facemasks) are preferred; they should be prioritized for situations where respiratory protection is most important and the care of patients with pathogens requiring Airborne Precautions (eg, tuberculosis, measles).

Resources:

  • AORN Guideline for Transmission-Based Precautions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Updated December 22, 2020.

Shoe covers are not required PPE when caring for a COVID-19 patient, as COVID-19 is caused by a respiratory virus, and for it to infect a new host it must enter someone’s nose, mouth or eyes through inhalation or direct contact with respiratory secretions.

Shoe covers and booties however may be used as PPE when participating in any patient surgery if the potential for exposure to large amounts of blood, body fluids, and irrigation is expected.

Resources:

Updated December 22, 2020.

Surgical masks with ear loops may be worn in the OR, provided that the mask completely covers the mouth, nose, and chin and fits snugly in a manner that prevents gaps at the sides of the mask. The wearer’s facial shape will determine which mask attachment (eg, ties, ear loops, elastic) provides the best fit. Masks with ear loops may not have been designed and intended for use as surgical masks. The type of surgical mask needed for the procedure should be selected according to the barrier level as stated on the product label. The level of protection provided by the mask may be determined by the ASTM barrier level as stated on the product label, with higher barrier levels providing more protection to the wearer.

Resources:

  • AORN Guideline for Transmission-Based Precautions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • ASTM F2100-11(2018): Standard Specification for Performance of Materials Used in Medical Face Masks. West Conshohocken, PA: ASTM International; 2018.

Updated December 22, 2020.

The decision to implement extended use of face masks should be determined by occupational health, infection prevention, and professionals managing respiratory protection program and should be based on prevalence of disease in region, severity of illness as well as local conditions (eg, number of disposable face masks available, current face mask use). The CDC recommendations for extended use involve the wearing of same facemask for repeated close contact with several different patients without removing the facemask between patients. However, the facemask should be removed and discarded if soiled or damaged after healthcare provider (HCP) leaves patient care area. The HCP should make every effort not to touch or readjust facemask, but if that occurs, they must immediately perform hand hygiene.

Resources:

Updated December 22, 2020.

An N95 respirator is a particulate filtering facepiece respirator that has been approved by the National Institute for Occupational Safety and Health (NIOSH), a US Federal agency responsible for conducting research and making recommendations for the prevention of work-related disease and injury, and cleared for use by the FDA in a medical setting. A surgical N95 respirator is a NIOSH-approved N95 respirator that has also been cleared by the FDA as a surgical mask (surgical masks provide barrier protection against droplets including large respiratory particles).

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Reviewed December 22, 2020.

An N95 respirator is not needed in the decontamination area for protection from SARS-CoV-2, a lipid-enveloped virus that is susceptible to detergents and disinfectants. Sterile processing personnel who perform decontamination should brush instruments only below the water line when hand washing and wear PPE consistent with the Guideline for Cleaning and Care of Surgical Instruments including a fluid resistant gown with sleeves, gloves that extend beyond the cuff of the gown, a mask with fluid barrier rating, eye protection or full face shield, and shoe covers or boots designed for use as PPE.

Resources:

  • AORN Guideline for Cleaning and Care of Surgical Instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • AORN Guideline for Sterilization Packaging Systems. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • AORN Guideline for Sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020.

There are many different scenarios that can occur after the procedure has been completed and the patient is ready for transport.

  • Some patients will be taken directly to ICU intubated.
  • Others may be extubated and recovered in the OR and then transferred directly to a patient room.
  • Others may be taken to a negative pressure room for extubation.

If the patient is recovered and extubated in the OR, transfer the patient directly to the ICU or patient room.

If the patient remains intubated, transfer the patient directly to the ICU.

Call the patient care team on the floor or in the ICU to notify them of the impending transfer.

  • Place a surgical mask on an unintubated patient if it can be tolerated or have the patient cover his or her mouth with a facial tissue.
  • Transfer the patient to a transport stretcher or the patient bed.
  • Cover the patient with a clean sheet.
  • Remove and dispose of the contaminated gowns and gloves and perform hand hygiene. Do not wear the same PPE for transport as worn during the procedure.
  • Keep the N95 respirator on during transport.
  • Keep eye protection on to conserve supplies.
  • Don clean gloves to cleanand disinfect high-touch areas on the stretcher or bed (eg, rails, headboard) and any controls that will be touched by personnel during transport.
  • Remove gloves and perform hand hygiene.
  • Assign an additional transporter who is not wearing PPE to open doors and secure elevator buttons.
  • If it is anticipated that the transport team will come in contact with the patient, wear a gown and gloves in addition to eye protection and a respirator.

Resources:

  • AORN Guideline for Transmission-Based Precautions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • Siegel JD, Rhinehart E, Jackson M, Chiarello L; Health Care Infection Control Practices Advisory Committee. 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007; 35(10 Suppl 2):S65–S164.

Reviewed December 22, 2020.

According to the most recent information from the Centers for Disease Control, management of medical waste can be performed in accordance with routine procedures as outlined in your state and federal regulations. This directive also includes laundry. There is no evidence that novel coronavirus needs additional treatment.

Resources:

  • CDC. “Clinical Questions about COVID-19: Questions and Answers.”
  • Sehulster L, Chinn RY, Arduino MJ et al. Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). Chicago, IL: American Society for Healthcare Engineering/American Hospital Association; 2004.

Updated December 22, 2020.

In addition to standard precautions, the CDC currently recommends use of a respirator (preferred) or facemask, gown, gloves, and eye protection when caring for a patient with known or suspected COVID-19. When scrubbed, a sterile gown and gloves should be worn. The World Health Organization recommends using an N95 or equivalent respiratory protection if aerosol-generating procedures (eg, intubation) are performed. Refer to the CDC, your local health authority, and your organization’s policies and procedures for the latest guidance.

Resources:

Updated December 22, 2020.

Donning of PPE should occur outside the OR. For scrubbed team members, respiratory protection and eye protection or a face shield should be donned outside of the room, but the sterile gown and gloves should be donned inside the room after surgical hand antisepsis.

Doffing of the PPE should occur inside the OR, but the respiratory protection and eye protection should be removed after exiting and closing the door to the OR.

Resources:

Updated December 22, 2020.

A joint statement by the American Society of Anesthesiologists (ASA), American Association of Nurse Anesthetists (AANA) and the Anesthesia Patient Safety Foundation (APSF) states that when performing intubation and other aerosol generating procedures there should be minimal personnel at head of bed and they should wear properly fitted N95 respirators, eye protection, gowns and gloves. However, ASA, AANA, and APSF recognize that the population density, hospital size and resources, location, and access to supply chains presents unique challenges and therefore endorses the temporary mitigation plans as outlined by CDC for limited reuse of N95 respirators.

Resources:

Updated December 22, 2020.

A facility interdisciplinary team including an infection preventionist and occupation health professional should determine whether a PAPR may be used for respiratory protection in the perioperative environment when a sterile field is present. It is important to note that the Centers for Disease Control and Prevention does not recommend that PAPRs with exhalation valves be used during invasive procedures when a sterile field is present. If the interdisciplinary facility team determines that PAPR use is allowed, a standardized procedure should be created that outlines perioperative PAPR use and how the sterile field will be protected from contamination. These measures may include covering portions of the sterile field and designating the direction that the blower will be exhausted.

Resources:

Updated December 22, 2020.

When supplies of disposable isolation and surgical gowns are depleted, gown use can be shifted to cloth isolation gowns which are usually made of polyester or polyester-cotton fabrics. Gowns made of these fabrics can be laundered, but additional laundry operations and personnel may be needed due to increased loads and cycles. Systems should also be in place to routinely inspect and maintain the gowns. The CDC’s guidance for Considerations for Selecting Protective Clothing used in Healthcare for Protections against Microorganisms in Blood and Body Fluids outlines the evidence and standards, test methods, and specifications for fluid-resistant and impervious gowns and can serve as guide to selection of reusable gown material.

Resources:

Updated December 22, 2020.

Vaccine

The most recent recommendations for vaccine administration can be found on the CDC website at the following links.

Resource:

Reviewed January 28, 2021.

Surgical Precautions

Forced air warmers may be used during surgical procedures in COVID-19 positive patients to decrease the risk of hypothermia. In consultation with the unit’s manufacturer, an interdisciplinary team should determine when the unit will be activated. One consideration is to turn the unit off during intubation and extubation for the time that it takes to clear the air of airborne contaminants. The manufacturer of the device should also be consulted to determine if the filters in the devices need to be changed more frequently.

Resource:

  • AORN Guideline for Prevention of Hypothermia. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020.

All surgical smoke should be evacuated. In the Occupational Safety and Health Administration (OSHA) hierarchy of controls, room ventilation and smoke evacuation are considered the first line of protection against surgical smoke hazards. For the patient with known or suspected COVID-19 infection, wearing a fit-tested surgical N95 filtering face piece respirator is secondary protection against residual surgical smoke.

Resource:

Reviewed December 22, 2020.

The CDC’s “ Considerations for Inpatient Obstetric Healthcare Settings” will help you safely care for obstetric patients. One of the first things that the obstetric patient who is confirmed or suspected COVID-19 or the medical transport personnel should do is to alert the obstetric unit of her impending arrival. This notification will allow the unit to gather PPE and alert health care personnel on the team who will be caring for her. The American College of Obstetricians and Gynecologists also suggest that infants born to mothers with confirmed COVID-19 should be considered persons under investigation (PUI) and should be isolated according to the Infection Prevention and Control Guidance for PUIs until the mother’s transmission-based precautions are discontinued.

Resource:

Reviewed December 22, 2020.

There is no literature or research to support using smoke evacuators in this manner. Also, the smoke evacuators have not be tested and approved by the FDA for this type of application. Please check with your manufacturer of your smoke evacuator for further direction.

Resource:

  • AORN Guideline for Surgical Smoke Safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020.

AORN recommends that each facility base their decision to use an air-transfer device for a known or suspected COVID-19 patient on a risk assessment by an interdisciplinary team weighing the potential risk of contamination with using the device against the potential for musculoskeletal injuries when moving a patient manually.

Any air movement from an air-assisted device will keep the virus in the air for a longer period. Some air-assisted transfer devices have HEPA filters that filter the air before the air enters the device system (i.e., blower, hose, mattress). If using a device without a HEPA filter with a known or suspected COVID-19 patient, the contaminated air can enter the device and be forced back out into the room through the holes in the mattress.

Contamination may be minimized with both types of devices if the blower is used after the patient is intubated, before the patient is extubated, and the correct number of air exchanges and the time has elapsed. Follow the manufacturer’s instructions for use for cleaning and decontamination. Contact your device manufacturer for guidance and filtration specifics.

Please refer to the Guideline for Safe Patient Handling and Movement for additional information on assessing the patient and developing a plan of care for safe patient handling. Consider alternatives to the air-transfer device including slide sheets, slide boards, and rollers.

Resource:

  • AORN Guideline for Safe Patient Handling and Movement. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • AORN Guideline for Environmental Cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020.

AORN has several existing educational programs on surgical smoke available to our members.

Resource:

  • AORN Guideline for Surgical Smoke. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Check with your local product representative and/or the manufacturer of your smoke evacuation devices for their specific instructions for use. Your manufacturers are your best resource for this information. Several manufacturers are sending letters to their customers and providing guidance and resources on their websites regarding COVID-19. If you have not received the information, contact your local product representative and the manufacturer.

Resource:  

  • AORN Guideline for Surgical Smoke Safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020

Society of American Gastroenterologists and Endoscopic Surgeons (SAGES) has detailed recommendations for reducing the risk of aerosolization during laparoscopy.

Resources:

Ideally intubation should occur with a minimal number of personnel at head of the bed utilizing properly fitted surgical N95 respirators, which have not been reprocessed, eye protection, gowns and gloves. If the surgical team remains in the OR with the necessary PPE, they should distance themselves from head of bed during intubation. Once patient is intubated and stabilized, surgical antisepsis, draping and procedure could begin without waiting for full air exchange. However, no one should enter or leave the OR during this initial timeframe.

Resources:

Reviewed December 22, 2020.

Ideally, COVID-19 inpatients should bypass the preoperative area and go straight to the OR. If the patient must come to the preoperative area, place them in a negative pressure airborne infection isolation room (AIIR). If an AIIR is not available use a doored examination room with the door closed or create a separate, well-ventilated space that separates them from other patients by six or more feet. Another option is for the facility to allow waiting patients to remain in a personal vehicle or outside the where they can be contacted by mobile phone when it is their turn to be evaluated.

Postoperatively, the American Society of Anesthesiologists advises against bringing a COVID-19 patient into the PACU. Instead, the patient may be recovered in the OR or moved to another designated OR for anesthesia recovery. Ideally the patient would be extubated and recovered in a negative pressure airborne infection isolation room.

Resources:

Reviewed December 22, 2020.

The CDC has identified specific AGPs that are linked to the potential for transmission from respiratory droplets (Table 1). There is a known risk for transmission from smaller aerosolized respiratory droplets that may occur during AGPs. The CDC recommends that health care providers in the room during these procedures wear respiratory protection such as N95 respirators.

AORN has identified procedures that may occur during surgery that can aerosolize blood and body fluids. According to limited data from the CDC, COVID-19 has been detected in blood specimens, and it is unknown whether the virus is viable or infectious in extrapulmonary specimens (specimens that come from outside the lungs). The risk for transmission from aerosolized blood and body fluid remains unknown at this time. Out of an abundance of caution, AORN recommends taking precautions including wearing respiratory protection, to prevent transmission of aerosolized blood and body fluids that may be present. Bronchoscopy, tracheostomy, and thoracic procedures may present a higher risk for airborne transmission of COVID-19 because these procedures involve the respiratory tract, which could lead to aerosolization of the virus. There have been some reports that COVID-19 is present in stool and may be transmissible through the fecal-oral route.

Table 1. Aerosol-Generating Procedures

Potential Risk

Uncertain Risk

  • Open suctioning of airways1
  • Sputum induction1
  • Cardiopulmonary resuscitation1
  • Intubation and extubation1
  • Non-invasive ventilation (eg, BiPAP, CPAP) 1
  • Bronchoscopy1
  • Manual ventilation1
  • Surgical procedures involving the airway (eg, tracheostomy, ENT, thoracic, thoracoscopy)
  • Other procedures that aerosolize respiratory secretions

 

  • Nebulizer administration1
  • High flow O2 delivery1
  • Endoscopy (eg, EGD, colonoscopy, transesophageal echocardiogram [TEE])
  • Laparoscopy
  • Use of energy-generating devices (eg, electrosurgery, laser, ultrasonic)
  • Use of high-speed powered equipment (eg, saws, drills)
  • Use of intraoperative debridement devices with irrigation (eg, hydrosurgery, ultrasonic debridement, pulse lavage)
  • Other procedures that aerosolize blood and body fluids

Reference

Healthcare infection prevention and control FAQs for COVID-19: Which procedures are considered aerosol generating procedures in healthcare settings? Centers for Disease Control and Prevention. Updated October 5, 2020. Accessed November 2, 2020.

Resources:

Reviewed December 22, 2020.

Either door may be opened during the procedure to bring in supplies, but all door openings should be kept to a minimum. When determining which door to open, consideration should be given to which door would provide the least amount of air flow disruption. In some facilities, the door to the outer hallway (the patient door) is much larger than the door to the core or it may be automated and remain open longer. If either of these situations exist, then the door to the core should be used for bringing in supplies during the procedure. When opening the door, it should be opened only as far as necessary to bring in the supplies.

Resource:

  • Guideline for sterile technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2024.

Updated April 5, 2024.

Intubation is an aerosol-generating procedure and there may be a risk of aerosolized particles from intubation settling on the sterile field. However, the impact of aerosolized respiratory particles causing or contributing to surgical site infection in the same patient is unknown. Out of an abundance of caution, measures to prevent exposure of the sterile field to airborne contaminates should be used. Some examples of precautionary measures that could be taken to prevent contamination of the sterile field from aerosolized particulates include

  • Setting up a procedure after intubation
  • Covering of sterile fields

Setting up for a procedure after intubation may reduce the risk of particulate landing on the sterile field during intubation. Table covering is another measure that has been shown to reduce contamination of sterile fields over time. The Guideline for Sterile Technique recommends that sterile fields should be covered if not used immediately or during periods of increased activity. One period of increased activity identified in the literature is the time prior to incision which includes intubation. There are two recommended methods for table covering. One is the two-“cuffed”-drape method (Figure 1) using two sterile drapes and the second is use of a sterile drape designed for table covering. (Figure 2) When using a drape made for covering tables follow the manufacturer’s written instructions for use.

 

Figure 1: Covering a Sterile Field with Two-Cuffed Method

Illustration demonstrating covering a sterile field.


Illustration by Colleen Ladny and Kurt Jones


Figure 2. Covering Using a Drape Designed for Covering

Illustration showing using draping as covering.

Illustration by Kurt Jones

Resources:

Reviewed December 22, 2020.

The amount of time is dependent on the number of air changes per hour with individual OR. Most ORs have either 15 or 20 air changes per hour but some have more. If you do not know the number of air changes per hour contact your maintenance or plant operations department. According to the CDC the time required to reach 99 % efficiency at 15 air changes per hour is 18 minutes and for 99.9 % efficiency it is 28 minutes. If the air changes per hour is 20 the time required for 99 % efficiency is 14 minutes and 21 minutes for 99.9 % efficiency.

Resources:

Reviewed December 22, 2020.

Minimizing the amount of equipment, supplies and personnel in room is one proven action to prevent transmission. However, each facility will need to develop their own protocol based on the number of operating rooms, negative pressure or airborne infection isolation rooms (AIIR), prevalence of disease in their region, and the availability of equipment and supplies. When surgeries for patients who do not have COVID-19 are performed in the same surgical suite, every effort should be taken to distance these patients.

AORN has an online guide for protecting staff and safely managing COVID-19 patients throughout the surgical process entitled Perioperative Care of the COVID-19 Patient that is available for purchase.

Some guidelines and protocols have been published by the American College of Surgeons, The Canadian Anesthesiologists Society, and Nebraska Medicine which include:

  • Developing a dedicated COVID-19 OR
  • Maintaining supply of proper personal protective equipment
  • If available, utilizing a negative pressure anteroom with separate entrance between OR and main hallway that is used for:
    • Donning and doffing PPE
    • Placing supplies that are needed after the case begins
  • Dedicated equipment, anesthesia and medication carts
  • Dedicated OR team for COVID-19 patients
  • Detailed education of perioperative team on infection prevention strategies, including visual reminders
  • Defined roles and responsibilities of each team member
  • Thoughtful and judicious preparation for procedure, with removal of all items not needed before patient enters room
  • Runner outside OR who will retrieve medications, instrumentation and other supplies
  • Utilization of mobile telephones to request needed items from runner and when they are available for circulator
  • Double-bag specimens

Resources:

Reviewed December 22, 2020.

 

Depending on your local situation and patient population, it may be ideal to have everyone in the OR wear respiratory protection for all patients regardless of COVID-19 status, but this decision should take into account not only your N95 supply in the present time but also your projected usage, as this shortage is expected to continue for months. While there have been concerns about lab testing and asymptomatic patients, many places simply do not have the resources to use N95 respirators as a universal approach for all surgical patients. The CDC currently only recommends N95 use for known or suspected COVID patients, and use of N95s should be prioritized for these patients.

Resources:

Reviewed December 22, 2020.

Normally, the direction of airflow should be from the operating room (OR) to the hallway (positive pressure) to minimize contamination of the surgical field. In some hospitals there are ORs with reversible airflow or pressure, whereas others have positive-pressure rooms with a negative pressure anteroom.

Precautions should be taken when performing aerosol-generating procedures such as intubation, extubation, bronchoscopy and suctioning of airways. CDC states that AGPs should ideally take place in an airborne infection isolation room (AIIR), but this negative pressure can put patients who are having surgery at risk for surgical site infections. A risk assessment should be performed by an interdisciplinary team to determine if COVID-19 suspected or confirmed positive patient’s surgery can be postponed until they are no longer infectious.

If it is determined that an AII room will be used for a surgical procedure, keep the doors to the AIIR or OR closed, and minimize traffic into and out of the room. When possible, perform the procedure when the fewest people are in the surgical suite. After the procedure, leave the room vacant while the OR air exchanges clear any airborne contaminants that may remain in the room. Air exchanges that remove airborne contaminants should occur before anyone who is not wearing respiratory protection enters the room, and before environmental cleaning is done.

If you are considering conversion of the OR to negative pressure, consult with your engineering and maintenance team. It is important to evaluate whether altering the pressure to be negative in one or more ORs will affect the air balancing in adjacent areas.

Resources:

Reviewed December 22, 2020.

 

Yes, an interdisciplinary team may decide to use a positive pressure room for a procedure on a COVID-19 patient when there is an increased risk for SSI or converting the OR to negative pressure is not feasible. If possible, perform the procedure when the least amount of people are in the surgical suite. In other words, this is a risk versus benefit decision that will be specific to the situation, patient needs, and proximity of other patients in the operating room.

During the procedure:

  • Limit traffic during procedure and only open the door if it is absolutely necessary.
  • If you use a runner or an additional circulating RN outside the OR to secure supplies, that person may wear a surgical mask but should not enter the OR. If you have an anteroom or substerile room this can be used as a drop off point, making sure one door is closed before the other is opened.

When performing intubation and/or extubation in a positive pressure OR:

  • Ideally intubate patients in an AII room and then transfer them to the positive pressure OR (once intubated they are considered low risk because it is a closed system). Also consider transferring the patient to an AII room for extubation.
  • Only essential personnel wearing respiratory protection, such as an N95 respirator or PAPR, should be in the OR when intubation and extubation occur, including the RN Circulator. A time should be established for when it is safe for other team members who do not have respiratory protection can enter the room after intubation or extubation. This time should be determined in conjunction with facilities personnel who can provide information about number of air exchanges. Also, if extubation is performed in the OR, the scrubbed person should prioritize point of use treatment of surgical instruments to reduce the drying of bioburden on them before extubation occurs and they leave the room. This can be achieved by using the method that your facility has chosen to keep instruments moist until decontamination in the sterile processing area occurs.
  • An interdisciplinary team in consultation with manufacturer may determine that a portable high-efficiency particulate air (HEPA) filtration unit may be used
  • A portable anteroom system (PAS)-HEPA combination unit may also be used.

After the procedure:

  • Adequate air exchanges should occur before environmental services enters the room for cleaning. With 15-20 air exchanges it will be around 30 minutes.

Resources:

Updated December 22, 2020.

Consult with your maintenance /plant operations department to determine how a joint air handling system that is shared with adjacent areas is filtered and if the air is vented directly outside and will not affect the air in the adjacent rooms, including the hallway outside the OR and the sterile core.

Resource:

  • ANSI/ASHRAE/ASHE Standard 170-2017: Ventilation of Health Care Facilities. New York, NY: American Society of Heating, Refrigerating and Air-Conditioning Engineers; 2017.

Reviewed December 22, 2020.

If it is determined that a portable HEPA filter device will be used, consult the manufacturer of device, as well as facility management and infection prevention to determine the duration of device activation.

Resources:

  • AORN Guideline for Sterile Technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • AORN Guideline for Transmission-Based Precautions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020.

Transmission-Based Precautions

Review of currently available evidence suggests that most individuals do not become re-infected within 3 months of resolution of SARS-CoV-2 infection. Re-infection has not been definitively identified to date. However, if symptoms develop, the HCP should be evaluated to identify potential alternative etiologies for their symptoms.

Resource:

Updated December 22, 2020.

AORN recommends the evacuation of all surgical smoke as it contains hazardous chemicals, ultra-fine particles, viruses, bacteria, and cancer cells. During higher-risk, aerosol generating procedures or procedures with known or suspected aerosol transmissible diseases, such as tuberculosis, the perioperative team should wear a fit-tested surgical N95 filtering face piece respirator in addition to using a smoke evacuator. Wearing a fit-tested surgical N95 filtering face piece respirator is secondary protection against residual surgical smoke.

The earliest detected case of COVID-19 was in China on November 17, 2019. As such, there is currently no research on transmission of the virus through surgical smoke. However, there is no indication or proof that COVID-19 is not transmissible through surgical smoke.

Research studies have demonstrated the presence of viruses (e.g., human papilloma virus) in surgical smoke with documented transmission to health care providers. According to limited data from the CDC, SARS-CoV-2 RNA has been detected in blood specimens, and it is unknown whether the virus is viable or infectious in extrapulmonary (outside the lungs) specimens. In similar coronaviruses, viable and infectious SARS-CoV was isolated from blood specimens, although infectious MERS-CoV was only isolated from the respiratory tract.

Consult with your infection preventionist on measures (eg, smoke evacuation, fit-tested surgical N95) to take when performing surgery on a patient with known or suspected COVID-19. Consistent smoke evacuation is recommended for all surgical patients.

Resources

Updated December 22, 2020.

Environmental Cleaning

As surgical smoke contains potentially infectious material such viruses, bacteria, blood, and cancer cells, OSHA and the AORN Guideline for Surgical Smoke Safety requires that the used filters, tubing, electrosurgical pencils with evacuation tubing, be handled using standard precautions and disposed of as biohazardous waste.

Resources:

  • AORN Guideline for Surgical Smoke Safety. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • AORN Guideline for Transmission-Based Precautions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020.

The current CDC guidance states that routine cleaning and disinfection procedures using an EPA-registered, hospital-grade disinfectant from List N, are appropriate for SARS-CoV-2 in healthcare settings. Upon patient leaving the room, entry should be delayed until sufficient time has elapsed for enough air changes to remove aerosolized infectious particles. The AORN Guideline for Environmental Cleaning outlines recommended cleaning procedures that should be monitored for quality and consistency. Linen and medical waste should follow the routine established practices as outlined by local, state and federal regulations.

Resources:

Reviewed December 22, 2020.

The AORN Guideline for Radiation Safety provides recommendations to minimize radiation exposure to the patient. One strategy includes covering areas of the patient outside of the direct radiation beam with lead or lead-equivalent shielding.

For patients who require this shielding during certain procedures and who may have COVID-19, the lead shielding should be cleaned and disinfected according to manufacturer’s instructions. The coronavirus is an enveloped virus, which makes it easier to destroy with the appropriate EPA-registered disinfectants. You can find List N (Products with Emerging Viral Pathogens AND Human Coronavirus claims for use against SARS-CoV-2), including those appropriate for porous surfaces, linked through the CDC. Assemble an interdisciplinary team including your infection preventionist and radiation safety officer to assure the appropriate disinfectant is being used for the shielding devices you have in your facility. As the covering is often a porous material, be sure to allow the disinfectant to dry completely and store the aprons and thyroid shields in a manner that prevents folding or creasing. You may also consider protecting the lead shielding with a fluid-resistant cover, such as plastic sheeting material, to prevent contamination.

Resources:

Reviewed December 22, 2020.

Once sufficient time has elapsed to remove infectious particles, individuals performing cleaning can enter the room after performing hand hygiene, donning a facemask (for source control), a gown, and gloves. Eye protection or full face shield should also be worn if splash or sprays are anticipated during cleaning or if they are required by disinfectant instructions for use. Shoe covers are not necessary as part of PPE.

Resources:

Reviewed December 22, 2020.

 

The EPA website has a list of disinfectants that have qualified under EPA’s emerging pathogen viral pathogens program for use against SARS-CoV-2. Reviewing this list for products that could be obtained from other vendors may be an option. Contact your local health authority for guidance or access to stockpile resources.

When EPA-registered product is not available, the CDC allows the use of generic sodium hypochlorite solutions, using a 1:100 dilution (500-615ppm). However, it is important to note that this solution is not a cleaning agent and can be both caustic and corrosive, especially on stainless steel surfaces. Therefore, cleaning with detergent and water must occur before using the solution. Use of any alternative solutions should be discontinued once List N EPA-registered disinfectants are obtained.

Resources:

Reviewed December 22, 2020.

SARS-CoV-2, the virus that causes COVID-19 can survive up to three hours in aerosols when air is not circulated or moving, and up two to three days on plastic and stainless steel. Therefore, sufficient air exchanges need to occur before cleaning begins and why thorough cleaning and disinfection of high touch stainless steel surfaces is so important.

In their recommendation on care of COVID-19 patient, the American Society of Anesthesiologists (ASA) suggests that it may be beneficial to utilize disposable covers (eg, plastic sheets for surfaces) to reduce droplet and contact contamination of equipment and surfaces. Wearing proper PPE, the sheets could be discarded prior to cleaning and disinfection of surfaces.

Resources:

Reviewed December 22, 2020.

 

The current CDC guidance states that routine cleaning and disinfection procedures using an EPA-registered, hospital-grade disinfectant from List N, are appropriate for SARS-CoV-2 in healthcare settings. However, it is important that all items touched during patient care, as well as high touch surfaces within the operating room are cleaned and disinfected after the surgical procedure due to potential spray of blood and body fluids. The AORN Guideline for Environmental Cleaning provides examples of high-touch objects, such as, mobile devices, anesthesia equipment, door handles and computer accessories, as well as areas to concentrate on when performing cleaning like control panels, knobs and switches. Facilities may already have a policy and procedure for room cleaning following transmission-based precaution procedures which can be used, or an interdisciplinary team can be established to identify which surfaces to include and the frequency they will be cleaned.

Resources:

Reviewed December 22, 2020.

Leadership

During a crisis it is important that leaders facilitate shared responsibilities, as well as recognize when one or more team members may be experiencing more severe responses in order to direct them to professional assistance. The CDC also suggests developing a buddy system in which coworkers are partnered up to support each other at work. Leadership can also encourage deep breathing and mindfulness practices during breaks, limit voluntary overtime, and create a culture of respect and open communication for team members to ask for breaks and discuss their concerns.

Resource:

Reviewed December 22, 2020.

 

The long-term effects to your health may limit your resilience to stress. Take time to reflect on your day and talk about your feelings and experiences, maintain a healthy diet, exercise, and sleep routine. For example, you can practice gratitude and self-affirmations while practicing yoga, talk about experiences and take a moment to stretch while cooking dinner with the family, or meditate with sleep music and aromatherapy before bed. If distress impacts activities of your daily life for several days or weeks, talk to a clergy member, counselor, or doctor, or contact the SAMHSA helpline at 1-800-985-5990.

Resources:

Reviewed December 22, 2020.

 

Always consult your local hospital policies and health department or state board regulations for guidance on scope of practice during this pandemic, however, perioperative staff may be asked to contribute their nursing skills in other areas of the hospital in order to respond to the influx of patients due to the Covid-19 pandemic. Perioperative nurses are experts in infection prevention, sterile technique, donning and doffing PPE, team communication, patient positioning, and preventing cross-contamination, which are important skills to manage the Covid-19 pandemic.

Available free cross-training resources during the Covid-19 pandemic include:

Resource:

  • American Association of Critical-Care Nurses (AACN)
  • AORN Guidelines for Perioperative Practice
  • Society of Critical Care Medicine (SCCM)

Updated December 22, 2020.

 

A facility should perform a risk assessment that takes into account perioperative personnel available, appropriate PPE is provided and worn, or if there are perioperative personnel who are in the high-risk category due to morbidities, or age. According to the CDC, wearing appropriate PPE, that is gown, gloves, eye protection and a respirator, should protect HCP having prolonged close contact with patients infected with COVID-19. However, to account for any inconsistencies, or human error, HCP should still perform self-monitoring and report any signs of illness and isolate themselves if ill.

Resources:

Reviewed December 22, 2020.

 

The American College of Surgeons (ACS) recommends the following:

Hospitals and surgery centers should consider the patient’s needs, and the ability of the facility to meet those needs at the real time the decision is being made. For example, during a surge in a facility of COVID-19 patients, ORs may become ICUs, resources may be limited.

The risk to the patient should include an aggregate assessment of the real risk of proceeding and the real risk of delay, including the possibility that a delay of 6-8 weeks could be required to a time COVID-19 is less prevalent.

Resources:

Reviewed December 22, 2020.

According to the American Medical Association, emergency surgery is performed to relieve or eliminate emergency medical conditions, such as those causing serious jeopardy to the health of a patient, impairment of bodily functions or dysfunction of bodily organs or parts. A 2017 study published in JAMA on the risks associated with urgent surgery versus elective and emergency surgery, the authors took a simple but reasonable approach and defined urgent procedures as those "not elective but not emergent."

Each hospital may already have established definitions that are part of their protocol for scheduling procedures. However, the urgency of a surgery must be evaluated on an individual basis by the surgeon, with consideration of the patient’s medical risks if surgery were to be delayed, geographical location (eg, area of high community spread) and facility resources (ie, beds, staff, equipment, supplies).

On March 24th ACS, ASA and AORN released a joint statement calling for the creation of a surgical review committee, composed of representatives from surgery, anesthesia, and nursing leadership that would meet on a daily basis to conduct surgical triage decisions regarding scheduled surgery, that was preferably no later than the day before scheduled surgery. To assist in the committee’s decisions, the American College of Surgeons, in conjunction with associated surgical specialty societies, has developed triage criteria according to specialty which can be found on the ACS website.

Resources:

Reviewed December 22, 2020.

ASCs

A Guide to Operational Management includes 30+ customizable tools. Find the full list of what’s included in the Course Syllabus under “Implementation Tools.”

ASC administrators or leaders covering multiple roles in the ASC. The ASC Academy Leadership Guides Series was created in response to the overwhelming request for “short courses with plug and play tools for practical application of the information.” 

ASC leaders are wearing multiple hats and need resources to solve problems related to regulatory compliance, accreditation surveys, quality reporting and safety measures in an easy-to-understand, timesaving, manageable format with implementation tools.  

Yes, you will benefit from this course. This course provides a refresher on the relevant course material and includes customizable tools, templates, and video-based instructions to guide you through the process of orientation and training, patient rights and responsibilities, and medical records management. It gives you the how-to elements for practical application. 

ASC administrators or leaders covering multiple roles in the ASC. The ASC Academy Leadership Guides Series was created in response to the overwhelming request for “short courses with plug and play tools for practical application of the information.” 

ASC leaders are wearing multiple hats and need resources to solve problems related to regulatory compliance, accreditation surveys, quality reporting and safety measures in an easy-to-understand, timesaving, manageable format with implementation tools.  

Yes, you will benefit from this course. It provides a refresher on governance, licensure, certification, and accreditation course material. It also includes the customizable tools, templates, and video-based instructions to guide you through the process of contracting, governing body operations, credentialing, recredentialing, and peer review. It gives you the how-to elements for practical application.

A Guide to Governance includes 40+ customizable tools. Find the full list of what’s included in the Course Syllabus under “Implementation Tools.”

ASC administrators or leaders covering multiple roles in the ASC.  The ASC Academy Leadership Guides Series was created in response to the overwhelming request for “short courses with plug and play tools for practical application of the information.” 

ASC leaders are wearing multiple hats and need resources to solve problems related to regulatory compliance, accreditation surveys, quality reporting and safety measures in an easy-to-understand, timesaving, manageable format with implementation tools.  

Yes, you will benefit from this course. It provides a refresher on the Quality & Risk Management course content, plus it includes customizable tools, templates, and video-based instructions to guide you through the process of the ASC Quality Reporting submission and in developing and maintaining a successful Quality and Risk Management program specific to the facility’s needs. It gives you the how-to elements for practical application.

Find the full list of included tools and templates in the Course Syllabus under “Implementation Tools.”

Ambulatory Surgery Center Association (ASCA) concurs with ACS that “the risk to the patient should include an aggregate assessment of the real risk of proceeding and the real risk of delay, including the expectation that a delay of 6-8 weeks or more may be required to emerge from an environment in which COVID-19 is less prevalent”

Examples of procedures that might still need to proceed include:

  • acute infection
  • acute trauma that would significantly worsen without surgery
  • potential malignancy
  • uncontrollable pain that would otherwise require hospital admission
  • a condition where prognosis would significantly worsen with a delay in treatment

According to ASCA, ASCs need to be prepared for the possibility that the pandemic may proceed to a point that strains the system such that hospitals will need to shift necessary surgeries to ASCs and/or hospitals may need the ASCs resources.

Resources:

Reviewed December 22, 2020.

ORs can be cleaned before shutdown. Likely it is unknown when a center will reopen, and facility staff may not be allowed to return until restrictions due to COVID-19 have been lifted. When it does reopen ORs should be terminally cleaned and supplies and equipment should be evaluated for signs of contamination.

Resources:

  • AORN Guideline for Environmental Cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020.

There are several things to consider before shutting down an ASC. If it will be shut down for an indefinite period, take inventory of equipment and supplies and include expiration dates. This will assist you in determining supplies that could be used by a hospital in the event of shortages and will assist you when occupancy is restored for supplies that may need to be restocked or retrieved. ASCA has developed a checklist for this. Some of you may be part of your community emergency preparedness program and may be asked to provide resources and this could also include using your facility if and when a surge of COVID-19 patients occur.

Before utilities are shutdown, conduct a risk assessment and consider the following:

  • Determine if equipment or supplies will be affected by temperature and humidity per manufacturer’s IFU. If a set back method is used, perform the same evaluation.
  • If utilities are shut down, determine if freezers that contain tissue and refrigerators that contain medications will be transferred to another facility.
  • Autoclaves will have to be brought back- up before procedures can be begin again and qualification testing may need to be conducted per manufacturer’s IFU and may involve industry service technicians.
  • Before HVAC is restored, the facility will need to be cleaned, if dust is found on surfaces it can be dispersed into the air after HVAC is restored. After a complete air exchange has occurred, a terminal cleaning will need to be done and supplies evaluated for contamination.
  • If utilities are not shut down, HVAC is monitored for variances in temperature and humidity.
  • AORN guidelines on Design and Maintenance of the surgical suite address utility and HVAC disruptions.
  • Environmental Cleaning Guideline addresses cleaning after utility disruptions.
  • Sterilization guideline addresses the processes for performance testing following shutdown of autoclaves and other sterilization equipment. Manufacturer’s IFU should be followed and facility management personnel consulted, when determining how to shut down and bring back up utilities and HVAC after a prolonged closure.

Resources:

Reviewed December 22, 2020.

Converting OR/Ventilators

This is a decision that should be made by an interdisciplinary team that includes at the least an infection preventionist, anesthesia provider, and a facility management representative that is familiar with the air handling in the perioperative department. Factors to consider are:

  • Whether or not the positive pressure operating rooms can be converted to a negative pressure room.
  • Whether adjacent ORs share the same air handling system.
  • How close to the converted ICU room is to operating rooms still being used for non-COVID surgery.

Resources:

Reviewed December 22, 2020.

The US Food & Drug Administration has provided guidance to health care providers on ventilator supply mitigation strategies. The FDA Letter to Health Care Providers provides recommendations for health care providers and facilities, based on the recently issued guidance, regarding use of devices with patients who develop respiratory compromise from COVID-19 or other respiratory disorders. The recommendations are intended to compliment the CDC COVID-19 recommendations. Health care organizations should have, as part of their pandemic planning, a procedure for use of anesthesia machines when the supply of ventilators does not meet the demand. This procedure should be defined by an interdisciplinary team including anesthesia professional(s), perioperative RN leaders, health care administrator(s), infection preventionist(s), and other stakeholders defined by the organization. This work should be informed by clear information from the anesthesia machine manufacturer about how functionality may be safely optimized for use as a critical care ventilator. The team should also establish a plan for and assess the availability of an anesthesia professional to put these machines into service and to manage them while in use. The Anesthesia Patient Safety Foundation provides FAQs on anesthesia machine use, protection, and decontamination during the COVID-19 pandemic.

Resources:

Reviewed December 22, 2020.

 

ASA provides guidance on conversion of PACUs into ICUs:

If the pandemic overcomes the capacity of a hospital ICUs, the PACUs can serve as overflow. Given the fact that PACUs are open units, the institution must decide if all the patients housed in the PACU will have COVID19 or non-COVID19 patients (but not both). Institutions will also need to draft a plan on who will provide medical care to these patients (e.g., Critical Care Anesthesiologists, Internists, Surgeons, ED Physicians, or combination).

Resources:

Reviewed December 22, 2020.

Reporting

Yes, any adverse events associated with PPE under an FDA EUA should be reported through the FDA MedWatch. MedWatch is the FDA’s safety information and adverse event reporting program. Reporting is voluntary but highly encouraged. Information about reporting and the FDA product codes currently covered under existing FDA EUAs is listed in the first link in the resources below.

Resources:

Updated December 22, 2020.

Yes, shortages and supply issues should be reported to the FDA. Reporting from end users to the FDA allows the Agency to respond to spikes and trends in supply shortage issues. However, the reporting mechanism is dependent on the specific item (eg, medical device, biologics [eg, blood, vaccines], medications) that is experiencing the shortage or supply issue. See the link under resources to determine which reporting mechanism pertains to the specific shortage or supply issue currently being experienced at the facility.

Resources:

Updated December 22, 2020.

Sterilization

Care of laryngoscopes should be according to manufacturer’s instructions for use and the AORN Guidelines for Cleaning and Care of Surgical Instruments.

  • Laryngoscope blades and their handles should be cleaned, decontaminated, dried, and stored in a manner that reduces the risk of exposing patients and personnel to potentially pathogenic microorganisms. [Recommendation]
  • After each use, clean laryngoscope blades and high-level disinfect or sterilize them according to the manufacturer’s written IFU. [Recommendation]
  • Clean and low-level disinfect laryngoscope handles after each use. Laryngoscope handles may be high-level disinfected or sterilized according to the manufacturer’s written IFU. [Recommendation]
  • Package and store laryngoscope blades and handles that have been cleaned and disinfected in a manner that prevents contamination. [Recommendation]
  • Store laryngoscope blades in individual packages. [Recommendation]

COVID-19 is an enveloped virus and is susceptible to EPA-registered disinfectants that are used in the health care setting. There are no additional recommendations by CDC for disinfection and sterilization of these items used for COVID-19 patients.

Resources:

AORN Guideline for Cleaning and Care of Surgical Instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020.

 

Instruments and devices that have been used in procedures for patients with known or suspected COVID-19 should be handled the same as other instruments. Reprocessing should follow manufacturer’s instructions for use (IFU) and be consistent with recommendations in the AORN Guidelines for Cleaning and Care of Surgical Instruments, Sterilization Packaging Systems, and Sterilization.

Resources:

  • AORN Guideline for Cleaning and Care of Surgical Instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • AORN Guideline for Sterilization Packaging Systems. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
  • AORN Guideline for Sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

Reviewed December 22, 2020.