Infection Prevention: Limit the Risks of COVID-19

Elective procedures are beginning again in areas of the country where the curve of the new coronavirus is flattening. If you already have strong infection prevention protocols in place, adjust them in response to novel COVID-19 challenges. If you don’t, this is a great time to establish them. Safely caring for patients and protecting your staff from exposure to dangerous bacteria and viruses has always required vigilance in following best practices. COVID-19 simply raises the stakes. Your “new normal” of infection prevention should include a renewed focus on environmental cleaning, rethinking anesthesia delivery and a deliberate ramp-up to a full case volume.

Surveil patients and surfaces. Obviously, your ability to test patients for COVID-19 before they enter your facility is critical. Testing patients is an excellent start in keeping the coronavirus out of your facility, but it’s also not enough to limit risks. If you’re using day-before RT-PCR oropharyngeal or nasopharyngeal screenings, false negatives can occur about 19% of the time. In communities with 1% of individuals testing positive, only about 0.24% would have COVID-19. That’s good news, but the bad news is facilities averaging fewer than 60 cases a day would then have a false negative most weeks. So, perform good hand hygiene, decontaminate patients with oral antisepsis and nasal decolonization, and clean and monitor reservoirs where the virus accumulates and persists.

Protect your staff and patients from COVID-19 by monitoring your ORs for locations where pathogens tend to be detected and, if present, address them. Closely monitor the environment in your ORs for pathogenic transmissions and increase your focus on cleaning the reservoirs you find. If you’re already surveilling for reservoirs of Enterococcus, Staphylococcus aureus, Klebsiella, Acinetobacter, Pseudomonas and Enterobacter spp. (ESKAPE) contamination, you’ll likely have a line on where COVID-19 would collect.

Alter anesthesia practices. Establish “clean” and “dirty” areas around anesthesia workstations. Put alcohol-based hand rubs on the IV pole to the provider’s left, and a wire basket lined with a zip-closure plastic bag for deposit of contaminated instruments on the IV pole to the provider’s right. Anesthesia providers should double-glove before touching the patient’s nose and mouth, and remove the outer gloves following contact. After patient positioning, wipe down equipment and high-touch surfaces with disinfecting wipes that contain a quaternary ammonium compound and alcohol.

If the prevalence of COVID-19 is high in your community, or if patient testing is not being done, conduct initial Phase I recovery in the OR instead of the PACU when general anesthesia is used or following an aerosol-producing procedure. With patients coughing after extubation, and mildly disoriented or with some bronchospasm after extubation, environmental contamination can occur from sputum. Remember, the coronavirus can remain active for four days on plastic and stainless steel surfaces. The goal is to reduce the chance an asymptomatic COVID-19 patient who tested false negative infects the PACU. In communities with a high prevalence of COVID-19 or in facilities where testing of all patients does not occur, OR cleaning between cases will be much longer after some procedures. In these ORs, consider employing multimodal environmental decontamination after every case, including UV-C light or similar technology. Also account for additional OR time where Phase I recoveries are monitored in ORs. If possible, dedicate surgeries involving general anesthesia exclusively to specific ORs to reduce the overall impact on your throughput. Some surgery centers have been hesitant to embrace local and regional anesthesia for qualified procedures. But by removing the need to intubate and extubate patients, initial recovery times and risk of transmission are greatly reduced.

Ramp up deliberately. The greatest throughput can be achieved safely by dedicating many of your ORs to short-duration procedures that aren’t aerosol-producing and can be performed without general anesthesia. Conveniently, these cases make up the majority of outpatient procedures. In addition to there being no need for airborne precautions when regional blocks are used, you can turn these cases over quickly and treat more patients with relatively minimal environmental concerns.

Reassure and remind

Even after your facility reopens, some patients still might not feel comfortable scheduling surgeries due to concerns about exposure to the coronavirus. Alleviate their fears through effective communication. Let them know that not only will they be tested for COVID-19, but every patient will be, and that your environment is consistently and effectively monitored and cleaned. SSIs are a much bigger risk of surgery than catching COVID-19. You’ve always been on alert for pathogenic organisms. COVID-19 is just the latest. OSM