COVID-19 Theatre Processes RHC Glasgow

1. COVID-19: Guidance for the remobilisation of services within health and care settings. Infection prevention and control recommendations. Joint guidance issued by UK Public Health Agencies including HPS issued on 20/08/20.
   
   
2. COVID-19 personal protective equipment. 
   
   
3. Health Protection Scotland website has up to date information on COVID-19 management in Scotland, including a recent review of the evidence in relation to AGPs 
   
   
4. StaffNet has a COVID-19 Information Hub with information from GGC and links to Health Protection Scotland (HPS). Staffnet is only available on GGC premises or from a device connected to the NHSGGC network.
   
   
5. RHC guideline for COVID-19 patient pathway in ED and ward admissions 

For COVID-19, the following procedures are reported to be aerosol generating and are associated with increased risk of respiratory transmission:

• tracheal intubation, extubation and related procedures

• manual ventilation

• tracheotomy or tracheostomy procedures (insertion or removal)

• bronchoscopy

• dental procedures (using high speed devices such as ultrasonic scalers or high-speed drills)

• non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)

• high flow nasal oxygen (HFNO)

• high frequency oscillatory ventilation (HFOV)

• induction of sputum using nebulised saline

• respiratory tract suctioning

• upper ENT airway procedures that involve suctioning

• upper ENT airway procedures that involve respiratory suctioning

• upper gastro-intestinal endoscopy where there is open suctioning of the upper respiratory tract

• high speed cutting in surgery/post mortem procedures if this involves the respiratory tract or paranasal sinuses

Certain other procedures/equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk. Procedures in this category include: administration of pressurised humidified oxygen; administration of medication via nebulisation.

There is no specific mention of other surgical procedures (e.g. laparoscopy), but these may also carry a risk of aerosol generation. The significance of this in the context of COVID-19 is unclear: use of FFP3 masks must be discussed as part of the theatre brief and theatre staff should make their own risk assessment regarding PPE use.

Air changes / pause times in RHC Glasgow:

Although laminar flow creates a very high flow under the canopy, the total theatre air flow may not be very different to a standard 25 air change per hour. Laminar flow further complicates theatre air changes and it is difficult to determine if it is of benefit or harm. Although some current guidelines recommend using laminar flow, the evidence of benefit is not great and in RHC it remains a choice. It may add to theatre noise levels when communication is already difficult because of PPE and so we recommend switching it off. If laminar flow is thought to be of particular benefit for surgery, this can be discussed at the theatre brief.

RHC guideline for COVID-19 patient pathway in ED and ward admissions is available here.

Case definition

Case definition is acute onset of any of the following symptoms:

• Fever >37.8
• Persistent cough (with or without sputum),
• Loss of sense of smell / taste

Be aware that COVID-19 may present with other symptoms. If in doubt discuss with another consultant. Fever alone may be attributable to the surgical condition and should be considered in that context.

All patients referred for surgery should be checked against the case definition for COVID-19.

All surgical services have altered their treatment protocols to prioritise clinical urgency.

Elective patients and  their household will be screened for symptoms and contacts, and have a COVID test done within 72 hours of admission.

Emergency patients will have a COVID test taken as soon as possible after a decision is made for surgery.

Selected patients are screened weekly (PICU, Haematology/Oncolgy in-patients and BOC). In these groups of patients, a negative result within one week of theatre can be used to determine pathway.

In the case of COVID-19 patients, careful MDT discussion is required to decide which patients should and should not be coming for surgery, i.e. only those requiring emergency or urgent surgery. Ideally surgery should be delayed until patient has recovered from COVID-19 illness.

Theatres must be informed in advance if patient being booked for theatre has COVID-19 infection – phone theatre booking extension 84852

Patient will be transferred from ward (via reception but not stopping) to cubicle in recovery room.

Pre-theatre checks will be carried out in recovery cubicle

Patient will be anaesthetised and fully recovered in theatre.

Anaesthetic room will not be used.

Following recovery in theatre, patient will be transferred to recovery cubicle and then to ward.

The theatre coordinator will limit corridor traffic during treatment of known or suspected patients. Commonly this will mean they are scheduled at the end of a list as per longstanding policies for other infectious cases.

Prior to surgery

Designate a senior nurse controller for the area to ensure the following:

• Adequate and appropriate staffing including for substitution depending on length and complexity of case: consider - 2 anaesthetists, 2 anaesthetic assistants, 2 surgeons, 5-6 theatre nurses
• PPE understood and trained. Locations for donning and doffing agreed.
• Roles understood
• Environment controlled
• Thorough Team Brief
• Patient transfer route
• Log staff undertaking case on Opera. Include COVID-19 status in free text.
• Control and log breaches of PPE on Datix – phone 84315 which will prompt for dataset.
• All automatic doors in theatre switched off.
• Signage at entrances to theatre and corridor indicating RED theatre.
• Check if image intensifier is required and inform Radiology.

Theatre Brief

Surgeon to provide copies of completed consent and checklist to be used for WHO checks then destroyed. Originals in patient record. Senior anaesthetic and surgical staff in order to expedite procedure. Consider sedation/regional / local anaesthetic to avoid AGPs.

Personal Protective Equipment

Use full respiratory PPE whenever attending to the patient in theatre:

• Gloves (not required to be sterile unless performing aseptic or sterile practices)
• Long-sleeved, fluid resistant disposable surgical gown
• FFP3 respirator mask – fit check after applying (cover filter and breath in, holding breath for 10 seconds. You should be aware of mask sucking on to your face with no air coming in round the seals while you hold your breath)
• Eye protection

All staff are required to train in the donning and doffing of PPE and will be fit tested for a FFP3 mask. Donning and doffing of PPE must be done in the correct order and in an unhurried manner.

Posters are displayed throughout theatres: https://www.nhsggc.org.uk/media/259081/ppe-donning-and-doffing-poster-for-covid-19-mar-20.pdf

All steps of donning are carried out before entering the COVID theatre.

The FFP3 respirator must always be removed outside the patient’s room or after leaving theatre disposal room.

Pre-op Assessment

By anaesthetist, on ward.

Consider collecting a mask (Fluid Resistant Surgical Mark, FRSM), apron/gown and gloves before leaving theatre suite.

Check paper and computer records first.

PPE: FRSM, apron and gloves to enter patient room. Consider wearing a gown to provide some protection of theatre scrubs at this stage. Maintain distance of >2m from patient and parent. Avoid touching surfaces in room. Inform family of changes to normal theatre practice re parental presence in anaesthetic room and during recovery period.

Careful doffing of PPE to exit patient room.

Complete anaesthetic chart and bring to theatre.

Low threshold for premedication

Anaesthetic Preparation

BE PREPARED - EVEN MORE THAN USUAL!

Airway

The COVID airway trolley has equipment organised by age group and will remain in the anaesthetic room of COVID theatre.

Select age appropriate equipment/materials and place on trolley inside theatre.

Use cuffed endotracheal tube for intubation

LMA is acceptable if appropriate.

Consider using in-line suction to avoid breaking the circuit for tracheal suction.

Plan to use videolaryngoscopy – McGrath or C-mac depending on requirements.

HMEF filters at machine and patient ends of circuit (as is usual in RHC theatres).

IV access & Drugs

Prepare anaesthetic drugs in anaesthetic room, including vasoconstrictor and fluid boluses.

Err on side of preparing more than you think you will need.

Trolley in theatre for drugs.

Single dose of NSAIDs is likely to be OK if no other contraindication.

Don’t forget local anaesthetic if appropriate.

Select range and ample supply of IV cannulae, syringes, needles, dressings.

Place all airway and IV equipment, and drugs inside theatre before patient arrives.

Consider using a Transwarmer as it is best to avoid use of a Bair Hugger until after AGP completed.

Ideally, set up surgical instruments in advance and cover appropriately. This will reduce the time scrub staff need to wear PPE.

After a patient is in theatre, drugs and other items can only be passed in on a tray onto a trolley. Avoid all touch contact. A member of the team in full PPE will be in the anaesthetic or prep room throughout the case for this purpose.

Any single-use equipment and all drugs (including CDs) must be disposed of in theatre. They must not be returned to the anaesthetic room. A Griff bin with orange waste bag will be placed in theatre for easy disposal of clinical waste.

Transfer to Theatre

PPE to be worn by team undertaking transfer: theatre gown, apron, fluid-resistant surgical mask with visor, gloves.

It is expected that a ward nurse and a member of theatre reception staff will transfer the patient to theatre. A theatre trolley will be used for transfer.

Route cleared to minimise exposure.

Shortest route used.

Two designated COVID lifts are available to transfer patients from the wards in RHC. Lifts require cleaning after use involving a COVID patient.

Patient should wear a fluid-resistant surgical mask where appropriate/possible. A Hudson mask may also provide some protection of staff

Accompanying parent should wear a fluid-resistant surgical mask.

Patient should be transferred directly to cubicle in Recovery Room via theatre reception. Route from theatre reception to recovery cubicle should be cleared of other staff and patients, so communication between staff members re timing is essential.

Theatre anaesthetic team will meet transfer team in recovery cubicle, and complete theatre checklist. Parent will leave at this point returning to ward with ward nurse. Parent must not access other areas of the hospital unless specifically allowed by ward staff.

Minimise transfers. Transfer from trolley to table, anaesthetise on table. Trolley will remain in theatre. For adult-sized patients it may be safer to anaesthetise on the trolley then transfer after pause time following on from induction.

Induction & Intubation

Intubation is an aerosol generating procedure (AGP), so full respiratory PPE as above must be used. Minimise the number of staff in the theatres at intubation while recognising that additional members cannot be added at short notice.

• Induction in theatre
• Patient should wear a surgical face mask if appropriate/possible before start of anaesthetic induction.
• May need 2 anaesthetists present at induction, one for airway, one for IV access & drugs, and one anaesthetic assistant. Additional anaesthetic assistant in full PPE in anaesthetic room to assist if required.
• Use circle in preference to T-piece. Don’t use high fresh gas flow.
• Preoxygenate if possible.
• Don’t switch on bair hugger until after AGPs are completed.
• Consider IV induction vs gas induction - choice should aim to minimise coughing / distress. Premedication will help.
• LMA may be used if appropriate.
• Give generous dose of muscle relaxant if using.
• Minimise bag-mask ventilation and tidal volume as this might generate aerosols
• Use Videolaryngoscopy (McGrath or C-Mac) to maximise anaesthetist distance from patient. Watch ETT distance through cords carefully.
• Do not ventilate until ETT cuff is inflated. Use cuff pressure monitor to inflate cuff. Do not get close to patient to listen for a leak. If an uncuffed ETT is used, place a throat pack to minimise effect of leak.
• Confirm ETT placement with ETCO2 trace and chest wall movement. There are single-use stethoscopes, but these are best avoided as difficult to use with PPE and risk of self-contamination.
• Use in-line endo-tracheal suction.
• PPE must be continued after intubation.
• Use tray/ plastic bag to store airway equipment until end of procedure.

Intraoperative Management

• Minimise traffic
• Government guidance recommends PPE be worn for sessional use – generally up to 4 hours – but you may not last this long. Plan for replacement during longer cases.
• Anaesthetic chart – complete pre and post-op in Theatre 1 for short cases. Can be completed by member of staff in anaesthetic room for longer, more complex cases or use large plastic bag to ‘quarantine’ the chart post-op. Use white board in theatre as an aid.
• Computers are available in theatre for documenting care, viewing x-rays. Keyboards have protective covers.
• Communication via phone in theatre should be kept to a strict minimum. Walkie-talkies are available for easier communication. Use phones on loud speaker to reduce self-contamination. Use runner to communicate with those outside theatre during case.
• Plan and avoid time critical manoeuvres with associated risk of PPE breach.
• Generous use of muscle relaxants to avoid coughing.
• Avoid ventilator disconnections.
• Consider using plastic sheets/drapes to enclose patient during AGPs if possible.
• If sterile procedure planned as part of anaesthetic (e.g. central line), doff gloves and gown into orange bin in scrub area, re-scrub and don sterile gown and gloves. Don’t change mask & googles/visor.

Minimising aerosol generation when changing between ventilators/circuits

• Turn off gas flow
• Ventilator to manual
• APL fully open
• Consider clamping ETT
• Disconnect circuit leaving HME connected to ETT
• Reconnect new ventilator to HME
• Unclamp ETT

Care if there are different CO2 sampling systems

Minimising Aerosol Generation during suctioning

• Only suction if required
• Use in-line suction
• Turn off fresh gas flow
• Ventilator to manual, APL fully open
• Clamp ETT connect in line suction circuit
• Unclamp ETT
• Suction
• Restart ventilator

Extubation and Recovery

• Transfer patient to trolley before extubation
• Only keep minimum staff in theatre
• Attempt to minimise coughing to minimise generation of aerosols
• Use sugammadex if appropriate
• Extubate to facemask & circle or T-piece
• Consider using plastic sheets to minimise aerosol spread
• Full recovery of patient in the same theatre, minimum 11 minutes to allow aerosol dispersal
• Patients sent back to the ward via agreed routes after appropriate coordination with receiving ward

Transfer from Theatre to Ward

• Contact Recovery Room prior to patient transfer
• Patient to be transferred to recovery room cubicle
• Extubating anaesthetist and assistant can transfer patient to recovery cubicle
• Ward nurse and reception staff member will transfer patient to ward
• Handover to ward staff will be done by phone from theatre during recovery period.

Theatre Cleaning

• See Public Health document ““COVID-19 Guidance for infection prevention and control in healthcare settings”. Joint document issued by UK Public Health Agencies including HPS (Key document 3 – see above for link) for additional information including cleaning and disposal of waste.
• Wear basic PPE (surgical mask with eye protection, gown/apron and gloves) to clean.
• Phone Facilities to arrange cleaning of recovery cubicle.

In RHC when a patients is asymptomatic, a COVID test result is NOT available, and surgery cannot be delayed, the patient will follow a pathway with additional precautions for AGPs.

Time for Air Changes

Following an AGP, time is allowed for 5 air changes before additional staff enter the room. The patient can be transferred from the room when clinically ready. There is no need to wait for air changes to do this.

For all theatres, Cath Lab and IR, time for 5 air changes is 11 minutes

For all anaesthetic rooms including MRI, time for 5 air changes is 18 minutes

Theatre Preparation

Advance preparation

All unnecessary equipment removed.

All automatic doors switched off, except theatre exit doors.

Theatre Brief in theatre to allow social distancing

To include the following:

• AGPs to be performed and timing
• Location of induction
• Parental presence
• Consider sedation / regional / local anaesthetic to avoid AGPs.
• Adequate and appropriate staffing including for substitution
• PPE understood and trained
• Locations for donning and doffing
• Roles understood
• Log staff undertaking case on Opera. Include COVID-19 status in free text.
• Control and log breaches of PPE on Datix – phone 84315 which will prompt for dataset.

Use Checklist to help with this.

Case records will accompany patient to theatre, but remain in the anaesthetic room or prep room until air change time has elapsed following induction.

Consider covering the anaesthetic machine and other equipment to minimise contamination.

Induction can take place in the anaesethetic room, provided cupboards and drawers can be closed so as to protect equipment from contamination.

Personal Protective Equipment

Use full respiratory PPE during any AGP and until air change time has elapsed (11 or 18 minutes):

• Gloves (not required to be sterile unless performing aseptic or sterile practices)
• Long-sleeved, fluid resistant disposable surgical gown
• FFP3 respirator mask – fit check after applying (cover filter and breath in, holding breath for 10 seconds. You should be aware of mask sucking on to your face with no air coming in round the seals while you hold your breath)
• Eye protection

All staff are required to train in the donning and doffing of PPE and will be fit tested for a FFP3 mask. Donning and doffing of PPE must be done in the correct order and in an unhurried manner.

Posters are displayed throughout theatres: https://www.nhsggc.org.uk/media/259081/ppe-donning-and-doffing-poster-for-covid-19-mar-20.pdf

All steps of donning are carried out before entering the COVID theatre.

The FFP3 respirator must always be removed outside the patient’s room or after leaving theatre disposal room.

Pre-op Assessment

By anaesthetist, on ward.

Consider collecting a mask (FRSM), apron and gloves before leaving theatre suite.

Check paper and computer records first.

PPE: FRSM, apron and gloves to enter patient room. Maintain distance of >2m from patient and parent. Avoid touching surfaces in room. Inform family of changes to normal theatre practice re parental presence in anaesthetic room and during recovery period.

Careful doffing of PPE to exit patient room.

Complete anaesthetic chart and file in case record.

Low threshold for premedication.

Anaesthetic Preparation

BE PREPARED - EVEN MORE THAN USUAL!

Airway

Select age appropriate equipment/materials and place on trolley inside theatre.

Use cuffed endotracheal tube for intubation, but consider LMA if that would be appropriate and would minimise coughing.

Have available and consider using clamp for ETT to minimise aerosol generation.

Consider using videolaryngoscopy – McGrath or C-mac depending on requirements.

Consider using in-line suction.

HMEF filters at machine and patient ends of circuit (as is usual in RHC theatres).

IV access & Drugs

Prepare anaesthetic drugs in anaesthetic room, including vasoconstrictor and fluid boluses as required.

Err on side of preparing more than you think you will need.

Trolley in theatre for drugs.

Single dose of NSAIDs is likely to be OK if no other contraindication.

Don’t forget local anaesthetic if appropriate.

Select range and ample supply of IV cannulae, syringes, needles, dressings.

Place all airway and IV equipment, and drugs inside theatre before patient arrives.

Consider using a Transwarmer as it is best to avoid use of a Bair Hugger until after AGP completed.

Consider setting up surgical instruments in advance and covering appropriately. This will reduce the time scrub staff need to wear PPE.

Have a member of the team in FRSM PPE in the anaesthetic room throughout the AGP and subsequent pause time if you think you might need access to the anaesthetic room.

Any single-use equipment and all drugs (including CDs) must be disposed of in theatre. They must not be returned to the anaesthetic room. A Griff bin with orange waste bag will be placed in theatre for easy disposal of clinical waste.

Transfer to Theatre

PPE will be worn by team undertaking transfer: apron, fluid-resistant surgical mask with visor, gloves.

It is expected that a ward nurse and a member of theatre reception staff will transfer the patient to theatre. A theatre trolley will be used for transfer.

Route cleared to minimise exposure.

Shortest route used.

Patient should wear a fluid-resistant surgical mask where appropriate/possible.

Accompanying parent should wear a fluid-resistant surgical mask.

Patient will arrive in theatre reception where checklist will be completed by theatre team member before transfer to anaesthetic room.

Parent will leave at this point returning to ward with ward nurse. Parent must not access other areas of the hospital unless specifically allowed by ward staff.

If parental presence at induction is necessary (as agreed by anaesthetist), parent will dress in gown, hat, face mask and theatre clogs to be admitted to theatre.

Induction & Intubation

In the Amber pathway, full respiratory PPE (FFP3 mask) is work for AGPs

• Patient should wear a surgical face mask if appropriate/possible before start of anaesthetic induction.
• Induction of anaesthesia in theatre
• Depending on complexity of patient or surgery, consider having additional anaesthetic staff in PPE at time of induction.
• Use circle in preference to T-piece. Don’t use high fresh gas flow.
• Preoxygenate if possible.
• Don’t switch on bair hugger until after AGPs are completed.
• Consider IV induction vs gas induction - choice should aim to minimise coughing / distress. Premedication will help.
• LMA may be used if appropriate.
• Give generous dose of muscle relaxant if using.
• Minimise bag-mask ventilation and tidal volume as this might generate aerosols
• Use Videolaryngoscopy (McGrath or C-Mac) to maximise anaesthetist distance from patient. Watch ETT distance through cords carefully.
• Do not ventilate until ETT cuff is inflated. Use cuff pressure monitor to inflate cuff. Do not get close to patient to listen for a leak.
• Confirm ETT placement with ETCO2 trace and chest wall movement. Stethoscopes are best avoided - difficult to use with PPE and risk of self-contamination.
• Use in-line endo-tracheal suction.
• PPE must be continued after intubation.
• Use tray to store airway equipment until end of procedure.

Intraoperative Management

• Minimise traffic
• Aim to keep time wearing PPE to 45-60 minutes - avoiding fatigue reduces likelihood of breaching PPE – plan for replacement during longer cases. Government guidance recommends PPE be worn for sessional use – generally up to 4 hours – but don’t expect to last this long.
• Don’t start anaesthetic chart until after pause time (11 or 18 minutes) has elapsed.
• Computers are available in theatre for documenting care, viewing x-rays. Keyboards have protective covers.
• Communication via phone in theatre should be kept to a strict minimum. Walkie-talkies are available for easier communication. Using phones on loud speaker will reduce self-contamination. Use runner to communicate with those outside theatre during case.
• Plan and avoid time critical manoeuvres with associated risk of PPE breach.
• Generous use of muscle relaxants to avoid coughing.
• Avoid ventilator disconnections.
• Consider using plastic sheets/drapes to enclose patient during AGPs
• If sterile procedure planned as part of anaesthetic (e.g. central line, epidural), doff gloves and gown into orange bin in scrub area, re-scrub and don sterile gown and gloves. Don’t change mask & googles/visor.

Extubation and Recovery

• Transfer patient to trolley before extubation.
• Only keep minimum staff in theatre.
• Attempt to minimise coughing and spluttering to minimise generation of aerosols
• Use sugammadex if appropriate
• Minimise suctioning
• Extubate to facemask & circle or T-piece
• Patient may be transferred to recovery immediately
• Cleaning of the clinical area may commence after 11 or 18 minutes pause time
• Recovery staff to wear FRSM, gloves, apron/gown
• Patients sent back to the ward via agreed routes after appropriate coordination with receiving ward

Transfer from Theatre to Recovery

• Anaesthetist and assistant will transfer patient from theatre exit to recovery, handover the patient & doff PPE in recovery
• Care to avoid contaminating surfaces

Theatre Cleaning 

• See Public Health document ““COVID-19 Guidance for infection prevention and control in healthcare settings”. Joint document issued by UK Public Health Agencies including HPS (Key document 3 – see above for link) for additional information including cleaning and disposal of waste.
• Wear basic PPE (surgical mask with eye protection, gown/apron and gloves) to clean.

Patients who are asymptomatic and have no household contacts, and who have a negative COVID test within 72 hours before admission/coming to theatre can be managed using droplet precaution PPE and standard pre-COVID theatre cleaning processes. Droplet precaution PPE is a FRSM, gown/apron and gloves. It can also include eye protection.

Selected patients are screened weekly (PICU, Haematology/Oncolgy in-patients and BOC). If a patient in this group has a negative result within one week of theatre and no COVID symptoms/contacts, they can be managed on the GREEN pathway.

Patients undergoing procedures involving sedation, regional anaesthethia or spontaneously breathing face-mask anaesthesia can be managed on the GREEN pathway regardless of COVID status or symptoms, provided the surgical procedure is also not an AGP. However, remember to consider the risk of conversion to general anaesthetic which would require an increase of PPE and a break in the procedure to facilitate airway management. At a minimum droplet precaution PPE must be worn.

1. Procedure done – SIGN OUT prior to extubation – any computer stuff to be done now also?
2. Patient cleaned and drapes put in the bin.
3. Equipment covered and bagged for disposal later.
4. Patient moved to trolley ready to be extubated. Move patient prior to staff leaving if bodies needed to help transfer.
5. Surgeons and floor nurses DOFF as per protocol through disposal room. Minimum of 2 and maximum of 3 at a time as it then gets crowded. Outer gloves off in theatre and the rest in doffing area. Clean shoes and glasses before putting on new surgical hat and exit to changing areas in second stage recovery. Once new blues on they can return to Theatre donning area to collect their phones/badges etc
6. Patient extubated by Anaes and AA in Theatre.
7. Patient recovered in Theatre – can phone to do handover to ward staff now. Using loudspeaker rather than holding to ear
8. They then take patient back to handover area or directly to ward and then return to theatre. They then ensure all covers are off equipment and put in a bin before they DOFF and exit.
9. Theatre needs cleaned with 11 min air change after everyone is out before staff can go in to clean and dispose of waste. All areas need cleaned including DOFFing room and AR.
10. DEBRIEF

• PRINT OFF CONSENT AND COMPLETED CHECKLIST FROM COMPUTER or GET WARD TO PHOTOCOPY THEM AND PICK THEM UP FROM THE WARD TO BE BROUGHT DOWN BEFORE STARTING THE BRIEF– THESE CAN BE BINNED AT THE END OF THE PROCEDURE
  
  
• MINIMUM PERSONNEL - SCRUB/FLOOR X2/AA X2/ANAES X2/SURG X2
  
  
• STAFF AND RUNNERS IN THEATRE 1
  
  
• INTRODUCTIONS
  
  
• SURGICAL EQUIPMENT
  
  
• ANAESTHETIC EQUIPMENT AND DRUGS ie local anaesthetic
  
  
• DO WE NEED IMAGE INTENSIFIER?
  
  
• WILL WE BE USING EQUIPMENT THAT GENERATES STICKERS?
  
  
• PRINT OFF BANK OF STICKERS

SET UP THEATRE AND RETURN TO FINISH BRIEF REMEMBER THE THEATRES ARE CLEAN BUT ADVICE IS STILL TO EXIT VIA DOUBLE DOORS AND ENTER VIA DOUBLE DOORS AS YOU WOULD WITH A COVID PATIENT IN THEATRE.

COMPLETION OF BRIEF WHEN ALL STAFF ARE BACK IN THEATRE 1 PRIOR TO SENDING FOR PATIENT.

GET EQUIPMENT INTO THEATRE ONCE PATIENT HAS ENTERED THEATRE:

Theatre corridor is deemed relatively safe whilst a patient is in theatre.

All equipment, blood etc that needs to come into theatre can be handed into the theatre anaesthetic room.  Staff must wear a minimum of a FRFM to do this task (not full PPE). The staff member in Anaesthetic room who is in PPE can then pass it through to theatre.

STAFF COMING OUT OF A COVID THEATRE MUST CHANGE THEIR BLUES

GET SAMPLES OUT OF THEATRE 2:

All samples that cannot wait until the end of the case to be sent to the lab must be bagged in theatre and handed to the staff member in the Anaesthetic room who can then pass them to staff in the corridor.

BEFORE THE PATIENT LEAVES THEATRE THEY NEED TO PHONE THE THEATRE COORDINATOR AND THE DESTINATION WARD TO LET THEM KNOW TO AVOID ACCIDENTAL CROSS CONTACT ON ROUTE.

This matrix is designed to facilitate discussion about individual patient surgical management during the Covid-19 pandemic.

The following principles have been agreed:

1. In line with all surgical specialities, various strategies have been introduced to reduce general surgical emergency theatre utilisation
2. Patients will only be booked for theatre if there is not an appropriate alternative non-operative strategy, or where one has failed
3. Consultant Surgeons will be involved in all decisions related to theatre booking, and will be present in theatre
4. Discussion related to the operative approach (see below) should involve consultant surgeons, anaesthetists and theatre nurses in advance.

SARS-CoV-2 has been isolated from the nasopharynx, upper and lower respiratory tract, the gastrointestinal tract from mouth to rectum, in blood, bile and faeces, and in the cells lining the respiratory and gastrointestinal tract. It has not been isolated in urine or CSF.¹ It is likely that the virus has multiple modes of transmission.

As a department, we are committed to deliver the highest quality care for our patients and ensure we act in a way that maintains the safest possible working environment for all of our colleagues.

We believe that the best way to balance these aims during the COVID-19 pandemic is by only performing the most essential operations and to utilise non-operative strategies wherever possible. We are only offering surgery in an emergency setting, or in children who require urgent treatment (defined as where surgical treatment would normally be undertaken within 4 weeks, or when a non-operative alternative confers a high risk of patient harm in the next 3 months). In the group of patients who meet the COVID-19 case definition (or are confirmed COVID-19 on testing) we aim to avoid operating if possible. We have introduced new pathways for management of appendicitis and testicular torsion to help achieve this aim.

The potential risk of minimally invasive surgery (MIS) during the COVID-19 pandemic has received much attention. Previous research has shown that laparoscopy can lead to aerosolisation of blood borne viruses^2-6, but there is no evidence to indicate that this effect is seen with COVID-19; nor that this effect would be limited to MIS procedures, or more likely compared to open surgery. The risk of aerosolisation during MIS is generally ascribed to the use of energy devices^2-4 which may result in a high concentration of smoke and aerosolised particles being generated in the confined space of a body compartment. The use of any electrosurgical device can be considered to be aerosol generating⁷ and infectious papillomavirus has been identified in the surgical plume generated during open excision of warts.⁸ However, dissemination and release of any aerosolised material into the operating room, either during desufflation in an uncontrolled fashion or via port-site leakage could occur. It should be emphasised that this is a theoretical risk with little supporting evidence to date.

On the 7th April 2020, the four UK public health bodies,⁹ with the endorsement of the four UK and Irish Royal Colleges of Surgery¹⁰ have recommended enhanced PPE (meaning the addition of FFP3 masks) for all aerosol generating procedures (AGPs) in all patients, regardless of COVID-19 risk status. Intubation and extubation are classified as AGPs, so the majority of surgical procedures will require the anaesthetic staff to wear enhanced PPE. Although MIS is not listed as an AGP, the Colleges document states that it “is considered to carry some risks of aerosol-type formation and infection and considerable caution is advised”. Until further evidence is made available, like many other centres, we have decided to advocate that all staff within 2m of a minimally invasive procedure should also wear enhanced PPE. We have developed a decision-making matrix to outline, in a transparent and consistent way, the criteria that should be met for us to perform minimally invasive surgery (MIS) during the COVID-19 pandemic. These will be reviewed at least every 2 weeks to take into account any new evidence or advice that is issued.

References

1. Wang, W, Xu Y, Gao, R et al. Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA epub 11th March 2020

2. Surgical smoke and infection control. Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. J Hosp Infect. 2006 Jan;62(1):1-5

3. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Kwak HD, Kim SH, Seo YS, et al. Occup Environ Med. 2016, 73:857––863.

4. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Choi SH, Kwon TG, Chung SK, Kim TH. Surg Endosc. 2014, 28 (8): 2374-80. 5.

5. SAGES and EAES recommendations regarding surgical response to COVID-19 crisis. (30/3/20)

6. Zheng, MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy. Ann Surg 26th March Published ahead of print.

7. Bree K, Barnhill S, Rundell W. The Dangers of Electrosurgical Smoke to Operating Room Personnel: A Review. Workplace Health Saf. 2017, 65 (11): 517-526.

8. Sawchuk WS, Weber PJ, Lowy DR, Dzubow LM. Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection. J Am Acad Dermatol. 1989;21:41–9.

9. Public Health England. Recommended PPE for healthcare workers by secondary care inpatient clinical setting, NHS and independent sector (9/4/20)

10. Royal College of Surgeons of England. Covid-19: Guidance for surgeons working during the pandemic. 

General measures

1. Only essential staff should be present in theatre.1

2. Unless there is an emergency, there should be no exchange of room staff.¹

3. All staff should use PPE as recommended by current local and national guidance.¹

Minimising smoke and aerosol production

4. Diathermy units should be set to the lowest possible settings for the desired effect. ¹

5. Avoid prolonged dissecting times on the same tissue to reduce surgical smoke production.²

6. Minimise use of aerosolizing adjuncts - monopolar diathermy, Harmonic scalpel and Ligasure. ¹

7. Use attached smoke evacuators when using external monopolar diathermy.¹

8. Keep instruments clean of blood and other body fluids to minimize contact time/ smoke.²

9. Surgical drains should be utilized only if absolutely necessary.²

Safe Management of the artificial pneumoperitoneum

10. Keep insufflation pressure/flow rates at lowest possible levels without compromising exposure.^1,2

11. Attach smoke evacuation filter to the designated evacuation port and outflow not exceed 7l/min

12. Limit time in the Trendelenburg position to minimise the effect on lung function/circulation.²

13. Avoid using two-way insufflator to prevent aerosolised particles reaching the insufflator.²

14. Use balloon ports at every port site to minimize inadvertent gas/aerosol leak.

Prevention and management of aerosol dispersal

15. Port site incisions should be as small as possible to create a seal around the port.¹

16. Keep port sites clean of blood and body fluids to minimize dispersal. ¹

17. Ports should not be vented.¹

18. Preformed ties should not be used – use either intracorporeal ties, clips or stapling devices.

19. Close valves before disconnecting tubing and only open once tubing is reconnected. Insufflator should be turned “on” before new port valve opened to prevent gas back-flow into insufflator.¹

20. Use suction devices to remove smoke/aerosol during operations and before converting to open surgery or any extra-peritoneal manoeuvre.³

21. Attach microfilter to the suction carousel to prevent smoke from the patient reaching the hospital vacuum system (not between patient and canister).

Desufflation of the abdomen

22. Avoid explosive dispersion of body fluids when removing trocars, ports and specimens.³

23. The patient should be supine and the least dependent port should be utilized for desufflation.³

24. Pneumoperitoneum should be safely evacuated via an ultrafiltration system before closure, trocar removal, specimen extraction or conversion to open.¹

25. All specimens should be placed in retrieval bags prior to desufflation to aid safe removal.

26. To desufflate, close the valve on the insufflating port before flow of CO2 on the insufflator is turned off and use suction device to desufflate.³

27. Specimens should only be removed once all CO2 and smoke has been evacuated.³

Additional teaching related to this guidance should be provided for all staff involved in minimally invasive surgical cases during the pandemic.

References (all accessed 01/04/2020 unless stated otherwise)

1. SAGES and EAES recommendations regarding surgical response to COVID-19 crisis. (30/3/20)

2. Zheng, MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy. Ann Surg Published ahead of print (26th March 2020).

3. SAGES. Resources for smoke & gas evacuation during open, laparoscopic, and endoscopic procedures (29/3/20)