Introduction

Coronavirus disease 2019 (COVID-19) was first detected in the city of Wuhan (China) in December 2019 and has spread quickly, with epidemic outbreaks that can grow at an exponential rate¹, and it is very likely that patients with confirmed or suspected infection will require surgical intervention at some point².

There are currently no therapies or vaccines to treat or prevent the infection and intensive efforts are being made to coordinate the rapid development of medical countermeasures³, given its high spreading and virulence rates (severe illness among confirmed cases)⁴.

Because this disease also affects surgical patients and the healthcare team, the aim of this report was to describe the changes introduced in the structure and processes of a surgical facility for the safe care of these patients, and to describe the initial results of their implementation.

Material and methods

We conducted a prospective, descriptive and observational study between April 1 and May 31, 2020.

The structural changes and the modifications introduced in the functioning processes within the surgical area of a university hospital adapted to the care of suspected and positive COVID-19 patients, and the activities developed in such area were documented.

The study was conducted following the ethical principles of the Declaration of Helsinki and revised in Tokyo. The clinical data were protected so as not to identify to whom they belong and not to be accessible to persons not bound by professional secrecy. All the patients signed an informed consent form approved by the Committee on Ethics of the institution.

Results

A transportation route was designed to transport COVID-19 positive or suspected patients from the isolation ward to the designated surgical area (Fig. 1). The operating room (OR) 17 was dedicated for these patients and signs were posted all along the route to the OR 17 (Fig. 2).

Figure 1 Overview of the surgical area for COVID-19 patients 

Figure 2 Overview of the operating room dedicated for COVID-19 patients and route of access. 

Table 1 describes the equipment designated for this OR and the functions carried out in the entrance hall (hand wash basin) and exit lobby.

Table 1 Equipment for exclusive use in the operating room 17. 

Entrance hall and functions of the circulating nurse

The circulating nurse was responsible for preparing the necessary equipment for the surgery (surgical and anesthesiology elements). The WHO Surgical Safety Checklist⁵ and documentation of implants were completed there. The circulating nurse did not enter the OR once surgery had begun².

The circulating nurse was responsible for supervising proper donning of personal protective equipment (PPE)⁶ and compliance with safety standards by the rest of the team:

▪▪No personal items or mobiles inside the OR.

▪▪Top of the scrub on the inside of the pant.

▪▪Closed shoes.

▪▪Two pairs of shoe covers.

▪▪N95 respirator (adjusted to personal anatomy).

▪▪Scrub hat or hood over the cloth hat or double disposable hat.

▪▪Surgical mask cover over the N95 respirator.

▪▪Goggles.

▪▪Face shield.

▪▪Surgical hand scrub before entering the OR.

The PPE was completed inside the OR with the help of the scrub nurse and supervised by a second scrub person⁷:

▪▪Donning the first pair of gloves.

▪▪Donning and fastening a fluid-resistant gown.

▪▪Second pair of gloves flipped up and over the cuff of the gown.

▪▪The exit lobby was equipped with:

▪▪Labeled trays (for the PPE of the surgical team).

▪▪Dispensers with 1% sodium hypochlorite, peracetic acid or alcohol.

▪▪A container with a lid for disposal of worn clothing.

▪▪Closed cabinet with disposable clothing to wear before moving around the surgical area again or transferring a patient.

▪▪The circulating nurse verified the actions of the surgical team before leaving the OR and was responsible for completing and signing the COVID-19 checklist (Fig. 3).

Figure 3 Surgical safety checklist for COVID-19 suspected or positive patients 

According to the current recommendations, the use of PPE depends on the level of care⁸ (Table 2).

Table 2 PPE levels according to the risk of exposure 

The Covid-199 checklist was implemented in patients with suspected or confirmed disease by rtPCR for SARS-CoV-2 with the criteria established by the National Ministry of Health to define suspected and positive cases¹⁰. This checklist was presented to the Crisis Committee of the University Hospital and was approved (Resolución Ejecutiva de la Dirección del Hospital 00757/12-05-20) (Fig. 3).

The first confirmed COVID-19 patient was hospitalized on March 17, 2020. Since then, 340 suspected cases were admitted (238 were discharged as negative cases), 75 were confirmed cases (38 have already been discharged) and 7 positive patients died¹¹.

In the study period, 309 surgeries were performed (136 scheduled surgeries and 173 emergency procedures). The OR protocol approved by the Crisis Committee for potentially infected patients was applied in all the cases⁹.

None of the patients undergoing scheduled surgeries had suspected or confirmed COVID-19 (136/309, 44%). Of those patients undergoing emergency procedures (173/309, 56%) 17 (9.8%) were suspected cases and 3 (1.7%) resulted positive COVID-19 patients confirmed by PCR tests (two cesarean sections and one tracheostomy in a patient hospitalized in the intensive care unit). There were no accidents or PPE shortage for the surgical team.

The checklists were properly filled in all the cases. There were no infections among the personnel working in the facility during the period analyzed.

When the number of scheduled and emergency surgeries performed between April and May 2019 were compared with the same period in 2020, there was a significant reduction in both types of surgeries, following the recommendations adopted during the pandemic (Table 3).

Table 3 Comparison of the number of surgeries performed over the sam period in 2019 and 2020 

Discussion

The information on this infectious disease is in permanent revision and is updated with an unusual dynamic due to its high transmissibility. Given its exponential growth, many COVID-19 positive or suspected patients may require an elective procedure that cannot be deferred or an emergency surgery. The current recommendations suggest limiting the number of scheduled surgeries, even in cancer patients, postponing or deferring those cases that do not affect disease progression and only operating those patients with occlusive, infected or bleeding neoplasms. Nevertheless, each case should be thoroughly analyzed². The number of scheduled surgeries in our hospital decreased by almost 80% according to the current recommendations issued and there were no patients with suspected/confirmed disease scheduled for surgery (136/309, 44%).

A total of 309 patients were operated on between April and May 2020 (two thirds less than in the same period over the previous year): of these, only 17 (9.8%) were suspected cases and 3 (1.7%) were confirmed cases with positive PCR test and all of them underwent emergency surgery. Previously, all these patients underwent triage for COVID-19 with the corresponding questionnaire, chest computed tomography scan or, in the absence of CT capabilities, a chest X-ray¹³. If possible, surgery should be postponed for a few hours if the patient is not compromised to obtain a specimen for PCR test according to the patient’s history and type of procedure, but it is necessary to consider that emergency surgeries should not be delayed to perform a PCR test².

In the hospital surgical area, structural changes were made in the operating rooms and in the circulation of patients, in order to reduce exposure among non-affected patients and suspected or positive patients, thus reducing the risk of transmission of the disease and ensuring safety of the surgical team and patients¹⁴.

The surgeon was required to contact the surgical area in advance to inform about the procedure he was going to perform and thus the specific supplies and materials were prepared before patient’s arrival. The materials were kept in the entrance hall of the operating room designated for COVID-19 patients.

It is important to emphasize that interventions on suspected or positive COVID-19 patients should always be performed by trained and experienced personnel. These health care professionals must be familiar with the measures to prevent transmission and circulation in restricted areas and with the correct use of PPE. They should have previously participated in simulation protocols to reduce the risk of disease transmission. In addition, experience is essential to shorten the duration of the procedure and decrease the exposure of the entire surgical team.

For this purpose, training in theory and practice is useful, carrying out simulations of pre-established protocols. These simulations are carried out in the institution every day with the entire surgical team (medical and non-medical staff).

Level 3 PPE should be worn in positive COVID-19 patient surgery⁶. Even in unconfirmed but suspected cases, in the current pandemic setting, all patients are supposed to be positive and the same protective measures are taken to avoid unnecessary exposure of the staff^2,8. PPE provide complete coverage of the skin, particularly of high-risk areas as the nose, mouth and eyes. Aerosolization can occur in surgical procedures, so PPE should protect against this particular route of transmission⁶.

The two scrub persons assigned to the surgical area prepare the OR bed before patient’s arrival. Once prepared, they request to transfer the patient to the established OR using disposable material if possible².

The patient enters the operating room through the established route (see Fig. 1) wearing a surgical mask, hat, gown and gloves under supervision of the circulating nurse. The anesthesia resident or tech assists the anesthesiologist during orotracheal intubation, and once the patient is ventilated, the surgical team is admitted to the OR to begin surgery. Doors should always be kept closed and the number of professionals inside the OR and their displacements should be limited in order to reduce the risk of contamination².

The stretcher-bearer is called when the surgery has finished and the patient is ready to be transported. If the patient will be transferred to the intensive care unit or coronary care unit, the anesthesiologist will doff the gown, gloves and shoe covers in the exit lobby under the supervision and assistance of the circulating nurse and will accompany the patient wearing new PPE.

The circulating nurse is be responsible for checking the exit actions of the surgical team and, for this purpose, a new checklist for safe surgery associated with a patient potentially infected by the coronavirus was designed and implemented. It is not intended to replace the checklist proposed by the WHO⁵ or the version used since 2010 in the operating rooms of our institution¹⁴; it is an addendum on the back of the checklist to facilitate its use, with fewer forms and adapted to the current situation⁹.

At the end of the surgery, the OR room is finally cleaned, with a focus on the flat and supporting surfaces. Disinfectants approved to kill viruses are sodium hypochlorite or other chlorides, alcohols, quaternary ammonium compounds and accelerated hydrogen peroxide¹⁵. Cleaning staff perform their task with appropriate PPE (Level 2)² and they must be trained and participate in the simulation protocols that are carried out every day in the surgical area. After one hour, the OR can be used again.

This disease, currently with high virus circulation in the community of the Buenos Aires Metropolitan Area (AMBA), demands special measures to reduce the possibility of transmission among patients, the exposure of the health care staff and the development of postoperative complications attributable to this pandemic.