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New OR Safety Recommendations for COVID-19 Pandemic

By HospiMedica International staff writers
Posted on 19 May 2020
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Image: The Stanford COVID-19 surgical decision-tree algorithm (Photo courtesy of JACC)
Image: The Stanford COVID-19 surgical decision-tree algorithm (Photo courtesy of JACC)
A decision-tree algorithm designed to protect operating room (OR) staff assumes that every patient is potentially infected with COVID-19, until proven otherwise.

The recommendations, devised by surgeons at Stanford University (CA, USA), are designed to protect OR staff, while at the same time conserving personal protective equipment (PPE) use. The recommendations include:
• For emergency procedures (or in situation where SARS-CoV-2 testing is not possible before surgery), personnel should use full PPE, including gown, gloves, eye protection, and a fitted N-95 respirator mask.
• Urgent procedures on symptomatic patients should be delayed if possible. If the procedure cannot be delayed, patients should undergo SARS-CoV-2 testing. Any urgent procedure where testing is positive should be approved by the anesthesia and surgical chair, and if the procedure is approved, personnel should use full PPE and follow the hospital's protocol for COVID-19 patients.
• Asymptomatic patients scheduled for high-risk procedures who test negative for SARS-CoV-2 and asymptomatic patients scheduled for low-risk procedures can proceed to surgery where OR members use standard surgical attire.
• For all intubations or extensive bag-mask ventilation, anesthesia personnel should wear a fitted N-95 mask plus face shield, and other personnel should leave the room for this portion of the procedure to avoid possible droplet and aerosol infection.

“This algorithm is based on the urgency of the operation, anticipated viral burden at the surgical site, opportunity for a procedure to aerosolize virus, and likelihood a patient could be infected based on symptoms and testing,” concluded lead author Joseph D. Forrester, MD, and colleagues. “It prioritizes patients based on disease severity, testing status, and symptoms, while ensuring rational use of PPE in a resource-constrained setting. It has been shared with healthcare providers and stakeholders nationwide and is expected to be widely adopted.”

At the time the guideline algorithm was created there was a nationwide shortage of N-95 face masks in the United States. To conserve the institution's supply, the algorithm requires a face shield to be placed over the mask. The U.S. federal government has recently announced that millions of face masks, face shields, surgical masks, gloves, and gowns are entering the medical supply chain.

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