Recommendation for Resuming Elective Surgery during the Normalising Period in COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19) is an infection caused by the severe acute respiratory syndrome coronavirus 2. It began at the end of 2019 in the Hubei province of China and quickly expanded worldwide. The World Health Organisation announced the determination of the Public Health Emergency of International Concern on 31 January, 2020, and later proclaimed a global pandemic on 10 March, 2020. The first case in Turkey was officially declared on 11 March, 2020. On 17 March, 2020, the Turkish Ministry of Health published a circular number 14500235-403.99, which regulated precautions to minimise the workload of healthcare systems as well as that of caregivers. This involves the cancellation of elective surgeries to ensure rational and effective use of healthcare resources during the pandemic to reduce viral transmission between patients and healthcare staff and to manage rationally critical care utilisation. In contrast, maintenance of non–COVID-19 healthcare and resumption of critical procedures are serious issues after 60 days of the pandemic. Oncological surgery, procedures to rescue affected limbs, operations to improve function or quality of life and alleviation of pain should be revised in this context and should be scheduled. Per the Turkish Association of Anaesthesia and Reanimation, we aimed to compile our suggestions about the elective surgery schedule, share them with public authority and guide our colleagues in decision making. Local factors with institutional features and opportunities should be considered with local authority coordination for these recommendations. Essential factors to consider while planning elective surgery are the regional incidence of the disease and patient population of the relevant institution before the pandemic. Evaluation of logistic conditions and institutional status within the pandemic would allow a reliable planning. Clearly redefining elective surgery would be advantageous in terms of a common language between departments and would improve collaboration. This guideline based on actual data involves recommendations for the management of anaesthesia and reanimation. Newer data or evidence will possibly weaken these suggestions. As a part of professional responsibility, one should follow current knowledge and regulations by communication channels of the Ministry of Health. Evaluation before planning elective surgery It is recommended to manage the transition period with an institutional scientific board committee. Collaboration with the head nursery is rational in this time course. Before resuming scheduled surgery, institutional opportunities should be assessed and coordination with local health authorities should be established. Moreover, local conditions of COVID-19 infection should be evaluated with a period of fall in the past 14 days (1). a) Assessment of patients with COVID-19 It is recommended to determine the prevalence for the relevant institution as well as the local rate, availability of ward beds and intensive care units (ICUs), discharge status and mortality rate before resuming. It is recommended to have a local policy for retest and follow-up for patients who are positive. Because COVID-19 is associated with high perioperative morbidity and mortality, surgery is conceivable only in life-threatening conditions for patients who are positive for COVID-19. b) Coronavirus disease 2019 diagnostic opportunities Diagnostic opportunities should be reviewed and updated before resuming scheduled surgery. Local policy for COVID-19 diagnosis would be rather established considering local factors with incidence of asymptomatic ratio. Despite the high incidence of false negatives (30%), reverse transcriptase-polymerase chain reaction (RT-PCR) testing is actually a standard tool. Resuming elective surgery can be planned when adequate diagnostic facilities for patients and staff are all available. c) Healthcare workers Considering fatigue and stress during the pandemic, it is recommended to carefully plan for working hours. Staff assigned in high-risk areas would benefit from a flexible programme. The availability of diagnostic tests for healthcare workers is crucial, and it would affect the development of local policy. High-sensitive antibody tests, whenever obtained, would be primarily suitable for caregivers working in high-risk areas. Administration of an immune chart would be appropriate, especially for this group. The safety of healthcare workers should be accepted as the first and most critical step of organisation. Prevalence in this special group should be closely monitored with vigilant follow-up. Before resuming elective surgery, a task distribution close to that of the pre-pandemic period would be suitable. Staff working out of their own places would rather return. Apart from operating rooms (ORs), adequate staff should be reserved for outpatient clinics or post-anaesthesia care units for perioperative period. d) Institutional facilities Normalisation should be established for ICU beds (ORs, paediatric ICUs used for patients with COVID-19 and so on) with an approximate capacity to that of the pre-pandemic period. COVID-19–dedicated building, OR, ICU or any department for diagnostic or therapeutic procedures should be revisited. Similar organisations should be ensured for patients without COVID-19. If these groups are to be treated in the same building, isolation standards, transport conditions between sections and disinfection or sterilisation protocols should be planned in detail (1). Staff should receive training in personal protective equipment (PPE), disinfection or sterilisation topics. Surgical timetables for elective procedures should be organised considering emergent cases, such as trauma. Other facilities for surgical patients, such as laboratory, radiological suits and postoperative care units, should be included in the preliminary plan. Any change in construction or acclimatisation would be planned with the technical department. e) Personal protective equipment It is mandatory to have an appropriate number of PPEs as described in guidelines (N95/FFP2 masks, face shield, gloves, gown, cap, shoe cover and antiseptic solutions) to ensure staff safety. PPE supply chain should be reliably assumed in collaboration with the local authority. A stock of at least 30 days for PPE is recommended in a hospital before the start of elective surgery. Elective surgery schedule a) Planning patients’ preparation (Figure 1) Open in a separate window Figure 1 Preoperative preparation diagram for resuming elective surgery