Strategies for daily operating room management of ambulatory surgery centers following resolution of the acute phase of the COVID-19 pandemic

Improving the mental health care process in response to Covid-19 pandemic: The case of a penitentiary mental health division

Covid-19 outbreak led all organizations to reorganize their processes to prevent infection and contagion risk. All healthcare facilities, included penitentiary mental health services, had to redesign their processes to safely deliver care services. In this paper, the case of a Penitentiary Mental Health Division located in southern Italy is presented. Soft System Methodology and Business process management principles and techniques are adopted to analyse and redesign the detainees' mental health care process. The process, characterized by direct, close and prolonged contact with patients, exposes detainees and healthcare staff to a high Covid-19 infection risk. Through document analysis, interviews with the actors involved in the process and direct observation, the process's inefficiencies and criticalities are identified. The process is redesigned to make it compliant with Covid-19 prevention provisions and national penitentiary regulations and address the other criticalities. The proposed methodological approach-which innovatively combines Soft System Methodology and Business Process Management-constitutes a human-centered process-based redesign approach that can be used both in healthcare and other organizational settings.

Exploration and Application of the Peri-anesthesia Nursing Management Mode of the Five-Sphere Integrated Plan

Objectives: The objective of this research was to test the application of peri-anesthesia nursing management (anesthesia preparation room, operating room, recovery room, post anesthesia visit, and anesthesia general management) on hospital services. Methods: We used a quantitative research design to collect data from 311 nurses, with structural equation modeling used for data analysis. Results: The application of the peri- anesthesia nursing management mode of the five-sphere integrated plan impacted hospital services for patients. Conclusion: The practice of the five-sphere integrated mode not only highlighted the professional characteristics of anesthesia nursing, but also ensured the quality of medical treatment of patients during peri-anesthesia, and provided new ideas and references for nursing management of other specialties.

Strategies for Safely Maintaining Surgical Volume During the COVID-19 Pandemic: A Mixed-Methods Study

Resuming elective surgeries that were canceled during the COVID-19 pandemic necessitated a change to preprocedure patient preparation at a pediatric tertiary care center in middle Tennessee. We conducted a prospective, observational, mixed-methods study to determine the effectiveness of a preprocedure COVID-19 testing team to prevent COVID-19-related cancellations among pediatric patients receiving planned anesthesia. The intervention involved family member and patient education and a change in health record reporting to include COVID-19 test results. A team tasked with follow-up reviewed test results, consulted with families, and coordinated the administration of rapid tests if necessary. We compared preimplementation and postimplementation cancellation rates in four procedural areas and found no significant difference in the cancellation or rescheduling rates (P = .89, 95% confidence interval = -4.29 to 3.09). The team-based intervention was associated with the preservation of low procedural cancellation rates by mitigating barriers to preprocedural testing.

Anxiety Severity and Influencing Factors in Day Surgery Patients or Relatives in Covid-19 Normalized Prevention Phase

BACKGROUND

As the 2019 Coronavirus Disease (COVID-19) repeated, the prevention and treatment will be normalized in a period. "Large number of patients" and " Turnover quickly" of the day surgery ward greatly increased the difficulty of policy formulation and implementation. The normalization also had a huge negative psychological impact on patients/family members. This study aims to introduce effective epidemic prevention and control measures in day surgery wards, and to clarify the influencing factors of anxiety and subjective discomfort of patients and their families during the normalization of COVID-19.

METHODS

To prepare for normalization of epidemic, research discuss improvements in the management of staff, environment, process. A total of 148 patients admitted to West China Hospital from December 2021 to March 2022 and their relatives were asked to complete a questionnaire effectively. Using the Self-rating Anxiety Scale, Social Support Rating Scale and Subjective Units of Distress scales to analyze anxiety and its risk factors.

RESULTS

Under normalized control measures, no staff was infected. The subjective discomfort score was higher in people with lower body mass index (BMI). Young and high social support score were risk factors for anxiety (P < .05), and social support was positively correlated with anxiety.

CONCLUSION

The normalization of epidemic is an inevitable trend in a period. A stable and safe medical environment needs to fully eliminate the policy defects, to fit the people and focus on mental health of the people. For patients/family members, who are younger,a lower BMI and higher social support should be attention more.

Average and longest expected treatment times for ultraviolet light disinfection of rooms

BACKGROUND

Planning Ultraviolet-C (UV-C) disinfection of operating rooms (ORs) is equivalent to scheduling brief OR cases. The study purpose was evaluation of methods for predicting surgical case duration applied to treatment times for ORs and hospital rooms.

METHODS

Data used were disinfection times with a 3-tower UV-C disinfection system in N=700 rooms each with ≥100 completed treatments.

RESULTS

The coefficient of variation of mean treatment duration among rooms was 19.6% (99% confidence interval [CI] 18.2%-21.0%); pooled mean 18.3 minutes among the 133,927 treatments. The 50^th percentile of coefficients of variation among treatments of the same room was 27.3% (CI 26.3%-28.4%), comparable to variabilities in durations of surgical procedures. The ratios of the 90^th percentile to mean differed among rooms. Log-normal distributions had poor fits for 33% of rooms. Combining results, we calculated 90% upper prediction limits for treatment times by room using a distribution-free method (e.g., third longest of preceding 29 durations). This approach was suitable because, once UV-C disinfection started, the median difference between the duration estimated by the system and actual time was 1 second.

CONCLUSIONS

Times for disinfection should be listed as treatment of a specific room (e.g., "UV-C main OR16"), not generically (e.g., "UV-C"). For estimating disinfection time after single surgical cases, use distribution-free upper prediction limits, because of considerable proportional variabilities in duration.

The impact of the SARS-CoV-2 pandemic on the management of chronic limb-threatening ischemia and wound care

In the wake of the coronavirus pandemic, the critical limb ischemia (CLI) Global Society aims to develop improved clinical guidance that will inform better care standards to reduce tissue loss and amputations during and following the new SARS‐CoV‐2 era. This will include developing standards of practice, improve gaps in care, and design improved research protocols to study new chronic limb‐threatening ischemia treatment and diagnostic options. Following a round table discussion that identified hypotheses and suppositions the wound care community had during the SARS‐CoV‐2 pandemic, the CLI Global Society undertook a critical review of literature using PubMed to confirm or rebut these hypotheses, identify knowledge gaps, and analyse the findings in terms of what in wound care has changed due to the pandemic and what wound care providers need to do differently as a result of these changes. Evidence was graded using the Oxford Centre for Evidence‐Based Medicine scheme. The majority of hypotheses and related suppositions were confirmed, but there is noticeable heterogeneity, so the experiences reported herein are not universal for wound care providers and centres. Moreover, the effects of the dynamic pandemic vary over time in geographic areas. Wound care will unlikely return to prepandemic practices. Importantly, Levels 2–5 evidence reveals a paradigm shift in wound care towards a hybrid telemedicine and home healthcare model to keep patients at home to minimize the number of in‐person visits at clinics and hospitalizations, with the exception of severe cases such as chronic limb‐threatening ischemia. The use of telemedicine and home care will likely continue and improve in the postpandemic era.

How privacy concerns and cultural differences affect public opinion during the COVID-19 pandemic: a case study

Purpose

COVID-19, an infectious disease first identified in China, has resulted in an ongoing pandemic all over the world. Most of the countries have been experiencing a difficult period during the fighting of this pandemic. The purpose of this study is to explore the effect of privacy concerns and cultural differences on public opinion related to the pandemic. The authors conducted a comparative analysis of public opinion in the US and in China as a case study, in order to determine the results.

Design/methodology/approach

National policies on important issues faced during the COVID-19 pandemic in the US and in China were examined through a comparative analysis. The authors used text clustering and visualization to mine public opinion on two popular social media platforms, Twitter and Weibo. From the perspectives of concern for privacy and of national culture, this study combines qualitative and quantitative analysis to discover the acceptance level of national policies by the public in the two countries.

Findings

The anti-pandemic policies and measures of the US and China reflect the different characteristics of their respective political systems and national cultures. When considering the culture of the US, it is hard to establish and enforce a rigorous regulation on either mask wearing in public or home quarantine on the national level. The opinions of US people are diverse, regarding national COVID-19 policies, but they are rather unified on privacy issues. On the other hand, Chinese people show a high acceptance of national policies based on their mask-wearing customs and their culture of collectivism.

Originality/value

Prior studies have paid insufficient attention to the ways in which user privacy and cultural difference affect public opinion on national policies between the US and China. This case study that compares public opinion on current and topical issues which are closely bound up with public life shows originality, as it innovatively provides a cross-cultural perspective on the research of public opinion dissemination during emergencies by considering the ongoing COVID-19 pandemic.

Quantifying and interpreting inequality of surgical site infections among operating rooms

PURPOSE

The incidence of surgical site infection differs among operating rooms (ORs). However, cost effectiveness of interventions targeting ORs depends on infection counts. The purpose of this study was to quantify the inequality of infection counts among ORs.

METHODS

We performed a single-centre historical cohort study of elective surgical cases spanning a 160-week period from May 2017 to May 2020, identifying cases of infection within 90 days using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes. We used the Gini index to measure inequality of infections among ORs. As a reference, the Gini index for inequality of household disposable income in the US in 2017 was 0.39, and 0.31 for Canada.

RESULTS

There were 3,148 (3.67%) infections among the 85,744 cases studied. The 20% of 57 ORs with the most and least infections accounted for 44% (99% confidence interval [CI], 36 to 52) and 5% (99% CI, 2 to 8), respectively. The Gini index was 0.40 (99% CI, 0.31 to 0.50), which is comparable to income inequality in the US. There were more infections in ORs with more minutes of cases (Spearman correlation ρ = 0.68; P < 0.001), but generally not in ORs with more total cases (ρ = 0.11; P = 0.43). Moderately long (3.3 to 4.8 hr) cases had a large effect, having greater incidences of infection, while not being so long as to have just one case per day per OR. There was substantially greater inequality in infection counts among the 557 observed combinations of OR specialty (Gini index 0.85; 99% CI, 0.81 to 0.88).

CONCLUSIONS

Inequality of infections among ORs is substantial and caused by both inequality in the incidence of infections and inequality in the total minutes of cases. Inequality in infections among OR and specialty combinations is due principally to inequality in total minutes of cases.

Operating room air delivery design to protect patient and surgical site results in particles released at surgical table having greater concentration along walls of the room than at the instrument tray

Background

During the coronavirus disease 2019 (COVID-19) pandemic, recommendations have included that personnel not involved in procedures releasing airborne contaminants reduce their exposure by moving >2 m away. We tested whether air particle concentrations in operating rooms (ORs) are greater in the periphery, downstream from the supply airflow.

Methods

We analyzed data from 15 mock surgical procedures performed in 3 ORs. Two ORs were modern, one with a single large diffuser system above the surgical table, and the other using a multiple diffuser array design. An air particle counting unit was located on the instrument table, another adjacent to an air return grille.

Results

Concentrations of air particles were greater at return grille than instrument table for the single large diffuser at 26 air exchanges per hour, and the multiple diffuser array at both 26 and 20 air exchanges per hour (all P ≤ .0044), including during electrocautery (all P ≤ .0072). The ratios of concentrations, return grille versus instrument table, were greater during electrocautery for 0.5 to 1.0-micron particles and 1.0 to 5.0-micron particles (both P < .0001).

Conclusions

Modern OR airflow systems are so effective at protecting the surgical field and team from airborne particles emitted during surgery that concentrations of particles released at the OR table are greater at the OR walls than near the center of the room.

Humanitarian Surgical Missions in Times of COVID-19: Recommendations to Safely Return to a Sub-Saharan Africa Low-Resource Setting

Background

Since the declaration of the pandemic, humanitarian medicine has been discontinued. Until now, there have been no general recommendations on how humanitarian surgical missions should be organized.

Methods

Based on our experience in the field of humanitarian surgical missions to Sub-Saharan Africa, a panel of recommendations in times of COVID-19 was developed. The fields under study were as follows: (1) Planning of a multidisciplinary project; (2) Organization of the infrastructure; (3) Screening, management and treatment of SARS-COV-2; (4) Diagnostic tests for SARS-COV-2; (5) Surgical priorization and (6) Context of patients during health-care assistance. We applied a risk bias measurement to obtain a consensus among humanitarian health-care providers with experience in this field.

Results

A total of 94.36% of agreement were reached for the approval of the recommendations. Emergency surgery must be a priority, and elective surgery adapted. For emergency surgery, we established a priority level 1a (< 24 h) and 1b (< 72 h). For an elective procedure, according our American College of Surgeon adaptation score, process with more than 60 points should be reconsidered. Due to the low life expectancy in many African countries, we consider 45–50 years as age of risk. In case of SARS-COV-2 active infection or high clinical suspicion, the screening, management and treatment should be following the international guidelines adapted to duration of the stay, available infrastructure, size of the cooperation team and medical resources.

Conclusions

Humanitarian surgical mission in times of COVID-19 is a challenge that must extrapolate the established recommendations to the local cooperation environment.

Supplementary Information

The online version contains supplementary material available at (10.1007/s00268-021-06001-x).

The impact of confirmed coronavirus disease 2019 (COVID-19) infection on ambulatory procedures and associated delays in care for asymptomatic patients

Background

Since the reopening of ambulatory centers, minimal data has been reported regarding positive tests among patients undergoing ambulatory procedures, associated delays in care, and outcomes of patients previously positive for coronavirus disease 2019.

Methods

A retrospective observational case series of ambulatory procedures was performed. Records since the reopening of ambulatory centers in New York were searched for patients with positive coronavirus disease 2019 nasal swab results who underwent ambulatory procedures. Chart reviews were conducted to determine coronavirus disease history and hospitalizations, demographic information, procedure details, and 30-day admissions.

Results

A total of 3,762 patients underwent ambulatory procedures. Of those, 53 were previously diagnosed with coronavirus disease 2019 but recovered and tested negative at preprocedural testing. Of the 3,709 asymptomatic patients, 37 (1.00%) tested positive during preprocedural testing; 21 patients had their procedures delayed on average 28.6 days until testing negative, while 16 had their procedures performed before testing negative owing to the time sensitivity of the procedure. There were no major complications or 30-day admissions in any of these asymptomatic patients. Three patients tested positive for coronavirus disease after having an ambulatory procedure.

Conclusion

Positive tests in asymptomatic patients led to procedure delays of 28.6 days. No patients who underwent ambulatory procedures after a positive coronavirus disease 2019 test had any coronavirus disease-related complications, regardless of whether or not the procedure was delayed until testing negative. Three patients tested positive for coronavirus disease 2019 after having an ambulatory procedure; however, at an average of 19.7 days after, these cases were likely community acquired making the rate of nosocomial infection negligible.

Review of Clinical and Operative Recommendations for Ophthalmology Practices During the COVID-19 Pandemic

In response to climbing global case and fatality rates of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its associated disease, COVID-19, ophthalmology practices have modified their clinical and operative approach to patient care in an attempt to reduce spread of the virus. The presence of SARS-CoV-2 viral RNA in the preocular tear film raises speculation that the ocular surface can act as an initial site of infection as well as a potential source of person-to-person viral transmission. More recently, conjunctival specimens and immunohistochemical analyses have identified the presence of cellular surface factors necessary for SARS-CoV-2 infection on the ocular surface. Together, these results highlight the importance of safety measures in ophthalmology practices to prevent transmission of SARS-CoV-2. As ophthalmic exams typically require close proximity between a patient's respiratory tract and the provider, clinical and surgical recommendations are aimed at reducing unnecessary patient-provider interactions. Subspecialty professional guidelines can be used to instruct ophthalmologists on the necessity of various procedures and best practice measures. Ophthalmology practice during the COVID-19 pandemic has been dramatically curtailed in an effort to reduce the risk of transmission and converse valuable personal protective equipment (PPE), and the impacts of the ongoing pandemic on ophthalmology practices will be felt for the foreseeable future.

Directives of general surgical practice during the COVID-19 pandemic: A systematic review

The coronavirus disease 2019 (COVID-19) is a serious global pandemic that has extremely affected health-care systems. This article aimed to review the perspectives of general surgical practice during the COVID-19 pandemic. A systematic review of the literature addressing modification to general surgical practice during the COVID-19 pandemic indexed in PubMed, Scopus, Google, and Google scholar was carried out on June 19-20, 2020. The literature review yielded 577 articles. The exclusion of duplication, articles not in English, and specialized ones in various surgical disciplines precluded 398 articles. Finally, following checking for relevance and publication status, 114 papers were included. Recommendations for surgical practice during the COVID-19 pandemic revolved around mitigation of the risk of virus transmission to patients and health-care workers. The emerging themes of safety precautions were related to patient prioritization and testing, mindful consideration of the operative strategy, optimum use of personal protective equipment, operative room setup, and departmental organization. However, those recommendations were often diverging and bore on a dearth of evidence and personal opinions. Multidisciplinary work and cooperation among surgical specialties are required to establish and validate the protocols for safe surgical practice during the pandemic and perhaps similar crises in future. The COVID-19 pandemic has brought several challenges to the field of medicine, including the surgical specialty. The centrality of safety precautions emerging in this crisis requires surgeons to adopt the new roles and work standards and translate them into practice during the pandemic and perhaps longer.

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.

Gastroenterology Procedures Generate Aerosols: An Air Quality Turnover Solution to Mitigate COVID-19's Propagation Risk

The growing fear of virus transmission during the 2019 coronavirus disease (COVID-19) pandemic has called for many scientists to look into the various vehicles of infection, including the potential to travel through aerosols. Few have looked into the issue that gastrointestinal (GI) procedures may produce an abundance of aerosols. The current process of risk management for clinics is to follow a clinic-specific HVAC formula, which is typically calculated once a year and assumes perfect mixing of the air within the space, to determine how many minutes each procedural room refreshes 99% of its air between procedures when doors are closed. This formula is not designed to fit the complex dynamic of small airborne particle transport and deposition that can potentially carry the virus in clinical conditions. It results in reduced procedure throughput as well as an excess of idle time in clinics that process a large number of short procedures such as outpatient GI centers. We present and tested a new cyber-physical system that continuously monitors airborne particle counts in procedural rooms and also at the same time automatically monitors the procedural rooms' state and flexible endoscope status without interfering with the clinic's workflow. We use our data gathered from over 1500 GI cases in one clinical suite to understand the correlation between air quality and standard procedure types as well as identify the risks involved with any HVAC system in a clinical suite environment. Thanks to this system, we demonstrate that standard GI procedures generate large quantities of aerosols, which can potentially promote viral airborne transmission among patients and healthcare staff. We provide a solution for the clinic to improve procedure turnover times and throughput, as well as to mitigate the risk of airborne transmission of the virus.

Simulation and Improvement of Patients' Workflow in Heart Clinics during COVID-19 Pandemic Using Timed Coloured Petri Nets

The COVID-19 epidemic has spread across the world within months and creates multiple challenges for healthcare providers. Patients with cardiovascular disease represent a vulnerable population when suffering from COVID-19. Most hospitals have been facing difficulties in the treatment of COVID-19 patients, and there is a need to minimise patient flow time so that staff health is less endangered, and more patients can be treated. This article shows how to use simulation techniques to prepare hospitals for a virus outbreak. The initial simulation of the current processes of the heart clinic first identified the bottlenecks. It confirmed that the current workflow is not optimal for COVID-19 patients; therefore, to reduce waiting time, three optimisation scenarios are proposed. In the best situation, the discrete-event simulation of the second scenario led to a 62.3% reduction in patient waiting time. This is one of the few studies that show how hospitals can use workflow modelling using timed coloured Petri nets to manage healthcare systems in practice. This technique would be valuable in these challenging times as the health of staff, and other patients are at risk from the nosocomial transmission.

Sample times for surveillance of S. aureus transmission to monitor effectiveness and provide feedback on intraoperative infection control

Background

Reductions in perioperative surgical site infections are obtained by a multifaceted approach including patient decolonization, vascular care, hand hygiene, and environmental cleaning. Associated surveillance of S. aureus transmission quantifies the effectiveness of these basic measures to prevent transmission of pathogenic bacteria and viruses to patients and clinicians, including Coronavirus Disease 2019 (COVID-19). To measure transmission, the observational units are pairs of successive surgical cases in the same operating room on the same day. In this prospective cohort study, we measured sampling times for inexperienced and experienced personnel.

Methods

OR PathTrac kits included 6 samples collected before the start of surgery and 7 after surgery. The time for consent also was recorded. We obtained 1677 measurements of time among 132 cases.

Results

Sampling times were not significantly affected by technician's experience, type of anesthetic, or patient's American Society of Anesthesiologists’ Physical Status. Sampling times before the start of surgery averaged less than 5 min (3.39 min [SE 0.23], P < 0.0001). Sampling times after surgery took approximately 5 min (4.39 [SE 0.25], P = 0.015). Total sampling times averaged less than 10 min without consent (7.79 [SE 0.50], P < 0.0001), and approximately 10 min with consent (10.22 [0.56], P = 0.70).

Conclusions

For routine use of monitoring S. aureus transmission, when done by personnel already present in the operating rooms of the cases, the personnel time budget can be 10 min per case.

Comparison of Percentage Prolonged Times to Tracheal Extubation Between a Japanese Teaching Hospital and One in the United States, Without and With a Phase I Postanesthesia Care Unit

BACKGROUND

Prolonged times to tracheal extubation are those from end of surgery (dressing on the patient) to extubation 15 minutes or longer. They are so long that others in the operating room (OR) generally have exhausted whatever activities can be done. They cause delays in the starts of surgeons' to-follow cases and are associated with longer duration workdays. Anesthesiologists rate them as being inferior quality. We compare prolonged times to extubation between a teaching hospital in the United States with a phase I postanesthesia care unit (PACU) and a teaching hospital in Japan without a PACU. Our report is especially important during the coronavirus disease 2019 (COVID-19) pandemic. Anesthesiologists with some patients undergoing general anesthetics and having initial PACU recovery in the ORs where they had surgery can learn from the Japanese anesthesiologists with all patients recovering in ORs.

METHODS

The historical cohort study included all patients undergoing gynecological surgery at a US hospital (N = 785) or Japanese hospital (N = 699), with the time from OR entrance to end of surgery of at least 4 hours.

RESULTS

The mean times from end of surgery to OR exit were slightly longer at the US hospital than at the Japanese hospital (mean difference 1.9 minutes, P < .0001). The mean from end of surgery to discharge to surgical ward at the US hospital also was longer (P < .0001), mean difference 2.2 hours. The sample standard deviations of times from end of surgery until tracheal extubation was 40 minutes for the US hospital versus 4 minutes at the Japanese hospital (P < .0001). Prolonged times to tracheal extubation were 39% of cases at the US hospital versus 6% at the Japanese hospital; relative risk 6.40, 99% confidence interval (CI), 4.28-9.56. Neither patient demographics, case characteristics, surgeon, anesthesiologist, nor anesthesia provider significantly revised the risk ratio. There were 39% of times to extubation that were prolonged among the patients receiving neither remifentanil nor desflurane (all such patients at the US hospital) versus 6% among the patients receiving both remifentanil and desflurane (all at the Japanese hospital). The relative risk 7.12 (99% CI, 4.59-11.05) was similar to that for the hospital groups.

CONCLUSIONS

Differences in anesthetic practice can facilitate major differences in patient recovery soon after anesthesia, useful when the patient will recover initially in the OR or if the phase I PACU is expected to be unable to admit the patient.

Anesthesiologist behavior and anesthesia machine use in the operating room during the COVID-19 pandemic: awareness and changes to cope with the risk of infection transmission

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease [coronavirus disease 2019 (COVID-19) infection] first appeared in December 2019 in China and is now spreading worldwide. Because SARS-CoV-2 can be transmitted via aerosols and surface contaminations of the environment, appropriate use of anesthesia machines and appropriate behavior in the operation room (OR) are required specifically in relation to this disease. The use of high-performance hydrophobic filters with a high rate of virus rejection is recommended as the type of viral filter, and surgical team behaviors that result in aerosol splashes should be avoided. Appropriate hand hygiene by the anesthesiologist is crucial to prevent unexpected environmental contamination. When the anesthesia machine is used instead of an intensive care unit ventilator, it is important to keep the fresh gas flow at least equal to the minute ventilation to prevent excessive humidity in the circuit and to monitor condensation in the circuit and inspiratory carbon dioxide pressure. In addition, both the surgical smoke inherent in thermal tissue destruction and the surgical team's shoe soles may be factors for the presence of SARS-CoV-2 in the operating room. Ensuring social distancing-even with a mask in the OR-may be beneficial because healthcare providers may be asymptomatic carriers. After the acute crisis period of COVID-19, the number of cases of essential but nonurgent surgeries for waiting patients is likely to increase; therefore, optimization of OR scheduling will be an important topic. Anesthesiologists will benefit from new standard practices focusing on the prevention of COVID-19 infection.

Policy Implications for the COVID-19 Pandemic in Light of Most Patients (≥72%) Spending at Most One Night at the Hospital After Elective, Major Therapeutic Procedures

A large number of inpatients with Coronavirus disease 2019 (COVID-19) in some regions of the United States may interfere with the ability of hospitals to take care of patients requiring treatment for other conditions. Nonetheless, many patients need surgery to improve their quality of life and to prevent deterioration in health. Curtailment of services also negatively affects the financial health of hospitals and health systems. Broad policies to prohibit all "elective" surgical procedures to ensure that there is sufficient hospital capacity for pandemic patients may be unnecessarily restrictive because, for many such procedures, patients are rarely admitted following surgery or only stay overnight. We studied all elective inpatient and ambulatory cases involving major therapeutic procedures performed in the state of Florida in 2018. We mapped the primary procedure to the corresponding Clinical Classification Software (CCS) category. We determined the distributions of lengths of stay overall and as stratified by CCS category, then calculated the percentage of cases that had a hospital length of stay of ≤1 night (i.e., 0 or 1 day). A threshold of one night was selected because patients discharged home on the day of surgery have no effect on the inpatient census, and those staying overnight would either have a transient effect or no effect if observed overnight in the postoperative care unit. Among the 1,852,391 elective cases with one or more major therapeutic procedures, 65.2% (95% lower confidence limit [LCL] = 65.1%) of cases had a length of stay of 0 days and 72.9% (95% LCL = 72.8%) had stay ≤1 day. There were 38 different CCS categories for which at least 95% of patients had a length of stay of ≤1 day. There were 28 CCS codes that identified 80% of the patients who were discharged with a length of stay ≤1 day, showing representation of multiple surgical specialties. Our results show that even in the face of constraints imposed by a high hospital census, many categories of major therapeutic elective procedures could be performed without necessarily compromising hospital capacity. Most patients will be discharged on the day of surgery. If overnight admission is required, there would be an option to care for them in the postanesthesia care unit, thus not affecting the census. Thus, policies can reasonably be based on allowing cases with a substantial probability of at most an overnight stay rather than a blanket ban on "elective" surgery or creating a carve-out for specified surgical subspecialties. Such policies would apply to at least 72% of elective, major therapeutic surgical procedures.

Caseload is increased by resequencing cases before and on the day of surgery at ambulatory surgery centers where initial patient recovery is in operating rooms and cleanup times are longer than typical

Study objective

The coronavirus disease 2019 (COVID-19) pandemic impacts operating room (OR) management in regions with high prevalence (e.g., >1.0% of asymptomatic patients testing positive). Cases with aerosol producing procedures are isolated to a few ORs, initial phase I recovery of those patients is in the ORs, and multimodal environmental decontamination applied. We quantified the potential increase in productivity from also resequencing these cases among those 2 or 3 ORs.

Design

Computer simulation provided sample sizes requiring >100 years experimentally. Resequencing was limited to changes in the start times of surgeons' lists of cases.

Setting

Ambulatory surgery center or hospital outpatient department.

Main results

With case resequencing applied before and on the day of surgery, there were 5.6% and 5.5% more cases per OR per day for the 2 ORs and 3 ORs, respectively, both standard errors (SE) < 0.1%. Resequencing cases among ORs to start cases earlier permitted increases in the hours into which cases could be scheduled from 10.5 to 11.0 h, while assuring >90% probability of each OR finishing within the prespecified 12-h shift. Thus, the additional cases were all scheduled before the day of surgery. The greater allocated time also resulted in less overutilized time, a mean of 4.2 min per OR per day for 2 ORs (SE 0.5) and 6.3 min per OR per day for 3 ORs (SE 0.4). The benefit could be achieved while limiting application of resequencing to days when the OR with the fewest estimated hours of cases has ≤8 h.

Conclusions

Some ambulatory surgery ORs have unusually long OR times and/or room cleanup times (e.g., infection control efforts because of the pandemic). Resequencing cases before and on the day of surgery should be considered, because moving 1 or 2 cases occasionally has little to no cost with substantive benefit.

•

COVID-19 influences management for aerosol producing procedures.

•

Simulation studied case resequencing applied before and on the day of surgery.

•

>5% more queued cases can be done per OR per day with practical heuristic.

Perioperative Infection Transmission: the Role of the Anesthesia Provider in Infection Control and Healthcare-Associated Infections

PURPOSE OF REVIEW

This review aims to highlight key factors in the perioperative environment that contribute to transmission of infectious pathogens, leading to healthcare-associated infection. This knowledge will provide anesthesia providers the tools to optimize preventive measures, with the goal of improved patient and provider safety.

RECENT FINDINGS

Over the past decade, much has been learned about the epidemiology of perioperative pathogen transmission. Patients, providers, and the environment serve as reservoirs of origin that contribute to infection development. Ongoing surveillance of pathogen transmission among these reservoirs is essential to ensure effective perioperative infection prevention.

SUMMARY

Recent work has proven the efficacy of a strategic approach for perioperative optimization of hand hygiene, environmental cleaning, patient decolonization, and intravascular catheter design and handling improvement protocols. This work, proven to generate substantial reductions in surgical site infections, can also be applied to aide prevention of SARS-CoV-2 spread in the COVID-19 era.

Resuming Elective Oncologic Surgery After CoVID-19 Outbreak: What Precautions Should be Taken?

The COVID 19 outbreak has caused the cancellation of most elective oncological surgery around the world to limit the risk of virus dissemination. As we are exiting the crisis, surgical teams will face strong challenges while resuming normal elective surgery. The accumulation of cases will have to be managed by defining strong selection criteria, taking into account the patient and the disease conditions. In order to reduce the risk of infection, non-COVID patients should be treated in dedicated non-COVID areas, preferably in separate buildings or hospitals. Departments, units and operative theaters should put in place rigorous actions and protocols to protect the patient and healthcare workers. Adequate protective equipment must be readily available for healthcare workers and patients. Finally, teams should keep an adaptive mindset by preparing strategies to maintain surgical activity in case of repeated COVID 19 waves. Keywords: COVID 19, Guidelines, Lockdown ease, Surgical oncology

Sample sizes for surveillance of S. aureus transmission to monitor effectiveness and provide feedback on intraoperative infection control including for COVID-19

Reductions in perioperative surgical site infections are obtained by a multifaceted approach including patient decolonization, hand hygiene, and hub disinfection, and environmental cleaning. Associated surveillance of S. aureus transmission quantifies the effectiveness of the basic measures to prevent the transmission to patients and clinicians of pathogenic bacteria and viruses, including Coronavirus Disease 2019 (COVID-19). To measure transmission, the observational units are pairs of successive surgical cases in the same operating room on the same day. We evaluated appropriate sample sizes and strategies for measuring transmission.

There was absence of serial correlation among observed counts of transmitted isolates within each of several periods (all P ≥.18). Similarly, observing transmission within or between cases of a pair did not increase the probability that the next sampled pair of cases also had observed transmission (all P ≥.23).

Most pairs of cases had no detected transmitted isolates. Also, although transmission (yes/no) was associated with surgical site infection (P =.004), among cases with transmission, there was no detected dose response between counts of transmitted isolates and probability of infection (P =.25).

The first of a fixed series of tests is to use the binomial test to compare the proportion of pairs of cases with S. aureus transmission to an acceptable threshold. An appropriate sample size for this screening is N =25 pairs. If significant, more samples are obtained while additional measures are implemented to reduce transmission and infections. Subsequent sampling is done to evaluate effectiveness. The two independent binomial proportions are compared using Boschloo's exact test. The total sample size for the 1^st and 2^nd stage is N =100 pairs.

Because S. aureus transmission is invisible without testing, when choosing what population(s) to screen for surveillance, another endpoint needs to be used (e.g., infections). Only 10/298 combinations of specialty and operating room were relatively common (≥1.0% of cases) and had expected incidence ≥0.20 infections per 8 hours of sampled cases. The 10 combinations encompassed ≅17% of cases, showing the value of targeting surveillance of transmission to a few combinations of specialties and rooms.

In conclusion, we created a sampling protocol and appropriate sample sizes for using S. aureus transmission within and between pairs of successive cases in the same operating room, the purpose being to monitor the quality of prevention of intraoperative spread of pathogenic bacteria and viruses.