Essential surgery during the covid 19 pandemic: The implementation of a pre-operative universal covid testing program.

Introduction

Emerging evidence from China and Europe suggest that performing surgery during the incubation period of COVID-19 infection or in patients who have tested positive leads to increased morbidity. , Pre-operative testing to identify positive, asymptomatic patients is one strategy that may improve patient outcomes and also protect the healthcare team. Here we describe our institution’s experience with implementing universal pre-operative COVID-19 screening. We aimed to determine our local asymptomatic carrier rate, evaluate operational feasibility of universal screening, and potentially enhance the safety of the perioperative team. Additionally, we explored the rate of conversions, or positive tests, within 14 days of surgery when available.

Methods

In accordance with the San Diego County mandate, UCSD Health cancelled all elective surgeries on March 18, 2020. Essential surgery, defined as any surgery in which a 4–6 week delay could adversely affect prognosis or quality of life, was allowed to continue. Cases were approved by the respective surgical chair and the peri-operative leadership consisting of a surgeon, anesthesiologist, and administrator. This triad worked in close communication with the COVID-19 Infection Control Team (ID), which supervised all COVID-19 related preventative measures and testing protocols of the healthcare system.

As of March 30, 2020, a total of 5 testing sites associated with UCSD Health were established throughout San Diego County and Imperial Valley. Reverse transcription polymerase chain reaction (RT-PCR) and FDA approved rapid molecular platforms were used to test all pre-operative patients within 72 hours of surgery. Once a surgery date was secured, the Anesthesia Preparedness Clinic ordered all COVID-19 screening tests. Patients who lived more than 2 hours away from the testing sites were screened using rapid molecular testing upon arrival to the pre-operative unit. Negative results were communicated through MyChart, the patient portal of the Epic medical chart system. Positive results were communicated via telephone by a trained nurse from the ID team. Quarantine guidelines were reviewed with the patient and triaging of the patient to self-care or inpatient evaluation was also performed during this call. If the procedure could be delayed, patients who tested positive were re-tested 14 days later at a dedicated COVID-19 clinic. If the procedure could not be delayed, it was performed in an operating room dedicated for COVID-19 patients, available at each hospital campus. N95 masks were required for all surgical personnel in addition to usual personal protective equipment (PPE). All patients then received at least one telehealth post-operative visit within two weeks of hospital discharge. Symptoms were reviewed at these visits and if suspicious for COVID-19, the patients were then rescreened. Patients scheduled for repeat procedures, chemotherapy, or radiation were also screened for COVID-19 prior to these interventions.

Additionally, with our rapid expansion of available testing platforms and surgical services, as of April 22, 2020, all healthcare workers were mandated for COVID-19 screening, prioritizing healthcare workers in the emergency room and perioperative services including surgeons, anesthesiologists, and nursing staff. After initial testing, unlimited screening was available for all healthcare workers with symptoms or potential exposures.

We performed a retrospective chart review of all operative patients between March 30- May 8, 2020 in the UCSD Health System. Patient demographics, assigned surgical service, and pre- and post-operative COVID-19 testing results were described using percentages. This study was approved by the Institutional Review Board at the University of California, San Diego (#200598X).

Results

A total of 1491 unique patients received surgery. In this patient population, 56.7% were female and 70.3% were under the age of 65. Fifty-six percent of patients were white, 28.7% Hispanic, 6.3% Asian and 6.1% Black. The acute care and trauma surgical services performed the most procedures during this study period. Thirty-three percent of surgeries were performed emergently (for life-threatening indications) or urgently (for potentially life-threatening indication, to be performed within 4–8 hours). Of the scheduled surgical cases, 27.8% were performed for active or suspected malignancies.

We achieved a 100% test rate of surgical patients within 18 days of initiating the pre-operative COVID-19 testing program. In the study period, 3 patients (0.2%) tested positive, one of which was asymptomatic, thus resulting in an asymptomatic carrier rate of 0.07%. Of all the patients who tested negative pre-operatively, 621 (39%) underwent secondary screening postoperatively. Of these patients, the vast majority (99.8%) remained negative, with only 1 patient testing positive 17 days after surgery.

Discussion

Our findings indicate that universal screening of preoperative patients is feasible. The disease and asymptomatic carrier rates were low among those who were tested both pre-operatively and post-operatively. To date, there have been no known peri-operative healthcare workers within the UCSD Health System who have tested positive for COVID-19. Based on these results, as well as our supply of essential resources, we have developed a surgical resumption plan which includes continued pre-operative testing of all patients, testing of healthcare workers, social distancing, and a mandatory masking policy. In addition, a gradual stepwise increase in surgical indications and surgical volume based on clinical priority has been implemented and monitored by the perioperative leadership. For those centers that are unable to perform universal screening, some experts have advocated for universal respiratory precautions for all surgical patients.

Declaration of competing interest

No authors have any conflicts of interests relevant to this publication.