Viewers of this material should review these FAQs with appropriate medical and legal counsel and make their own determinations as to relevance to their particular practice setting and compliance with state and federal laws and regulations. The ASA has used its best efforts to provide accurate information. However, this material is provided only for informational purposes and does not constitute medical or legal advice. This response also should not be construed as representing ASA policy (unless otherwise stated), making clinical recommendations, dictating payment policy, or substituting for the judgment of a physician and consultation with independent legal counsel.
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updated April 5, 2020
1. Where can I find the ASA recommendations on treating COVID-19 and suspected COVID-19 patients?
2. What is the ASA position on cancelling or rescheduling elective surgeries?
3. What is the position of the ASA, APSF, AAAA and AANA on the use of Personal Protective Equipment, including an N95 mask?
4. What is the position of the ASA on placing multiple patients on a single mechanical ventilator?
- ASA, the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), Anesthesia Patient Safety Foundation (APSF), American Association of Critical‐Care Nurses (AACN) and American College of Chest Physicians (CHEST) issued a consensus statement on the concept of placing multiple patients on a single mechanical ventilator on March 26.
5. Where can I find information on purposing anesthesia machines as ICU ventilators?
6. Where can I find resources for training on critical care medicine?
7. Where can I find recordings of the ASA Town Halls?
- Recordings of the ASA Town Halls are accessible via the ASA COVID-19 "In the Spotlight" page. Links to receiving CME credit for reviewing the Town Hall is available via that page as well.
HOSPITAL & FACILITY ADMINISTRATION
1. My hospital believes that the ASA recommendations are too stringent or do not align with the CDC recommendations. Do the CDC recommendations include diagnostic, therapeutic or surgical patient considerations? How should I discuss anesthesia recommendations with my hospital?
- ASA recommendations are written to protect other patients, other health care workers and the anesthesia professional. They are derived from the CDC guidelines for health care workers regarding the current SARS-CoV-2 (COVID-19) virus as well as the interim guidance provided during the SARS outbreak in 2003-4. When the CDC investigated the SARS outbreak in the early 2000’s, they found that the health care workers caring for these patients became infected with SARS despite using contact and droplet precautions. Droplet particles may become aerosolized into finer particles by coughing and sneezing or airway procedures such as laryngoscopy, intubation, suctioning, and bronchoscopy. These finer particles may become suspended in air currents and penetrate ordinary surgical mask barriers. The CDC has the same recommendation for patients if they have known or suspected of infection with the current SARS-CoV-2 virus, and for all diagnostic, therapeutic or surgical considerations.
- ASA recommendations call for the anesthesia professional to consider measures that limit the potential for aerosolization of droplet particles. These include:
- In each location where intubations take place, the most experienced professional for that location should perform the intubation. In the operating room, this should be the most experienced anesthesia professional available. In non-operating room locations, including the Emergency Room and ICU, this should be an emergency medicine, critical care medicine or anesthesia professional, depending on availability and staffing for the facility. Every facility should develop a protocol for which medical service responds to the need for non-OR intubations.
- Wearing personal protective equipment (PPE) including:
- Either an N95 mask, for which one has been fit-tested, or a powered air-purifying respirator (PAPR);
- A face shield or goggles;
- A gown;
- Avoid awake fiberoptic intubation unless specifically indicated.
- Consider a rapid sequence induction (RSI) in order to avoid manual ventilation of patient’s lungs and potential aerosolization. If manual ventilation is required, apply small tidal volumes.
2. Should our hospital convert our PACUs into makeshift ICUs?
- If the pandemic overcomes the capacity of a hospital ICUs, the PACUs can serve as overflow. Given the fact that PACUs are open units, the institution must decide if all the patients housed in the PACU will have COVID19 or non-COVID19 patients (but not both). Institutions will also need to draft a plan on who will provide medical care to these patients (e.g., Critical Care Anesthesiologists, Internists, Surgeons, ED Physicians, or combination).
3. Does the ASA have any kind of algorithm or decision tree on how to handle patients coming through for elective, urgent and emergent surgery? We are trying to maintain operations while having the ability to scale back as the situation around us may require.
- We have not produced an algorithm on how local hospitals should handle elective, urgent and emergent surgery. There are many contingencies that a hospital must consider, including, but not limited to, patient population, community COVID-19 spread, social distancing, equipment availability and type of elective procedure (will a delay cause more harm?). Hospitals, anesthesiology departments and other healthcare workers should work together to create their own institutional algorithm or decision tree based on these factors. Please also consider the “ASA-APSF Joint Statement on Non-Urgent Care During the COVID-19 Outbreak”.
4. What is the definition of elective cases? I am receiving pushback from my hospital, surgeons and others who believe that many of their cases are urgent or emergent.
- We are concerned that elective and non-essential surgeries appear to be continuing in locations where community spread is significant. While the Anesthesia Quality Institute definition of elective surgery is “a surgical, therapeutic or diagnostic procedure that can be performed at any time or date between the surgeon and patient,” this definition doesn’t reflect nuances that exist in scheduling operative procedures at the current time.
- Please review the ASA-APSF Joint Statement on Non-Urgent Care During the COVID-19 Outbreak as well as the Centers for Medicare and Medicaid Services (CMS) guidance on non-essential planned surgeries (PDF).
- When working with surgeons on scheduling cases, consider reviewing the ACS statement that includes an Elective Surgery Acuity Scale (ESAS) that balances a patient’s need or impact of a surgical procedure with available resources. Many cancer cases are considered time-sensitive. We recommend close collaboration between surgeons, anesthesiologists, and hospital administration to balance individual patient needs with system resource constraints.
5. I am concerned about intubating and extubating patients who could be asymptomatic carriers. I am concerned that current PPE guidelines do not reflect the transmission risks from asymptomatic individuals.
- ASA, APSF, AAAA and AANA have provided PPE recommendations highlighting the uncertainty of patients’ COVID-19 status and the need for practitioner safety, addressing contingencies that anesthesiologists face at their local facilities. The decision on whether a patient is suspected of COVID-19 infection should be made individually based on clinical, history and testing criteria where possible. The suspicion of asymptomatic COVID-19 infection should be considered in areas with community spread. Ideally, anesthesiologists and other members of the healthcare team should have an adequate supply of N95 masks for caring of all patients whether symptomatic or not.
- We know that PPE is in short supply in many areas of the country. Therefore, limiting surgical case volume should help reduce the frequency of provider exposure. We further encourage physicians to discuss the availability of PPE and other resources with your local leadership and to develop a plan to balance resource constraints with need to protect all providers.
- Please review the Personal Protective Equipment FAQ section for additional details on reusing N95 masks. In general, The CDC and NIOSH have released guidance on reusing PPE. Anesthesiologists should also contact the manufacturer of devices and PPE to ensure that cleaning and reusing such devices and materials are safe and maintain their effectiveness. Please also see the APSF recommendations for processes to eliminate coronavirus from N95 masks.
6. We are currently using CDC guidelines for at-risk patients. Is there any data on at-risk caregivers, such as those who are older or are immunosuppressed?
- Data indicate that older individuals and those with co-existing conditions are at increased risk of severe disease and have higher mortality if infected. There is reasonable concern about these anesthesiologists for providing care to COVID-19 patients and suspected COVID-19 patients. There are no national recommendations on mitigating exposure of higher risk physicians, and neither does ASA. These discussions need to occur on the local level addressing the specific issues and concerns and might include deploying those physicians into lower risk clinical situations if this can be accommodated.
7. Does the ASA have guidelines or recommendations for physicians who are pregnant? We are concerned about our increased risk for exposure.
8. How should the operating room be decontaminated following surgery on a COVID-19 patient?
- We do not have specific guidance on how to decontaminate the operating room after a procedure with a COVID-19 patient. The current CDC guidance states that routine cleaning and disinfection procedures using an EPA-registered, hospital-grade disinfectant from List N, are appropriate for SARS-CoV-2 in healthcare settings. Upon patient leaving the room, entry should be delayed until sufficient time has elapsed for enough air changes to remove aerosolized infectious particles. The AORN Guideline for Environmental Cleaning outlines recommended cleaning procedures that should be monitored for quality and consistency. Linen and medical waste should follow the routine established practices as outlined by local, state and federal regulations.
- Please contact your local infection disease and environmental management personnel for information. Please review APSF recommendations for more information.
9. What are some elements of patient blood management that I should consider?
- The ASA Committee on Patient Blood Management has developed a resource for anesthesiologists with regard to pandemics and patient blood management. The resource also includes references and links to relevant literature.
10. I'm concerned about resource allocation and scarcity at my hospital. Does ASA have any guidance I can use when developing a local policy?
- The ASA Committee on Ethics has developed a resource for anesthesiologists with regard to resource allocation in pandemics. The resource includes components of an institutional policy or guideline as well as references and links to relevant literature.
- Please also see the Clinical Care FAQ #17 regarding unilateral do-not-resuscitate (DNR) orders below.
11. Do you have any advice on staffing models? My hospital administration has asked for volunteers to staff a designated COVID-19 unit, whereby the unit will be closed and staff members stay in the unit for long durations.
- We recognize that each hospital has different resources, patient needs and operational plans to address the COVID-19 population. ASA cannot review specific staffing models or provide specific guidance on staffing models. Please work with your hospital administration and other departments on staffing models.
12. I'm trying to set up an intubation team to do all intubations for the entire hospital to minimize staff exposure and PPE used. Has this been done and what is the optimal number of persons or teams that my hospital should designate?
- Several team-based models have been implemented in hospitals within the United States – including those for intubation/extubation, patient positioning and other features of COVID-19 care. There are many examples based upon local need and resources. At one hospital, an initial team is made of five physician anesthesiologists are working a 12-hour shift. This team and others use PPE that follows CDC guidance, including the use of N95 masks, gloves, gowns and eye protection. Equipment also includes the use of a video laryngoscope while performing an RSI. A powered air-purifying respirator (PAPR) can also be used for intubation if individuals have received training for donning and doffing for the device.
ANESTHESIA MACHINE & EQUIPMENT MAINTENANCE
1. What type of breathing circuit filters should be used to prevent passage of the COVID-19 virus into the anesthesia machine, which could then become a vector for subsequent patients?
- There are no data testing the efficacy of breathing circuit filters for preventing transmission COVID-19 to the anesthesia machine. All breathing circuit filters decrease viral transmission, but we do not know the minimum performance specification that will be protective. To our knowledge, all breathing circuit filters are rated with a viral filtration efficiency (VFE) of at least 99.99%. Some have a VFE of 99.9999% or better. Using more than one filter is recommended, because it magnifies the total VFE. The VFE of any particular breathing circuit filter is listed in the manufacture’s specifications for that product, as is the internal volume. The internal volume is important because it adds that amount of deadspace when placed between the breathing circuit and endotracheal tube. The ASA recommendations coincide with APSF guidance on filters.
2. Does the anesthesia machine need to be decontaminated after use on a COVID-19 patient? We have breathing circuit filters in the circuit and the gas sampling line is also filtered.
- Please refer to ASA Guidance that states, “After the case, clean and disinfect high-touch surfaces on the anesthesia machine and anesthesia work area with an EPA-approved hospital disinfectant.” The internal components of the anesthesia machine and breathing system do not need “terminal cleaning” if breathing circuit filters have been used as directed. Please also see guidance from the APSF on decontamination.
3. Should we purpose our anesthesia machines from our operating rooms for use in ICUs?
- If the pandemic overcomes the capacity of the hospital ICUs to provide ventilators, unused operating room anesthesia machines can be purposed for use in the ICUs. Please refer to ASA and APSF Guidance for further information.
Anesthesia machine manufacturers have also provided their recommendations on repurposing the anesthesia machine for ICU use; links are provided in the ASA and APSF guidance documents.
4. Where in the anesthesia circuit should we place the breathing circuit filter to protect the gas sampling tubing?
- The gas sampling line should be protected by placing a breathing circuit filter at patient end after the Y-piece and then sampling from the side of the filter opposite to the patient. If there is a sampling port on the patient side, it must be capped. Then, both the anesthesia circuit to and from the machine and the gas sampling are filtered.
- For example, please see the photo below.
- The sampling port delivers sampled gas to the analyzer, either a capnometer or multi-gas analyzer. A capnometer, typically used in ICUs and for procedural sedation, transfers the output gas into the room. Multi-gas analyzers, typically used with or integrated into anesthesia machines, transfer the output gas back into the anesthesia breathing system, or into the scavenging system and out of the hospital. It is especially important to filter the analyzer gas if the effluent is discharged into the room, or back into the breathing system.
5. We are placing our breathing circuit filter at the end of the circuit where the tubing attaches to the anesthesia machine. I haven’t been able to find a small breathing circuit filter to attach to the sampling port. Do you know if such a product exists?
- Please see “Where in the anesthesia circuit should we place the breathing circuit filter to protect the gas sampling tubing?” question. We cannot recommend any particular sample line filter.
6. For the pediatric patient how do you protect the sampling line due to the fact the breathing circuit filter adds deadspace and is too heavy for ETT?
- There are smaller volume breathing circuit filters designed for use in larger children, but they may not be available and are not designed for use in small children and infants.
- When a breathing circuit filter is not placed at the airway, APSF guidance is to place a high efficiency filter on the expiratory limb of the breathing circuit and filter the sampling line separately. Placing a 0.2 micron drug injection filter at the entry to the water trap will be effective. This is the same filter that is typically placed in an epidural tray for filtering epidural injections. Wipe surface of the drug filter if not changed between patients. Change the filter and water trap after use on a COVID-19 patient.
- New information from GE is that the D-Fend water trap also contains a 99.999% viral filtration efficiency filter. Draeger is conducting tests on the efficiency of their gas analyzer filter, but it will work with an added 0.2 micron drug injection filter.
- We recommend you review the APSF website for more information on this topic.
7. Where can I buy breathing circuit filters? Where can I find compatible breathing circuit filters?
- Hospitals have supply chain managers who generally have established relationships with the contracted suppliers because breathing circuit filters are commonly used on ICU ventilators and anesthesia machines. Anesthesia supply businesses are a second option. When buying breathing circuit filters, obtain those with the highest VRE. Purchase some with smaller internal volume if your practice includes pediatrics.
8. We are using breathing circuit filters that filter 99.9999%. We also have HMEF filters that filter even more. Which filters should I use for patients? We don’t want to exhaust all of our higher filtration filters if they are not necessarily required for patient care.
- Depending on the presence and level of community spread of COVID-19 in your area and levels of current supplies will help you determine how to best allocate scarce resources to provide the most good and least harm. Reserving the higher filtration breathing circuit filters for the patients with the highest viral titers seems appropriate. Note that a filter may have different filtering capabilities for different pathogens. Please also consult with your local infectious disease physicians and infection control staff. We also recommend you review the APSF website for a discussion on anesthesia machines.
9. With an incubation period of 14 days and the ability to shed the Coronavirus while asymptomatic, why is the ASA not recommending the use of breathing circuit filters for ALL general anesthetics since we don’t know who is infected?
- Breathing circuit filters or combined heat and moisture exchange filters (HMEF) are already commonly used for all general anesthetics. This is best practice that should be adopted as standard policy in all practice locations now. The filters are VFE rated, and we recommend, at a minimum, filters with a VFE of 99.99% that are already commonly being used.
10. Should I be concerned that my anesthesia machine is a vector for transmission?
11. If an anesthesia machine is used in the ICU on a COVID-19 patient, when could it be returned to routine operating room use?
PERSONAL PROTECTIVE EQUIPMENT
1. We don't always know if patients are COVID positive. What PPE should we use?
2. Can I reuse my N95 mask and other Personal Protective Equipment?
- The CDC and NIOSH have released guidance on reusing PPE and additional information. Anesthesiologists should also contact the manufacturer of devices and PPE to ensure that cleaning and reusing such devices and materials are safe and maintain their effectiveness.
- Please see the APSF recommendations for processes to eliminate coronavirus from N95 masks. The inventor of the material used in the N95 mask, Dr. Peter Tsai, suggests that droplets and viable viruses will dry and no longer carry risk of transmission if the masks are not obviously soiled and are carefully stored in brown paper bags (so that air can circulate to them for drying) for at least 3 days. The CDC supports this approach if really necessary to allow re-use but suggests a 5 day period of drying . A practical application, if sufficient numbers of N95 masks are available, would be to issue 5 masks to everyone, and then have them rotate the use and storage of masks in a cycle. Information circulating through social media suggests that placing N95 masks in ovens at 70° C for 30 minutes will decontaminate N95 masks, also. The CDC explicitly does not support this approach to decontaminating N95 masks, suggesting that the dry heat may harm the protective integrity of the masks.
- ASA has also learned of other ways practices are reusing masks. We recognize that personal protective equipment, including N95 masks, is in short supply and that anesthesiologists may need additional information on reusing or repurposing PPE. In one case, members of the anesthesia care team are planning to reuse disposable PAPR (Powered Air-Purifying Respirator) hoods after wiping them down as well as using available reusable military grade PAPR. The PAPR filter cartridges will also be reused with care to avoid contamination. Groups have also planned to create their own ‘N95’ utilizing an anesthesia circuit mask plus a Pall Ultipor® filter plus a strap to secure a makeshift solution. This may be helpful for short, but high-risk procedures. We also are aware of hospitals and facilities using ultraviolet germicidal irradiation (UVGI) as a practical method to decontaminate the N95 mask. We recommend members conduct literature reviews and assess the risks and benefits associated with such actions.
- We recommend members conduct literature reviews, review resources on the CDC and NIOSH websites, contact the manufacturers and assess the risks and benefits associated with such actions.
3. What if my facility is unable to supply me with appropriate PPE because of supply chain issues? Can I buy and use my own?
- COVID-19 community transmission is becoming widespread, and reports of health care workers becoming infected are increasing. The American Society of Anesthesiologists supports that anesthesia professionals may purchase and wear alternate approved respirators, if they choose to do so. The Joint Commission also supports “allowing staff to bring their own standard face masks or respirators to wear at work”. There are no regulatory prohibitions that forbid health care professionals from wearing PPE when not required to. The ASA statement “Purchase and Wearing of Personal Protective Equipment by Anesthesiologists and other Anesthesia Professionals” provides CDC references that support this as well.
4. Because of a severe shortage of N95 masks, anesthesiologists are turning to the Internet/social media for solutions. What is ASA policy on reusing N95 masks and/or what are legitimate resources ASA can point to?
5. For what procedures does ASA recommend the use of N95 masks?
- ASA recommends as optimal practice that all anesthesia professionals should utilize PPE appropriate for aerosol-generating procedures for all patients, during all diagnostic, therapeutic, and surgical procedures, when working near the airway. More complete guidance can be found in the ASA-APSF-AAAA- AANA joint statement. Appropriate PPE for aerosol-generating procedures including airway protection with N95 masks or PAPRs.
6. What types of masks should we use if N95s are not available?
- We support anesthesia professionals purchasing and wearing alternate approved respirators, if they choose to do so. The Joint Commission also supports “allowing staff to bring their own standard face masks or respirators to wear at work.” There are no regulatory prohibitions that forbid health care professionals from wearing PPE when not required to. It is inappropriate for facilities to prohibit their employees from purchasing and wearing approved PPE.
- Please review the CDC website for appropriate masks to use. We recommend industrial masks that offer equal to or greater protection than N95 (e.g. N100). Some facilities have considered the use of a tight mask that can be constructed with available anesthesia supplies (disposable anesthesia mask, straps, and HEPA filter) or other full-face masks with straps and HEPA filter. We do not recommend hand sewn or other fabric masks that have not undergone careful testing because of concerns about fit and filtration capability.
7. Does ASA have any specific recommendations on hand hygiene for a patient with COVID-19 for the duration of a surgical case once the airway has been secured? Should providers continue to double glove and remove outer glove when soiled? Or should providers single glove and perform hand hygiene between glove changes?
8. Regarding gowns vs coveralls, is there any additional need for neck protection during airway manipulation of patients with known or suspected COVID-19 infection? Do we need a hood with neck cover for potential splashes of droplets during intubation or extubation?
- Please see ASA guidance. We recognize the risk that airway management has when a patient coughs during intubation or extubation, leading to contaminated mist and droplet formation. All authorities recommend that you do not touch your hands to your face. A face shield will protect your eyes and also the N95 mask from surface contamination. Some are using a surgical mask over the N95 mask.
9. We have received feedback that specifying protection Level 3 for isolation gowns for operating room cases and intubations would be helpful. “Gowns” alone seems vague since they have different levels of protection.
- We recommend that you review guidance materials found on the CDC website. We encourage you to have conversations with infectious disease consultants, infection control staff and supply chain managers who can inform your judgment concerning the best of alternative choices to protect all your patients and staff.
10. I have tried to put on clean masks and gloves prior to interviewing my patients. However, I have heard that this practice is not allowed by CMS. I feel that clean gloves and masks in all patient contact areas should be allowed to help in curtailing spread of this highly infectious virus.
- CMS guidelines or accreditation organizations do not prohibit the use of masks or gloves outside an operating suite. However, this question highlights the need to be sensitive to resource utilization when critical shortages of supplies may occur. Current CDC recommendations do not include the use of PPE when in the presence of asymptomatic or pre-symptomatic patient. For all patients, hand hygiene remains a cornerstone of good medical practice to prevent the spread of any infectious disease.
11. We need active communication from the ASA regarding our safety, precautions, N95 fitting and increasing the production of this equipment. I’m doubting the CDC that surgical masks are adequate.
12. I have COVID-19. When can I return to work?
13. At the end of the day, are our loved ones at home safe from infection when we return home?
- We realize this is a sincere and earnest concern among all ASA members. Unfortunately, there is no federal guidance on the risk of possible exposure of physicians’ families. We recommend changing clothes on arriving and before leaving your workplace, showering in the facility if possible before entering your vehicle, and hand hygiene at every step.
1. Why are anesthesiologists being asked to perform more intubations in my facility when there are other physicians who are trained to do so?
- In each location where intubations take place, the most experienced professional for that location should perform the intubation. In the operating room, this should be the most experienced anesthesia professional available. In non-operating room locations, including the Emergency Room and ICU, this should be an emergency medicine, critical care medicine or anesthesia professional, depending on availability and staffing for the facility. Every facility should develop a protocol for which medical service responds to the need for non-OR intubations. This is not a training opportunity for students. Anesthesiologists would expect to be consulted when there are difficult intubations or to assist with a surge of patients. Anesthesiology departments should work with hospital administrators and other personnel who are trained in intubation (e.g. critical care and emergency departments) on clear guidance that protects healthcare worker and patient safety. Stakeholders should conduct debriefings to discuss how to improve the process.
2. Does ASA recommend a specific course of action or treatment for COVID-19 patients in the Intensive Care Unit?
- As a medical association, we cannot make specific medical recommendations for patients. We likewise do not track how physicians treat or may have treated individual patients.
- However, we have provided, in collaboration with the Society of Critical Care Anesthesiologists, SCCM and APSF, a number of educational and training resources for members to use. This material is known as the COVID Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) ICU Project.
3. What should we do about “MAC” cases, with an open airway?
- If dispersion of potentially contaminated exhaled gases from an open airway (e.g. “MAC”) is a risk, consider alternate anesthesia plans. Potential contamination of your workspace and the room should be considered. The safety of you and your colleagues is paramount.
4. Are there specific recommendations for EGD procedures and other procedures with a high risk of aerosolization?
- Decisions need to be based on an understanding of your local COVID-19 risk profile for community spread in your area in consultation with your local infectious disease and infection control experts. This information will help inform your own risk assessment development considering the patient, skill sets of the endoscopists and local resources. ETTs provide the most secure airway. Airway masks with apertures for gastroscopes such as a POM (Procedural Oxygen Mask by Curaplex) or similar masks may limit dispersion as an alternative when supplies of N95 are low. ASA has also released guidance for procedures where there is a high probability of aerosolization.
- Best practices may be in flux because of shortages of N95 masks, personal protective equipment and regional differences in known patients with COVID-19. As COVID-19 testing becomes more common, the regional risk profiles and supply chain limitations will help guide what is possible in a specific location.
5. With regard to COVID-19, does ASA have any recommendations for obstetric care overall and specifically related to epidurals and spinals?
- ASA members are encouraged to review the recent statement published by the Society for Obstetric Anesthesia and Perinatology (SOAP) regarding obstetric care. In general, we are unaware of coronavirus is a contraindication to a neuraxial block. Spinals and epidurals should take into consideration appropriate precautions, especially regarding COVID-19 patients or those suspected of having COVID-19. Such precautions may include isolating the infected or suspected patient and placing them in rooms identified for that purpose as well as having a dedicated operating room. Ideally, these operating rooms would be negative pressure rooms. We also recommend the use of N95 masks, double gloves, gowns and protective eyewear as appropriate.
6. Given the concern for immunosuppressive during this time of COVID-19, I question whether or not to administer dexamethasone for PONV. According to one article, it doesn’t look like in the doses we provide for PONV prophylaxis- that it would cause clinically significant suppression but was wondering if you might be able to comment.
- In general, low doses/single dose dexamethasone would not be regarded as clinically significant or sustained immunosuppression. Each patient is unique and we cannot comment on individual patient treatment options or anesthesia plans. To our knowledge, there is no clinical data on deciding whether to use or not use a single dose of dexamethasone in COVID-19 patients.
7. I have been hearing concerns of immunosuppression when performing steroid injections in the elderly population as it relates to COVID-19.
- We do not have specific guidance on epidural steroid injections and COVID-19 with regard to individual patient medical histories. We recommend that you assess each patient and also consider decreasing the dose of steroid administered, keeping in mind that the effect of the long acting steroids will last for a while in your patient.
8. What is the ASA’s stance on safety of regional anesthesia in appropriate patients (especially those many that haven’t been tested) vs general anesthesia?
9. Is ASA advocating use of a video laryngoscope as first line for intubation? We have a very limited supply of sleeves at my institution.
10. Should the plastic draping on any video laryngoscope you bring into a suspected or confirmed COVID-19 intubation patient be removed like doffing your gown each time or can the draping if plastic be wiped down?
- Dependent on your supplies, the plastic draping should be removed and discarded after use. However, if your supplies are constrained then consider wiping down your draping using appropriate cleaning procedures designated by the manufacturer.
11. How should I deliver supplemental O2 to a patient who is wearing a mask and who has or may have COVID-19?
- If a patient has or is likely to have COVID-19, the first consideration is for your safety and the safety of everyone in the room. It is important that you wear appropriate PPE. Being at the COVID-positive patient’s head there is always risk of coughing and of needing to physically support the airway with jaw thrusts or intermittent positive pressure ventilation by face mask. Therefore, PPE for aerosol-generating procedures should be worn. There will be insufficient time to garb if there is an urgent clinical development. For the patient, nasal prongs under surgical mask with low-flow oxygen or simple face mask over surgical mask might suffice. However, if patient oxygenation is not maintained on low-flow oxygen, higher oxygen flows may be unexpectedly needed that might increase aerosolization of COVID-containing respiratory secretions. Each patient will need to be evaluated on a case-by-case basis to consider the balance of aerosolization at the oxygen flow needed to maintain a satisfactory oxygen saturation, and whether to convert to a more closed airway system (LMA or ETT).
12. There is a lot of focus on intubation, but I have not seen much discussion of LMA use. What is the recommendation for LMA usage or MAC anesthesia? Or are we presuming ALL patients are carriers and LMA usage and MAC anesthesia be minimized? This would result in intubating all patients for general anesthesia and eliminating MAC anesthesia for most of our cases.
- A risk assessment should be performed based on the COVID community-wide transmission. At this time, no studies exist that assess risk of various airway techniques and anesthetic choices. However, expert opinion suggests that LMA use may carry greater risk of generating aerosols when compared to tracheal intubation. While LMA usually seals the airway at low pressures, there is concern that higher positive pressure, if used, might create a leak with aerosol production. LMA may be an acceptable option with selected patients because of the lower risk of coughing. Non-airway MAC cases with spontaneous ventilation may be acceptable if fresh gas flows are low, but consider the anesthesia provider’s proximity for jaw lifts or potential intermittent positive pressure ventilation if brief apnea occurs. Therefore, PPE for aerosol-generating procedures should be worn. However, airway cases, upper endoscopy, bronchoscopy, and situations that induce cough or sneeze should be considered high risk for aerosol production. There is potential risk for other providers present near the oropharyngeal airway as well, and gastroenterologist society recommendations warn of risk with upper and lower GI endoscopy. For anesthesia professionals, an additional consideration is that a failed MAC case may need to be transitioned rapidly to tracheal intubation that likely bears higher risk for suboptimal conditions. Local experts report that natural-airway MAC anesthesia is not being used in areas of high COVID-19 community prevalence, but instead, planned controlled endotracheal anesthetics.
13. Does ASA have any recommendations on using negative pressure rooms when intubating or delivering surgical care to COVID-19 patients?
- ASA recommendations state, “When possible, perform procedures in an airborne infection isolation room rather than in an operating room. An airborne isolation room has a negative-pressure relative to the surrounding area. In contrast, a typical operating room is designed to provide positive-pressure relative to the surrounding area and incoming air is often flow-directed, filtered, and temperature and humidity controlled. If a procedure cannot be postponed or done at the bedside, then schedule the patient when a minimum number of healthcare workers and other patients are present in the surgical suite.”
We recognize that limited resources and available rooms in a specific hospital may decrease the opportunity for this to occur. In those instances, considerations should include possibility of a difficult airway (benefit/risk OR vs ICU intubation), local resources and urgency of the situation.
We encourage anesthesiologists also contacting and collaborating with local infection control expertise on appropriate locations, planning and policy development.
14. Should we use negative pressure rooms for intubations and extubations in asymptomatic patients coming to an operating room?
- As with other considerations of asymptomatic patients, a risk assessment should take place to determine feasibility and assess safety considerations, including risk of transporting an intubated patient and the provision of bridging sedation. Next, an assessment of disease prevalence should be made. In locations with low prevalence (<1%), the risk of intubating and extubating an asymptomatic patient is most likely low. Currently there is no requirement or guidance that intubation and extubation of non-COVID19 patients should take place in a negative pressure environment. Nevertheless, planning is needed to minimize aerosolization of secretions in all patients (e.g., avoid coughing, temporary use of a transparent plastic cover during extubation), and wear appropriate PPE.
15. For an asymptomatic patient in an area with widespread community transmission (e.g., Metropolitan New York City) are there recommendations regarding avoiding the use of an LMA with positive pressure ventilation versus an endotracheal tube, in a standard operating room (positive pressure room)?
- The higher community spread/prevalence of COVID-19, the more pragmatic the approach – expert opinion discourages LMA, MAC and regional cases that have a risk for general anesthesia conversion.
16. Does ASA have any guidance on the treatment of stroke patients during the COVID-19 pandemic?
17. I have read that some hospitals are giving all COVID-19 patients a unilateral DNR, i.e. making them a DNR on admission regardless of physical status or prognosis. Is this ethical?
- There was an article in the Washington Post recently that used the term “universal” in the headline, though it seemed to be actually referring to “unilateral” DNR orders, i.e. making someone a DNR based on one’s clinical judgment but without consent of the patient or surrogate.
It is not considered ethical to make a class of patients DNR with no regard to their individual prognosis. However, during a time of public health crisis there may be a shortage of resources, high risk to caregivers and/or logistical problems involving donning the proper PPE.
In such cases caregivers may have a lower threshold to unilaterally decide that certain treatments are inappropriate and/or futile for individual patients and will not be provided or may have to be withdrawn. Certainly, if time permits, the patient and/or surrogates will be informed of this process but won’t necessarily have to agree with the decision. While these decisions will be gut wrenching for all involved, they are clearly in line with ethical principles.
This statement only addresses the ethics of the dilemma. If you have concerns about the legality of any medical decisions please contact your own legal counsel who will be familiar with the laws in your state.
1. What is ASA’s position on whether residents would continue to be paid (given the anticipated reduction in elective surgeries), student loan forbearance, how to treat possible quarantine of residents vis-a-vis their required number of residency hours. Can you please include in the advisory materials being developed?
2. ASA should be advocating for financial support for anesthesiologists who have been affected by the financial downturn and the clinical implications COVID-19 have had on our groups and practices.
- We are concerned both about anesthesiologist safety and protection as well as the financial implications that COVID-19 is having on anesthesia groups and practices. ASA Advocacy is working with Congress and the White House on appropriate aid and assistance to physicians. We are exploring all avenues – regulatory and legislative to provide much needed support.
- We have created a set of resources regarding economic relief for practices impacted by COVID-19. We realize that many practices and individuals are struggling financially as case loads and patient populations have shifted in recent weeks. ASA Advocacy continues to seek economic relief via legislative and regulatory avenues for anesthesiologists and their groups.
1. Where can I find educational modules for anesthesia residents?
2. Does ASA have any simulation resources for COVID-19?
- ASA does not have specific COVID-19 simulation resources available yet. Healthcare institutions have created PPE donning and doffing videos that can be found online, but physicians must follow the specific protocols of their own institution. Some generally relevant ASA educational resources include:
PRACTICE MANAGEMENT AND BILLING
1. My group and I have been hit hard financially. Where can I find information on economic relief, loans and other programs?
- We have created a set of resources regarding economic relief for practices impacted by COVID-19. We realize that many practices and individuals are struggling financially as case loads and patient populations have shifted in recent weeks. Our advocacy division continues to seek economic relief via legislative and regulatory avenues for anesthesiologists and their groups.
2. Where can I learn more about Medicare’s Accelerated and Advance Payment program - including information on how to apply?
- The Centers for Medicare & Medicaid Services (CMS) has expanded the Accelerated and Advance Payment program to make it more broadly available during the public health emergency in place due to COVID-19. This program provides an option to request advanced payment for up to 100% of your Medicare payments for a 3 month period during a disruption in the submission or processing of claims. Repayment is through recoupment of future claims starting 120 days after the payment is issued. For physicians and others who receive payment through Part B , recoupment of the full amount must be complete at 210 days after the payment was issued.
3. How can an anesthesia group bill for ICU services? We may also need to use our CRNAs as overflow ICU nurses and anesthesiologists as intensivists.
- Regarding billing, these are services that anesthesiologists could report. At this time, the care provided would most likely be either hospital E/M services or critical care coding depending on the patient condition and need. Ventilation management may also come into play. We recommend you work with your coding department on appropriate documentation and billing. Please review Sharon Merrick’s presentation and slides during the April 2, 2020 ASA Town Hall for additional considerations.
- For greater detail on billing, please visit the Timely Topics in Practice Management webpage.
- We recommend you work with your coding department on appropriate documentation and billing.
4. Has CMS released any information on appropriate billing during this period or healthcare waivers?
- Yes, CMS has issued certain waivers allowing licensed providers to render services outside their state of enrollment for purposes of billing Medicare and Medicaid; temporarily suspending certain enrollment requirements under Medicare, postponing revalidation actions, and expediting pending or new applications and extending timelines for filing Medicare Parts B, C, and D appeals. See the Emergency Declaration Fact Sheet (PDF) and the MLN Matters Number: SE20011 (PDF).
5. Where can I learn more about Telehealth to determine if that may be a good option for my patients and my practice?
6. I’m adding new providers to my group/practice. Where can I find more about Medicare Provider Enrollment Relief during the COVID emergency?
7. Has CMS suspended the Quality Payment Program and Merit-based Incentive Payment System (MIPS) reporting?
- CMS has delayed reporting MIPS data for performance year 2019 until April 30, 2020. Participants who have already submitted data to the Anesthesia Quality Institute (AQI) National Anesthesia Clinical Outcomes Registry (NACOR) do not have to submit additional data to AQI NACOR for 2019. If you reported 2019 data through another registry, please check with that registry for their process. If you are reporting via the CMS Web Portal, you now have until April 30, 2020 to submit your 2019 data.
- At this time, CMS has made no changes to MIPS reporting for 2020.
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