COVID-19 and Hospital and Facility Administration

1. 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 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.

2. 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.

3. 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 operating room vs ICU intubation), local resources and urgency of the situation.
• Preferably, surgical interventions should be conducted in a negative pressure room with a minimum of 12 air changes per hour (most operating rooms have 15-20 air exchanges per hour). Air is filtered with a HEPA filter and evacuated from these rooms to the external atmosphere. If a negative pressure operating room is unavailable, contact your bioengineering department for other means to optimize existing operating room ventilation (e.g., disable positive pressure flow, maximize the number of air exchanges per hour, use portable HEPA filtration system).
• We encourage anesthesiologists to also contact and collaborate with local infection control expertise on appropriate locations, planning and policy development.

4. 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.

5. How long should surgical personnel wait to enter the room after a COVID-19 patient has been intubated?

• For physicians and other healthcare workers, the time to enter the room after an intubation will likely be based upon the type of PPE they are wearing and the air exchange rate of the room. A table from the CDC shows the rate that airborne contaminants are removed with various air changes per hour (ACH). Please make sure to review the table to identify the room sizes and air exchange rates in your specific facility. Such information will help to guide your policy addressing when sufficient time has elapsed to clear the air of viral particles. The CDC table indicates the time required to reach 99% and 99.9% reduction in aerosolized particles. The “safe” threshold for re-entering the room wearing a surgical mask after intubation or extubation is not known. It is a local judgement to decide what threshold is considered safe.
• For example, in the referenced CDC table, if your operating room has a typical 15 air changes per hour (ACH), one can see that 99% of the airborne pathogens will be removed from an operating room in 18 minutes and 99.9% in 28 minutes. In that scenario, unnecessary staff who leave the operating room before the time of intubation could reenter wearing a surgical mask in 18-28 minutes to participate in a non-aerosol generating surgical procedure depending upon the “safe” threshold decision. Staff wearing N95 masks and other PPE for aerosol generating procedures identified in the ASA recommendations linked above can remain in the room during the aerosol generating procedures, including intubation and extubation.

6. For a patient who has tested negative for COVID-19, should we adhere to the Air Exchange Rate calculation for healthcare workers entering the operating room who are not wearing an N95 or other PPE?

• Because false-negatives may occur with testing, droplet precautions (surgical mask and eye covering) should be used by operating room staff for operative cases. Before performing an aerosol -generating procedure, health care providers within the room should wear an N95 mask, eye protection, gloves and a gown. 
• For physicians and other healthcare workers, the time to enter the room after an intubation will likely be based upon the type of PPE they are wearing and the air exchange rate (ACH) of the room. A table from the CDC shows the rate that airborne contaminants are removed with various ACH. Please make sure to review the table to identify the room sizes and air exchange rates for your specific operating as well as procedural facility locations. Such information will help to guide your policy addressing when sufficient time has elapsed to clear the air of viral particles . The CDC table indicates the time required to reach 99% and 99.9% reduction in aerosolized particles. The “safe” threshold for re-entering the room wearing a surgical mask after intubation or extubation is not known. It is a local judgement to decide what threshold is considered safe.
• For example, in the referenced CDC table, if your operating room has a typical 15 air changes per hour (ACH), one can see that 99% of the airborne pathogens will be removed from an operating room in 18 minutes and 99.9% in 28 minutes. In that scenario, unnecessary staff who leave the operating room before the time of intubation could reenter wearing a surgical mask in 18-28 minutes to participate in a non-aerosol generating surgical procedure depending upon the “safe” threshold decision. Staff wearing N95 masks and other PPE for aerosol generating procedures identified in the ASA recommendations linked above can remain in the room during the aerosol generating procedures, including intubation and extubation.

7. Do you have advice on COVID-19 unit staffing models?

• 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.

8. What is the optimal number of persons or teams that my hospital should designate for intubations?

• 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.

9. Can I buy and wear my own PPE if my facility is unable to supply me with appropriate PPE?

• COVID-19 community transmission is widespread in many areas and health care workers have been infected. The ASA supports that anesthesia professionals may purchase and wear alternate approved respirators, if they choose to do so. 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. The ASA statement “Purchase and Wearing of Personal Protective Equipment by Anesthesiologists and other Anesthesia Professionals” also includes CDC references that identify and support the use of alternate approved respirators. The Joint Commission (PDF) similarly supports “allowing staff to bring their own standard face masks or respirators to wear at work when their health care organizations cannot routinely provide access to protective equipment that is commensurate with the risk to which they are exposed."

10. Our hospital administrators will not allow us to wear PAPR in the operating room. How do I address this issue? 

• We recognize that some hospitals are reluctant to allow the use of PAPRs in the operating room based upon previous recommendations by the Association of periOperative Registered Nurses.” In 2020, AORN released a clarifying statement with the ASA that states, “When an N95 cannot be properly fit tested for use by healthcare personnel in the operating rooms and other invasive procedure areas or an N95 is not available for urgent/emergent procedures, we recommend that an interdisciplinary team including infection control, nursing, surgery and anesthesia personnel determine how PAPRs may be most safely used for respiratory protection in the perioperative environment when a sterile field is present.”
• A 2017 pilot study published in the American Journal of Infection Control details some considerations for PAPR use in the operating room. Prudent practice suggests adherence to CDC guidance of N95 use until more evidence is available. Also, CDC encourages inquirers to seek further guidance from the PAPR manufacturers.
• ASA has issued several recommendations and published FAQs related to the wearing of appropriate PPE when caring for a patient with known or suspected COVID-19 infection. ASA strongly supports that anesthesia professionals may purchase and wear alternate approved respirators that are equivalent to or better than N95 respirators, if they so choose. On April 19, the ASA issued an additional statement on “Facility Requirement for Personal Protective Equipment.”
• We recommend that you work with your anesthesia department, infection prevention personnel and other facility-level stakeholders consider the availability of N95s, failure of N95 fit testing and other contingencies that may affect healthcare worker safety and patient care.

11. 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 FAQs for more information.

12. How do we move patients to PACU? For social-distancing purposes, do we keep an empty PACU space between recovering patients?

• Each facility must assess how it is able to maintain adequate space between patients. Extubated patients who are not suspected or known to have COVID-19 should be brought to the PACU with a face mask in place, and should be spaced at a distance of 6 feet apart. Patients that are coughing or sneezing repeatedly due to airway irritation may require an enclosed room (such as a negative pressure isolation room, if available) with limited personnel who practice full airborne precautions with eye protection (e.g., N95 masks, gowns, gloves, and eye shields).

13. 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 during pandemics.

14. 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 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.

Additional Information

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Disclaimer

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.