The testing algorithm guides decision‐making with regard to further surgical management:
- Asymptomatic patients with negative test results proceed.
- Patients with positive test results are rescheduled after a minimum of 2 weeks, and a negative test result. Any case deemed urgent with a positive COVID‐19 test result will proceed.
- Patients presenting for an aerosol‐generating surgical procedure without preoperative COVID‐19 testing are either tested upon arrival, delaying the case until results become available, or have their surgery rescheduled with preoperative testing.
It does not address the appropriate approach to PPE, for which, our institution opted to follow the Anesthesia Patient Safety Foundation guidelines.5
The program was rolled out in two phases. Initially, due to a limited number of tests available and our inability to test all surgical patients, we developed an algorithm (Table 1) to standardize which patients should undergo testing. In this phase, prioritization was based on consensus among our institution’s surgeons, proceduralists, and infectious disease specialists in which we risk stratified COVID‐19 testing based on patient symptoms and procedure type. Any single SARS‐CoV‐2 related symptom was considered a high‐risk patient. Procedures were categorized as high or low risk depending on the potential viral burden at the surgical site and risk of aerosolization of virus particles, with the highest threat being procedures involving the oral cavity, upper and lower respiratory tracts, gastrointestinal tract, and ophthalmology.2–4 Need for aerosol‐generating procedures by the anesthesiologist (ie, intubation) was not considered in the testing algorithm because airway manipulation is involved in the vast majority of surgeries at our institution. Inpatients awaiting surgery were also tested according to the priority list described in Table 1.
|Surgery riska||Patient riska|
|Low risk||High risk|
|Low risk||Testing when possible
|High risk||Testing prioritized
- Abbreviation: N, positive test result.
- a High‐risk surgeries include all aerosol‐generating surgical procedures, including the following list. All other procedures are considered low risk. Ear, Nose, Throat: Tracheostomy, tonsillectomy and adenoidectomy, direct laryngoscopy and bronchoscopy, sinus surgery, nasal endoscopy, turbinate reduction, retropharyngeal or peritonsillar abscess (if intra‐oral approach), all oral procedures (frenulectomy, ranula excision, biopsies), cochlear implant, tympanomastoidectomy. General and Thoracic surgery: As above, esophagoscopy or bronchoscopy, upper aerodigestive foreign body removal, thoracotomy or thoracoscopy, laparotomy or laparoscopy. Upper Gastrointestinal Procedures. Urology: Hypospadias with buccal graft; Ophthalmology: Dacryocystorhinostomy, repair of damaged nasolacrimal duct, orbital surgery. Dental/Oral‐Maxillofacial: Dental rehabilitation, oral trauma, infection, cancer. Plastics: Mandibular osteotomy for Robin sequence, palatal devices for cleft lip/palate, trauma. Neurosurgery: Skull base surgery with intranasal approach.
- b High‐risk patient defined as a patient endorsing any COVID‐19 related symptoms including cough, fever, shortness of breath, runny nose, or sore throat over the last 2 weeks. All other patients defined as low risk.
Due to the 3‐4 hour processing time of the COVID‐19 test, it was logistically challenging to test outpatients on the day of procedure. Therefore, we created an outpatient preoperative “pop‐up” testing clinic to test patients prior to their scheduled surgery. The partially outdoor “pop‐up” site alleviates the need for families to enter the hospital and decreases risk of exposure among patients, their families, and healthcare staff. Patients are scheduled for outpatient testing usually within 48 hours of procedure date. To minimize risk of infection, patients are directed to avoid social contact and monitor for development of symptoms until their procedure.
Our outpatient testing clinic has been operating for eleven weeks. In the first phase (April 3‐April 22, 2020), we tested 140 patients based on priority per Table 1, of which four tested positive (2.9%). In the second phase of implementation (April 23—present), due to increased laboratory capacity and support for testing, we were able to test all outpatients scheduled to undergo surgery. In this phase, we tested 1215 patients of which 36 tested positive (3%). In total, we tested 1355 outpatients of which 40 were positive (3%), since we initiated outpatient preoperative testing on April 3. While our testing abilities have increased over time, our initial experience has shown that most asymptomatic pediatric patients in our community are not COVID‐19 carriers, but a small percentage have tested positive and will require additional management.
We believe a standardized approach to preoperative COVID‐19 testing based on patient symptoms, and risk of the procedure is crucial to ensure maximal safety of patients, their families, and hospital staff. This approach must not only be standardized but also adaptable in a changing environment taking into account the access to collection supplies, testing reagents, and changing surgical population.
1 , , , et al. Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID‐19 infection, EClinicalMedicine. 2020; 21:e100331.
2 , , , et al. SARS‐CoV‐2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020; 382(12): 1177‐ 1179.
3 , , , et al. Prolonged presence of SARS‐CoV‐2 viral RNA in faecal samples. Lancet Gastroenterol Hepatol. 2020; 5(5): 434‐ 435.
4 , , , , , . The severe acute respiratory syndrome coronavirus in tears. Br J Ophthalmol. 2004; 88(7): 861‐ 863.
5 , , , , . Perioperative Considerations for the 2019 Novel Coronavirus (COVID‐19). Anesthesia Patient Safety Foundation, 2020, Feb 12. https://www.apsf.org/news‐updates/perioperative‐considerations‐for‐the‐2019‐novel‐coronavirus‐covid‐19/. Accessed April 16, 2020.
6 , , , et al. Severe COVID‐19 in children and young adults in the Washington, DC Metropolitan region. J Pediatr. 2020.