SAGES/EAES “Closing the Back Door” recommendations in the fight against COVID-19
This Standard Operating Procedure (SOP) document outlines recommended procedures for screening, identification, tracking, and management of patients located in non-COVID-19 hospital units who may have symptomatic or asymptomatic COVID-19 infection.. Recommendations are also provided regarding screening and testing of patients scheduled for surgical interventions.
In our common global effort to defeat the COVID-19 pandemic, it is extremely important to promote the concept of “closing the back door” in order to avoid unsuspected transmission by asymptomatic COVID-19 positive patients .
While many healthcare professionals are managing patients with confirmed COVID-19 infection as well as patients under investigation (PUI) for COVID-19 infection in dedicated COVID-19 units, it is equally important to control the spread of the virus to and from non-COVID-19 or “clean areas” of our hospitals. Frequent screening of inpatients in “clean areas” as well as screening of all pre-operative patients, is essential for early identification and isolation of newly infected cases to minimize the spread of infection to other patients and healthcare professionals. Institutions with a high clinical burden of COVID-19 infections have also recommended systematic testing of all pre-operative patients regardless of whether they are symptomatic or not, in order to minimize the risk of unsuspected contamination.
This Standard Operating Procedures (SOP) document applies to medical care delivered in non-COVID-19 hospital units or “clean inpatient areas” during the COVID-19 pandemic, including Surgical and Medical Wards, Emergency Departments (ED), and Operating Rooms (OR).
4.1 Clinical units
In areas with high prevalence of COVID-19, visitors should be prohibited to enter hospitals, including visitors to emergency departments, inpatient units, ambulatory sites and other facilities. There may be exceptions for healthy visitors previously screened for symptoms of COVID-19 (e.g. labor and delivery, pediatric units, and palliative care settings).
- Inpatient setting
It is the responsibility of the designated responsible medical/surgical team leader to ensure that all patients are evaluated daily for symptoms suggestive of potential COVID-19 infection. COVID-19 testing should be promptly performed and the patient moved to a PUI unit if symptoms suggestive of infection are identified. All suspected COVID-19 infection-related precautions should be implemented by all members of the medical/surgical and nursing team.
4.2 Pre-operative setting
Patients scheduled to undergo any type of surgical intervention should be screened for COVID-19 symptoms within 24 hours of the scheduled intervention. In areas with a high clinical burden of COVID-19 infection, it is recommended that when possible all inpatients and outpatients scheduled for a surgical intervention, undergo COVID-19 PCR testing within 24-48 hours of the planned procedure. It is the responsibility of the surgical attending to ensure that testing is completed and results available prior to the procedure to inform the decision to proceed with surgery.
- Identification of newly suspected COVID-19 cases
- Clinical team to screen patients for typical and atypical symptoms of COVID-19:
- Most typical symptoms: respiratory symptoms and fever
- Other symptoms: diarrhea, anosmia, loss of taste, severe fatigue and/or weight loss
- During clinical assessment for COVID-19 symptoms, all members of the clinical team should maintain their distance, wear gloves and a surgical mask.
- Once a suspected case has been identified, the infectious disease department or equivalent institutional overseer must be informed, and PCR testing for COVID- 19 accomplished.
- While awaiting the test result, those patients with suspected symptoms must be placed in isolation according to PUI protocols.
- Any health care personnel attending those patients must wear PPE according to Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) recommendations, following institutional guidelines.
- If these patients are tested positive, then they will be transferred to a COVID unit.
- If they are negative, but still having symptoms, they should remain isolated until a second test results is available. PPE must be used by their health care team.
- These measures must also apply to any other clean areas such as the OR and or clean areas within the ED.
- For patients who have tested positive for COVID-19 pre-operatively, the clinical team (surgeon and anesthesiologist) will need to weigh the risk and benefits of proceeding with surgery or delaying intervention.