Last updated: May 18, 2020
Preoperative COVID Testing:
Examples From Around the U.S. on May 18, 2020
On April 29, 2020, the ASA and APSF released “Joint Statement on Perioperative Testing for the COVID-19 Virus”. Its recommendations include:
A population risk assessment identifying the prevalence of SARS-CoV-2 should be reviewed. When there is local or regional presence of SARS-CoV-2(14):
- All patients should be screened for symptoms prior to presenting to the hospital. Patients reporting symptoms should be referred for additional evaluation. All other patients should undergo nucleic acid amplification testing (including PCR tests) prior to undergoing non-emergent surgery.
- Because false-negatives may occur with testing, droplet precautions (surgical mask and eye covering) should be used by OR 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.(15)
- If a patient tests positive for SARS-CoV-2, elective surgical procedures should be delayed until the patient is no longer infectious and has demonstrated recovery from COVID-19. A patient may be infectious until either:
- CDC recommended test-based strategy
- Resolution of fever without the use of fever-reducing medications; and,
- Improvement in respiratory symptoms; and,
- Negative results from two SARS-CoV-2 tests ≥ 24 hours apart
- CDC non-test-based strategy
- At least 72 hours since resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms; and,
- At least 7 days since symptoms first appeared.*
- CDC recommended test-based strategy
- Recommendations regarding the definition of sufficient recovery from the physiologic changes from SARS-CoV-2 cannot be made at this time; however, evaluation should include an assessment of the patient’s exercise capacity (metabolic equivalents or METS).
When there is little or no regional presence of SARS-CoV-2:
- All patients should be screened for symptoms before presenting to the hospital.
- Patients reporting symptoms should be referred for further evaluation.
* Please note that the CDC recently revised its recommendation on time since symptoms first appeared (above 3.b.ii.) from 7 to 10 days.
Implementation of the recommendations:
While statements and recommendations can provide guidance to local health systems for perioperative COVID testing, implementation decisions are governed by many factors, including local population prevalence of COVID-19 infection, availability and accuracy of COVID-19 tests, and others. Therefore, to assist anesthesia professionals in implementation of perioperative testing, this summary provides actual testing policies from a sample of hospitals and medical centers around the U.S. as of the second week of May 2020. These facilities range from rural critical access hospitals to several of the country’s largest academic medical centers. The anesthesia practices in these facilities range from small private practices to very large group practices.
These examples are presented to provide a sense of the initial protocols used in COVID-19 perioperative testing. These protocols are continuously evolving. Those presented here come from the second week of May 2020, and many will rapidly evolve in future weeks as testing availability, accuracy, cost-effectiveness, and practice efficiency also evolve.
The participating health systems will be asked to provide any updated protocols every second week during the next two months so that this summary can be updated regularly. Please check the summary date to ensure you understand when this set of updates was made.
Chester County Hospital is a 248-bed inpatient complex in West Chester, PA. These are the guidelines of the hospital for the care of COVID patients in the perioperative unit as of May 13, 2020.
Pre-Procedure COVID Testing:
- All procedural patients will be screened for exposure and symptoms upon registering according to the following guidelines:
- Previous COVID diagnosis: If diagnosed positive within the last 14 days, treat as positive.
- Previous COVID diagnosis: If diagnosed positive within the last 15-28 days, obtain 2 negative swab results (1 day apart) to be treated as negative, otherwise treat as positive.
- Group Homes/Congregate Settings (i.e. Skilled Nursing Facilities): Testing required 2 days prior to procedure but are placed on COVID precautions regardless of result.
- ALL OTHER OUTPATIENTS: Testing required within 2 days prior to procedure.
- COVID Positive: No testing necessary (IP will manage the need for repeat testing per protocol)
- COVID Risk: No testing necessary, treated as positive (IP will manage the need for repeat testing per protocol)
- Non-COVID: Testing accepted within the last 7 days
- Group Homes/Congregate Settings (i.e. Skilled Nursing Facilities): Must be tested upon admission.
- All outpatients/24 hour/AM Admits will be notified to come in for testing the 2 days before their scheduled procedure.
- The patient will report to the Employee Resource Center for testing.
- Positive results will be reported to the surgeon to determine whether the case could be postponed.
- Positive results will be communicated to the patient.
Pre-Procedure COVID Considerations:
- Patients awaiting COVID rapid results (45 minutes) will not be transported to the Operating Room until results are obtained and communicated (exception for ruptured AAA).
- The nurse pulling the patient onto the Snap Board must notify PACU of the patients COVID status.
- COVID patients will be assigned to a private room in ACC and will be brought directly from ACC to the OR.
- PPE requirements for COVID patients in ACC will observe droplet-based precautions, which include gown, gloves, standard mask, and eye protection. The patient should be given a hospital-issued mask immediately upon arrival.
- (Inpatients Only): Prior to being brought to the OR, if the COVID patient is already in a negative pressure inpatient room, they will be intubated in that room prior to transport; consult anesthesia team
The State of Hawaii has a population of ~ 1.4 million. The current COVID Rt is 0.71 and the state’s epidemiological curve shows almost all community exposure source since early April. Approximately 42,000 citizens of the state’s 1.4 million population have been tested (a COVID positive rate of 1.5%). There has not been wide antibody testing. The state has < 650 infections and a COVID hospitalization rate of 12.7%.
The local contagiousness of the disease, tested COVID positive rate (current proxy for prevalence), rate of new cases/active cases in relation to our health system capacity, burden/burn rate of PPE, capacity for testing, and known high specificity/sensitivity of the state’s testing using PCR-testing were all factors in designing the current recommendations as the state’s medical community has moved back into elective surgery. Although the COVID infection rates are currently very low, the state anticipates subsequent waves. These algorithms were developed to create a new discipline that would sustain the state and its medical community through future waves.
This summary describes two community hospital systems and their approaches to preoperative COVID testing. Hospital A is a four-hospital system with a free-standing ambulatory surgery center. Hospital B is a four-hospital system with a Level-1 designated trauma center. Both have presences on neighboring islands—this geography complicates patient access to testing.
What is similar between the two community hospital systems and their preoperative COVID testing protocols:
- Testing all elective surgeries and procedures (including elective labor inductions and elective C-sections) with a nasal swab PCR-test in a given short time-frame prior to procedure/surgery.
- Rapid testing is generally not used as hospital capacity/availability for this is limited.
- Utilizing internal laboratory testing with known high levels of sensitivity and designated testing centers with known reliability.
- Results must be available prior to surgery to avoid cancellation
What is different:
- Some exceptions (e.g. serial ECTs or opthalmologic surgeries—See Example B, document 1)
- Responsibility of ordering test (Example A lies with the surgeon/proceduralist; Example B lies with a centralized presurgical center with a hotline)
- 48 hour window vs. 1-5 day window. Both systems reviewed their workflow to create the most disciplined, reliable results.
Personally, what is different in my practice is arranging a pre-anesthetic video consultation with every elective patient, if possible. Patients only see me with mask/faceshield on the day of surgery. This additional consultation allows us the opportunity to “see” each other, develop an anesthesiologist-patient relationship, perform a video airway exam, review COVID screening, and explain and answer questions regarding the new safeguards we have put in place since COVID.
System requirements for testing 48 hours prior to procedure, surgeon/proceduralist orders PCR test.
Hospital System with workflow for all procedural/surgeries routed through Pre-Surgery Center to screen and order PCR testing (through a Transfer Hotline)
A large private practice anesthesia group provides professional services at a dominant tertiary healthcare system in Houston, Texas. The main facility is over 1000 beds and located in the Texas Medical Center. The healthcare system also includes 5 other satellite hospitals located within the city and surrounding community. All of the system hospitals are currently using the perioperative testing protocol outlined below.
The current incidence of COVID-19 in Houston is low/moderate. Facilities have sufficient inpatient and ICU capacity, and Personal Protective Equipment is readily available. Texas is undergoing a relatively accelerated timeline for resuming business activity. This protocol is from May 2020.
- The physician orders the test via electronic medical record or fax.
- The physician schedules the procedure or surgery with the appropriate department
- The patient is contacted by the hospital to schedule the COVID-19 test.
- There are no interviews to screen patients for symptoms or to determine if they have had recent exposure to potentially infected persons.
- COVID-19 testing is required for ALL patients undergoing any surgery, procedure, or MRI which will require intubation. Testing is also required for all patients undergoing transesophageal echocardiography.
- The test is a COVID-19 Polymerase Chain Reaction (PCR) from a nasal swab sample.
- Patients must have testing done at least 5 business days and no greater than 8 business days prior to the surgery/procedure date.
- Patients are asked to quarantine after testing until the day of surgery or procedure.
- If the preoperative COVID-19 test is positive, elective surgery is postponed.
COVID-19 testing is also available for symptomatic patients who do not have a scheduled procedure.
The Mayo Clinic is a large health care system. There are three major regions: the upper Midwest, northeast Florida, and Arizona. Of these, the upper Midwest is comprised of one large tertiary medical center and 15 additional hospitals/facilities within 200 miles of Rochester, MN. For simplicity, this document will provide information on only those facilities within the upper Midwest. The upper Midwest facilities range in size from critical access hospitals in small, rural cities to a large complex in Rochester that provides anesthetic care for more than 400 inpatients and outpatients, including non-operating room procedures, daily. In general, the upper Midwest has a low incidence of COVID infection except in the large metropolitan area of Minneapolis and St. Paul.
The Mayo Clinic adult preoperative testing protocol is continuously evolving as we learn more about COVID testing and its impact on outcomes. As of May 13, 2020, the protocol entails at least a two-day process:
STEP 1: Telephone Interview, Testing Instructions
Adult patients will be contacted by the perioperative team for a telephone-based interview. As part of this process, each patient will be asked several brief questions:
Does the patient, anyone in the household, or anyone they have had prolonged exposure with in the past 5 days have any of the following?
- Fever ≥ 38.0o C (100.5o F) last 24 hours
- Symptoms: cough or shortness of breath, sore throat, diarrhea, respiratory distress, chills, myalgias, loss of smell, or change or loss of taste sensation
- Does the patient have close contact with a person under quarantine or isolation or who is a LABORATORY CONFIRMED case of COVID-19? Close contact is defined by the CDC as being within approximately 6 feet of a COVID-19 patient for more than 5 minutes or having direct contact with infectious secretions of a COVID-19 case (e.g. being coughed upon)
- Has the patient been tested for COVID-19 with a positive or pending result?
A positive answer to any of these questions will result in the patient being considered interview-positive. This knowledge will be communicated to the perioperative team responsible for the operation and the patient will be placed on a deferred list.
Even if telephone interview responses are negative, patients will be referred for COVID screening tests (see STEP 2 below).
If patient interview is negative, proceed with the following steps:
- PCR/Serology Testing
- The foundation of our screening is a COVID-19 PCR swab obtained from the nasopharynx. Best practice should be to obtain this sample 2 days prior to surgery to ensure timely results as close to the date of surgery as possible.
- If the patient has had a negative PCR within one week of the operative date and remains asymptomatic and interview screen negative, it may be appropriate to not repeat the test.
STEP 2: Preop Appointments (Surgical Day -1)
On pre-op day -1, adult patients will undergo any additional preoperative appointments/testing pending a negative PCR result.
The perioperative team will communicate positive test results and next steps after case deferral. If positive, surgery will be deferred for at least two weeks pending resolution of symptoms and additional testing.
McLaren Greater Lansing (formerly Ingham Regional Medical Center), a teaching hospital located in Lansing, Michigan, is a subsidiary of the McLaren Health Care Corporation. It is affiliated with both the College of Human Medicine and the College of Osteopathic Medicine of Michigan State University.
At McLaren Greater Lansing, they are testing all patients with PCR test (Roche) 72 hours prior to surgery. Some are tested 48 hours, but there is a 72 hr cut off since Monday morning patients could get tested on Friday, and Tuesday patients could come in on Saturday for their nasal swab test. If negative, the patients proceed to surgery. If positive (has not happened yet), then patients are sent home to quarantine unless it is emergent.
Mercy, is a large health system located in the lower Midwest that includes more than 40 acute care, managed and specialty (heart, children’s, orthopedic and rehab) hospitals, 900 physician practices and outpatient facilities, 45,000 co-workers and 2,400 Mercy Clinic physicians in Arkansas, Kansas, Missouri and Oklahoma. Mercy also has clinics, outpatient services and outreach ministries in Arkansas, Louisiana, Mississippi and Texas. In addition, Mercy’s IT division, Mercy Technology Services, and Mercy Virtual commercially serve providers and patients from coast to coast.
These documents have been developed for application across all Mercy facilities which include a range from critical access hospitals in rural settings, to ambulatory surgery and procedure centers, to destination medical campus facilities providing anesthesiology care to hundreds of inpatients and outpatients on a daily basis. There is some variability in service provided across facilities and more complex locations have developed supplementary interpretive guidance consistent with System statements that address nuances of more complex care. Of the regions served by Mercy, the St. Louis metropolitan region has a higher incidence of COVID infection while other regions have been less severely impacted.
Mercy guidance remains under continuous review. The most recently updated materials are provided here.
Recently, Cook County in Chicago, IL, was marked as the city in the USA with the most documented cases by the Johns Hopkins University (92,457 cases). NorthShore University HealthSystem is a five hospital system largely located in the north shore of Chicago. Our largest hospital is located in Evanston, IL, and serves as the tertiary care center for both two hospitals in Lake County (Highland Park Hospital and Glenbrook Hospital) and another hospital in Cook County (Swedish Covenant). NorthShore University HealthSystem provides anesthetic care for more 70,000 patients, including non-operating room procedures, annually. University of Chicago is an academic affiliate of NorthShore and provides a complement of anesthesia residents for a variety of clinical care experiences. In addition, our system provides clinical education for SRNAs. Lastly, we have over 75 CRNAs, and over 60 anesthesiologists covering the 5 hospital system. Elective surgeries have restarted as of May 11, 2020 at three of our hospitals. We continue to isolate our COVID-19 patients to one hospital in our system to minimize exposure to our elective surgical patients in the other hospitals.
The NorthShore University HealthSystem adult preoperative testing protocol is continuously evolving as we learn more about COVID testing and its impact on outcomes. As of May 11, 2020, the protocol entails the following processes and algorithm: See appendices for detailed information on the process of COVID-19 preoperative testing and management.
- MEMO – Elective Procedure COVID-19 Testing Memo [PDF]
- APPENDIX A – Pre-Surgical Procedure COVID Testing Scripting [PDF]
- APPENDIX B – COVID Tent Testing Messaging and Handouts [PDF]
- APPENDIX C – ALGORITHM Elective Procedure COVID-19 Testing Flow Chart [PDF]
NYU is a major academic medical center in the heart of New York City. NYU has been significantly impacted by the COVID-19 pandemic. The center has in-hospital and outpatient facilities, but have developed one policy for preoperative COVID testing of all patients for COVID status. The following is a component of the preoperative process we currently use for care of patients, and as we are constantly reassessing our process, it should not be construed as a recommendation for others to use.
Preadmission and Day Before Procedure Call Process
The patient is screened for COVID related issues including symptoms and fever, however not all patients are reached on preoperative or preadmission testing calls. If symptomatic or issues related to COVID there is a joint collaboration among the preoperative team, the surgical team and patient to follow evidence based institutional guidelines.
Current Policy on Testing:
Perform Pre-op Testing (NP-PCR) for all patients requiring surgery
Process for Pre-op Testing of Inpatients if unknown COVID status on admission:
- Pre-op testing performed within 72 hours for all inpatients
Process for Pre-op Testing Same Day Admit/ambulatory surgery
- OPTION 1- (preferred) Testing 3-7 days before surgery (while not official policy-preference is for testing closer to 3 days)
- OPTION 2 – Testing Day of Surgery in pre-op area – this requires up to 2 hr. for result time
Day of Surgery
The patient is screened for COVID related issues and symptoms and their temperature is obtained.
For asymptomatic patients with NP-PCR COVID Positive test – if possible, defer surgery for 2 weeks and reschedule without repeat testing.
Partners HealthCare is a Boston-based non-profit hospital and physicians network that includes Brigham and Women’s Hospital (BWH) and Massachusetts General Hospital (MGH), two of the nation’s largest teaching institutions. It is comprised of 9 hospitals and a number of ambulatory/outpatient facilities and specialized service providers.
Facilities within the Partners Healthcare system follow general guidelines revised as of May 14, 2020 that represent a balance between identifying clinical and operational needs for testing and current capacity for testing. They include preoperative COVID-19 testing for:
- Patients who have planned admissions to a Partners facility, including directadmissions from procedures (test within 48h of admission)
- Patients who will undergo aerosol-generating procedures such as airway surgeries, organ transplants/donations, etc.
Preoperative COVID-19 testing is not required for patients who are asymptomatic, do not have high risk for COVID-19 infection, and who are not anticipated to need admission after their procedures. Airway management procedures (e.g., intubation) that might generate aerosolization of nasopharyngeal secretions are not included as criteria for preoperative COVID-19 testing.
Stanford University Medical Center is a medical complex which includes Stanford Health Care and Stanford Children’s Health. Stanford Health Care provides both general acute care services and tertiary medical care for patients locally, nationally and internationally. The hospital plays a key role in the training of physicians and other medical professionals. It provides a clinical environment for the medical school’s researchers as they study ways to translate new knowledge into effective patient care. Full-time Stanford faculty and community physicians make up the hospital medical staff. Stanford Hospital is home to a Level I trauma center.
All elective patients will have COVID-19 rtPCR testing within 72 hours of surgery. The intent is that the testing is done within 3 calendar days (or 3 midnights). Thus, a patient who has a PCR test done on Friday can have surgery on Saturday, Sunday, or Monday but not on Tuesday on the basis of the test. The table below provides the specifics:
Patients who are tested outside of this range can have the Cepheid test performed on the day of surgery (turnaround time approximately 2-3 hours). Based on the very low incidence of positive tests in asymptomatic patients (currently less than 1 per 1,000), patients who will not be admitted to the hospital after surgery can proceed to the operating room before the Cepheid result. However, our goal is to test the large majority of patients before surgery.
The Tulane Medical Center consists of two facilities, which include our Downtown Campus and our Lakeside Campus. For simplicity, other affiliated medical centers are excluded. The Downtown Campus is a 235 bed facility in the City of New Orleans and houses several intensive care units and a wide array of surgical and procedural services. The Downtown Campus serves as the main practice location and teaching facility for the Tulane Medical School faculty. The Tulane Lakeside Campus is 120 bed facility and houses the obstetric unit as well as surgical suites serving as the primary location for orthopedic services. The Lakeside Campus is in Metairie, a suburb of New Orleans, less than 10 miles from the Downtown Campus. The metropolitan New Orleans area has widely been described as a “hot-spot” in the COVID-19 pandemic.
The Tulane preoperative screening and testing protocol was put into action on Monday, April 27, 2020, which coincided with the expansion of surgery and procedures in Louisiana from simply emergency only to now include time-sensitive procedures as described by the Louisiana Department of Health and ordered by Governor John Bel Edwards.
Pre-Operative COVID-19 Screening Protocol:
- Initial Screening:
- All patients scheduled for elective surgery must have a Pre-admission Testing evaluation and all out-patients must be tested using the Roche Diagnostics cobas® SARS-CoV-2 test complete a COVID-19 symptom survey.
- Perform Roche test 5-7 days not greater than 9 days pre-operatively
- PAT Nurse Practitioner will order the test
- If the patient cannot physically come in 5-7 days out because of where they live, has approval from the Doctor of the Day Anesthesiologist and screens negative for symptoms, an Abbott ID Now test should be done 24-48 hours out and the morning of surgery/procedure.
- All test results will be emailed to the clinic manager, if positive the PAT staff will call the surgeon. If the case is the following day and the clinic is closed the OPS nurse will notify the surgeon. Test results will be on the patient’s medical chart the morning of surgery.
- ALL patients scheduled for elective surgery must have a phone interview or tele-visit with a PAT NP. If the patient physically cannot come to PAT for testing, the surgeon must discuss with the anesthesiologist Doctor of the Day. On the day of surgery, all patients must comply with temperature screening and complete the COVID symptom questionnaire, regardless of the test result. Patients will minimize any possible exposure and self-isolate if possible until their surgery.
- All in-patients requiring surgery must have a test performed within 48 hours of the scheduled procedure. This may be the Roche test that is completed upon admission. If outside the 48-hour window, repeat the Roche test if time allows, otherwise will need the Abbott ID NOWä test. If an updated test is needed, the surgeon must order the test and it must be completed before the patient comes to the OR.
- Positive Results: If positive COVID-19 testing or positive symptom survey, serious consideration must be given to canceling the procedure. A Multidisciplinary meeting may be held to discuss the risk/benefit ratio of proceeding with surgery if required. Possible scenarios include:
- If positive symptom survey and negative COVID-19 testing: re-test for COVID-19 and/or ruling out other infections, i.e. influenza.
- If positive COVID-19 testing and negative symptom survey: postpone the procedure and, if needed, hold a meeting with the Multidisciplinary Board for a risk/benefit evaluation to consider proceeding with the surgery or procedure.
- If positive symptom survey and COVID-19 test: Postpone the procedure and, if needed, consult with the Multidisciplinary Board meeting to perform risk/benefit evaluation if the procedure cannot be postponed.
- Second Screening: On the morning of surgery, all out-patients must be retested using point-of-care ABBOTT ID NOW (bilateral swab) and re-perform the symptom survey.
- Day of surgery
- OPS staff will adhere to PPE requirements for handling COVID19 specimens
- The surgeon must add this test to their pre-op surgery orders. If not readily available, the test will be ordered by an anesthesiologist.
- If negative screening and negative ABBOTT test à proceed with the procedure
- If positive screening and/or positive ABBOTT test à the procedure needs to be postponed and, if unable to be postponed, consult Multidisciplinary Board to determine risk/benefit
- Day of surgery
- Multidisciplinary Board: Can be convened to decide concern performing a procedure on a patient with a positive COVID-19 test and/or positive symptom survey. The Multidisciplinary Board will consist of a surgical team member, the Director of Surgical Services, an anesthesiologist, a critical care specialist, and an infectious disease specialist. The Multidisciplinary Board will assess the risk/benefit of proceeding to surgery in the event that surgery should no longer be postponed. Retesting may be necessary.
- PPE Protocol Adherence: The PAT and OPS staff will wear level 3 masks throughout the patient’s care visit even if the test is negative. During testing in PAT, the staff will adhere to the PPE requirements (N95 Mask, gown, and face shield). If the test is positive all members will wear an N95 with a face shield.
The survey must be completed within:
- 5-7 days, and not greater than 9 days pre-operatively
- Day of surgery (or day prior, surgeon’s discretion)
The questionnaire must cover typical symptoms1 of COVID-19 infection:
- How are you feeling?
- Have you had any recent:
- Shortness of breath?
- Muscle aches/pains?
- Abdominal pain, nausea, vomiting?
- Loss/decrease in taste and/or smell?
Epidemiological Risk Assessment:
- Have you recently been hospitalized for COVID-19 / Coronavirus or a flu-like illness? If yes, when?
- Have you recently been diagnosed with COVID-19 / Coronavirus? If yes, when?
- Have you recently been tested for COVID-19 / Coronavirus? If yes, when?
- Do you believe that you have had close contact with a person or family member who currently has or has recently had COVID-19 / Coronavirus? If yes, when? In what context?
- Do you live with anyone who currently has or has recently had (last 14 days) fever/chills, cough, SOB, muscle aches/pains, or flu-like symptoms?
- Do you have any close contacts or family members who are currently in the hospital or were recently in the hospital for COVID-19 / Coronavirus or a flu-like illness? If yes, assess if there was recent close contact with this person.
- Do you have a home thermometer?