Episode #2 Introducing the Novel Covid-19 Anesthesia Resource Center

Hello and welcome back to the Anesthesia Patient Safety Foundation Podcast.  I’m your host, Dr. Alli Bechtel. Thank you for joining me for another show.

On the show today we are going to highlight just a few of the extensive resources that the APSF has put together throughout the Covid-19 pandemic.  This is a challenging time for patient safety and the APSF is continuing to work hard to help keep patients and providers safe from harm and from Covid-19.  After you are done listening to this podcast or maybe even while you are listening be sure to check out the APSF Novel Coronavirus (Covid-19) Anesthesia Resources Center and I will link to it in the show notes.  Covid-19 has impacted so many of the 12 patient safety priorities from preventing, detecting, and mitigating clinical deterioration in the perioperative period, to safety in out-of-OR locations, to medication safety, with a renewed spotlight on hospital acquired infections and environmental contamination and transmission, to airway management difficulties, skills, and equipment, to anesthesia professionals and burnout, and distractions in procedural areas.  For a complete list of the 12 patient safety priorities of the APSF, please see the show notes, but you can see this disease has a wide ranging impact on patient safety and the APSF resource center offers information including news and articles, joint statements, drug-drug interactions, a frequently asked questions section, media and guides, links to further resources, and international resources to help keep patients safe.  The international resources include information that is translated in Chinese, French, Japanese, Spanish, Polish and Portuguese.

I am going to take a quick pause to review the disclaimer that we included with our Novel Coronavirus Anesthesia Resource Center.  Viewers of the material and listeners to this podcast should review the information presented 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 APSF has used its best efforts to provide accurate information, but keep in mind that this material is provided only for informational purposes and does not constitute medical or legal advice.  I will also include the full disclaimer in the show notes for this episode.

The resource center has a LOT of information about COVID, PPE, ventilators, perioperative best practices and protocols. Today, I’m going to focus on three very exciting resources – the intubateCOVID Global Registry, an important safety warning from the Institute for Safe Medication Practices (ISMP), and Perioperative COVID testing.

1. The newly created intubateCOVID Global Registry has been used to describe the risk of COVID-19 outcomes in terms of testing positive and developing new symptoms in Healthcare Workers who were involved in Tracheal Intubation of Patients with known or presumed COVID-19. Research has evolved rapidly since healthcare professionals first began taking care of patients with Covid-19.  A global registry was created by an international team including investigators from Guy’s and St Thomas’ Hospital in London and the University of Pennsylvania School of medicine to study healthcare workers who intubated Covid-19 positive or presumed positive patients leading to a prospective, multicenter international cohort study. I will link to the registry in the show notes as well because this registry is for any healthcare worker to submit information for every intubation that they performed on Covid-19 positive and presumed positive patients. In this APSF-supported study, the authors report a 3.1% risk of new lab-confirmed Covid-19 and an 8.4% risk of new symptoms requiring self-isolation or hospitalization in the healthcare workers. This is important data since we are seeing this new increased risk from the procedure of intubation that is common for many anesthesia professionals and healthcare providers.

2. The second resources I’d like to highlight today is an important note from Institute for Safe Medication Practices (ISMP). This piece warns clinicians that vials of commonly used neuromuscular blocking drugs, Vecuronium Bromide and Rocuronium Bromide will be released without the warning statement printed on the vial caps.  This has occurred due to the increased covid-19 demand for these drugs in intensive care units and alterations in the supply chain leading to the decreased supply of the safety caps.  The good news is that this is hopefully just a temporary change, but be sure to read the drug vial labels carefully and pay particular when drawing up drugs since this important safety feature will be missing on the vial caps.  I will link to the June 4th ISMP newsletter as well as the related FDA announcement if you are looking for further information.

3. The last resource – well, really two related resources,  that we will discuss today are about Perioperative COVID protocols.   We’ll look at recommendations, and then we’ll cover specific examples of what centers are actually doing in our article Perioperative Covid Testing: Examples from around the US.  Before we get to the examples, let’s review the April 29th ASA and APSF Joint Statement on Perioperative Testing for the Covid-19 Virus.  This is so important as centers across the US and the world consider best practices for surgery, especially elective surgery. As we’re still very early in the ‘re-opening phase’ it’s important to note that the recommendations may evolve from what we’re discussing today.  The recommendations required assessment of the prevalence of SARS-CoV-2 in the local population and then, when there is evidence of local presence of SARS-CoV-2 the following recommendations should be considered.  First, all patients require symptom screening before they present to the hospital and patients with symptoms will require additional evaluation. In addition, all other patients should undergo nucleic acid amplification (including PCR tests) prior to undergoing non-emergent surgery.  PPE recommendations include droplet precautions with surgical mask and eye covering by all OR staff for cases even if patients have a negative test since false-negatives may occur.  Before an aerosol-generating procedure, healthcare providers in the room should wear an N95 mask, eye protection, gloves, and a gown.  Patients who test positive for SARS-CoV-2 should not undergo elective surgery until the patient is not infectious and has recovered from COVID-19.  In order to determine if a patient is infectious, the CDC recommends a test-based strategy with resolution of fever without fever-reducing medications AND improved respiratory symptoms AND 2 negative SARS-CoV-2 test results that are done more than 24 hours apart.  The CDC recommended non-test based strategy includes greater than 72 hours since the last known fever without using fever-reducing medications AND improved respiratory symptoms and 10 or more days since first symptom onset. It is also important to take into consideration the patient’s functional status and exercise capacity in terms of metabolic equivalents when evaluating recovery from COVID-19, although there is no specific recommendation at this time.  In areas where there is little or no regional presence of SARS-CoV-2, the recommendations are different in that all patients should be screened for symptoms before they come to the hospital and patients with symptoms will need further evaluation, but testing for all non-urgent and non-emergent cases is not recommended.

So, there you have it, the recommendations, pretty straightforward and simple right? Not so fast, the statements and recommendations help local health systems decide what to do for perioperative Covid testing, but actual implementation of a perioperative COVID testing protocol depends on many factors including local prevalence of the disease, testing availability and accuracy and keep in mind that these numbers and resources are changing frequently. The APSF included these examples to help guide anesthesia professionals to develop appropriate perioperative testing protocols and these examples are from a variety of practice settings and locations. These examples offer a snapshot into perioperative testing since the protocols may be updated frequently. The good news is that the health systems who shared their protocols with us will also provide us with updates to their protocols every two weeks for a couple of months and we will keep the examples updated on the APSF website. If you check the summary date, you can check to see if you have the most up-to-date protocols.

Let’s take a look at an example one of these protocols from the heavy hit area, New York City. New York University in NYC is in an area that has been majorly impacted by Covid-19.  The NYU policy for perioperative testing is the same for inpatient and outpatient surgery areas. Before admission, on the day before the procedure the patient is called and screened for possible COVID symptoms including fever or significant exposure. Decision-making for patients who are symptomatic or screen positive for COVID-related issues depends on collaboration between the preop team as well as the surgery and anesthesia teams and the patient is advised according to specific institutional guidelines.  NYU adapted a policy on preoperative testing that included pre-op NP-PCR testing for all patients requiring surgery and testing for all inpatients within 72 hours of surgery if their covid status was unknown at the time of admission. The preferred testing option for preop patients included 3-7 days prior to surgery with the second choice option being testing in the pre-op area and waiting for the results to return prior to going to the OR.  Finally, all patients are screened again for any COVID-related issues on the day of surgery and temperature checked as well.  Asymptomatic patients who test positive for COVID are postponed whenever possible after discussion with the surgery team for 2 weeks and do not require repeat testing as long as they remain asymptomatic.

Now, let’s travel north to Boston and take a closer look at the Perioperative Covid testing policy that was adopted by Partners Healthcare in Boston, Massachusetts.  Partners Healthcare includes 9 hospitals and many additional outpatient centers as well as Brigham and Women’s hospital and Massachusetts General Hospital.  This healthcare system acknowledged that their policy attempts to strike a balance between the needs for testing patients and the availability of testing resources.  This has definitely been an important consideration for many healthcare systems across the country and around the world.  Their policy includes preoperative COVID testing within 48 hours of admission for patients with planned admission to a Partners Healthcare facility including direct admission patients following procedures. Testing is also required for patients scheduled to have an aerosol-generating procedure or organ transplantation or donation surgery. Now, for patients who do not have symptoms and are at low risk for infection and will likely not require postop admission, preop COVID testing is not required.

There is still so much that we didn’t have time to cover in the Resource Center today. Don’t worry, I plan to return to the Resource Center for future episodes so that we can continue to review the latest information and research to help keep our patients safe under anesthesia in the midst of this pandemic.

If you find that the APSF Coronavirus Resource Center has become your go-to for up-to-date information about how to keep your patients safe and how to stay safe personally during this pandemic, please consider donating to the APSF. Remember that this is a volunteer organization and our volunteers have been on a mission to continue our commitment to patient safety and healthcare professionals throughout this very difficult time and we will continue to do so! You can make a difference with your contribution no matter the size. I am wrapping up this podcast so just check out the show notes, click on the link and donate!!  We are keeping it simple for you.  And for those of you who like hashtags, there is something really special for you because you can join the #APSFCrowd by donating just $15 a year as part of the APSF’s first-ever crowd-funding initiative.

Well, that is all the time we have for today.  Thank you so much for joining me on this journey towards improved patient safety.  If you have any questions or comments from today’s show, please email me at [email protected] Don’t forget to subscribe to the podcast through iTunes or your favorite podcast app, visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2020, The Anesthesia Patient Safety Foundation