Four leading American medical organizations for OR personnel have issued a joint road map for when and how hospitals across the United States can safely resume elective surgery, as several governors announced plans to lift the pause on nonessential care in their states.

In a statement, the American College of Surgeons, American Society of Anesthesiologists, Association of periOperative Registered Nurses and American Hospital Association outlined the key steps that should guide health care providers and organizations in returning to elective surgery after cases of COVID-19 peak in their area.

“When the first wave of this pandemic is behind us, the pent-up patient demand for surgical and procedural care may be immense, and health care organizations, physicians and nurses must be prepared to meet this demand,” the medical groups said.

Readiness to resume elective surgery will vary by geographic location depending on the rate of COVID-19 cases locally and the availability of trained staff and supplies, the groups said.

They called for a sustained reduction in the rate of new COVID-19 cases in the geographic area for at least 14 days before elective surgery begins. In addition, they said every facility should have an appropriate number of ICU and non-ICU beds, personal protective equipment (PPE), ventilators and trained staff to treat all non–elective surgery patients without resorting to a crisis standard of care.

Among other recommendations, facilities should do the following:

• Implement a policy for testing staff and patients for COVID-19, accounting for accuracy and availability of testing and response when a staff member or patient tests positive.
• Form a committee with representatives from surgery, anesthesiology and nursing to develop a prioritization policy for surgeries.
• Develop policies addressing care issues specific to COVID-19 and the postponement of surgical scheduling, including a reevaluation if patients have had COVID-19–related illness. All surgical patients should undergo a recent history and physical examination within 30 days of surgery to confirm no interim change in a patient’s health status.
• Social distancing measures should remain in place for staff, patients and visitors in nonrestricted areas in anticipation of a second wave of COVID-19 activity. Health care facilities should reevaluate and reassess procedures frequently, based on COVID-19–related data, resources, testing and other clinical information.

In the joint statement, the medical organizations did not specify that all patients should be tested prior to surgery but said if testing is not available, hospitals and surgery centers should consider a policy that addresses evidence-based infection prevention techniques, access control, workflow and distancing processes to create a safe environment in which elective surgery can occur.

“If there is uncertainty about patients’ COVID-19 status, PPE appropriate for the clinical tasks should be provided for the surgical team,” the groups said.

Several governors, including Oklahoma Gov. Kevin Stitt and Texas Gov. Greg Abbott, announced plans to allow hospitals to resume some elective procedures. On April 19, the Centers for Medicare & Medicaid Services (CMS) issued the first in a series of recommendations for allowing elective procedures to resume. The CMS plan requires states or regions to meet specific gating criteria before phasing in elective procedures. The agency also called for a downward trajectory of COVID-19 cases for a 14-day period before resumption of services.

Mary Dale Peterson, MD, the president of the American Society of Anesthesiologists, said the number of postponed elective procedures across the United States is unknown but dramatic. Countless patients are waiting for surgical procedures, even though some may lose their insurance as job losses mount.

“We are estimating that 70% of surgeries have been canceled,” said Dr. Peterson, the executive vice president and chief operating officer of Driscoll Health System and emeritus staff at Driscoll Children’s Hospital, in Corpus Christi, Texas. “We need to take appropriate precautions, but we do need to start opening up.”

The medical organizations said institutions need to weigh several factors in deciding which cases will take priority once operating rooms are reopened. These include:

• previously canceled and postponed cases;
• objective priority scoring;
• specialty prioritization for cancer, organ transplantation, cardiac surgery and trauma surgery;
• a strategy for allotting daytime OR/procedural time;
• identification of essential health care professionals and medical device representatives per procedure; and
• phased opening of ORs and issues associated with increased OR/procedural volume.

The ACS also issued a separate, more detailed guidance for resumption of elective surgery, including a 10-page checklist for facilities. The ACS statement highlights the need to track local capabilities and constraints, while monitoring for potential subsequent waves of COVID-19.

The ACS checklist is separated into four categories: awareness, preparedness, patient issues and delivery of safe high-quality surgery.

The ACS asked surgeons to know their community’s COVID-19 numbers, including prevalence, incidence and isolation mandates. It also is imperative that surgeons know the local COVID-19 testing availability, and policies for patients and health care workers.

The organization called on surgeons to get involved in setting policies at their institution.

“Surgeons should be involved in institutional policymaking since the risk to the patient and the staff varies with the type of procedure, the patient’s condition, local circumstances and over time. Some surgeon discretion is necessary and should be permitted,” the ACS said.

The surgical organization cautioned that testing availability might decrease as community testing demands increase. The ACS also highlighted the need for retesting of patients, noting false-negative results have been reported to be as high as 30%.

“It’s going to be a challenge, obviously, to restart elective surgery and get caught up, but we’ll get there,” said David Hoyt, MD, the executive director of the ACS.

The ACS has been involved in disaster planning for four decades, particularly in the area of trauma and mass casualty events. But the pandemic required an approach on an unprecedented scale with the number of cities and countries affected. “What we experienced is really the exhaustion of resources,” Dr. Hoyt said. “I personally could not be prouder of the way surgeons and hospitals and nurses and everybody pulled together to do what’s right for our patients.”

The ACS has developed a COVID-19 registry, available to all hospitals. The registry, which was developed by experts currently treating COVID-19 patients, will collect data on COVID-19 patients who undergo surgery and those who did not.

All surgeons who are interested in participating are asked to contact COVID19registry@facs.org or Amy Sachs, the senior manager, ACS Program and Registry Operations, for more information.

The Ambulatory Surgery Center Association issued a statement to support lifting the pause in elective, nonurgent surgery: “The reality is that regions across the nation are impacted by COVID-19 to varying degrees. There are some communities that are ready for a strategic restart of deferred healthcare at this time, while continuing to focus on limiting COVID-19 spread.”