COVID-19
Standard Operating Procedure for the Management of Patients with Suspected or Confirmed COVID-19 Requiring Surgery During the Corona virus Outbreak (Red patients)
Scope of SOP
Principles
Preparation and Management of the procedure
Donning & Doffing
Scope of SOP
The scope of this SOP is to provide clear guidance for the management of patients with suspected or confirmed COVID-19 requiring surgery in theatre during the Corona virus outbreak. The purpose of this document is to provide staff with clear information on how these patients should be managed in theatre, including patient flow and the use of PPE in different scenarios.
Principles
This document takes account of the latest PHE and Trust IPC guidelines on the correct use of PPE (03/04/2020) and is based on the following principles:
Staff and patient safety are of paramount importance at all times.
All patients could potentially have COVID-19 even if asymptomatic.
PPE is a valuable and limited resource and the use of this need to be tailored depending on the risk involved and not used indiscriminately.
This is an evolving situation and these guidelines are likely to change so flexible working practices and good communication is of paramount importance.
General Management
Decision to operate out of hours
Out of hours teams should determine whether it is essential that the patient needs to come to theatre out of hours or can safely wait to have surgery in core hours.
At least 4 staff will be needed to operate at night for a Covid patient, therefore, consider the use of the on call team to support the staffing numbers if the night staff team is not adequate.
If the on call team are to be used, consultant on call and the DOS rep need to be informed that there will be no facility to operate any other cases for the duration of the Covid case.
At weekend Covid cases should be triaged and included in the acute plan.
These procedures are not to be part of a teaching case. Each case will take longer than usual and in order to maximise efficiency the most appropriate/senior member of the team should perform the procedure.
Preparing for Theatre
Prior to sending for the patient the theatre should be prepared accordingly
Make sure the theatre is empty of as much equipment as possible leaving essential items only
Remove any trolleys or items which you may need e.g. suture trolley into the clean area outside the main theatre to be brought in as and when needed
Close all drawers and doors in theatre, remove all items from the counter tops.
Cover PC keyboards with a see through plastic swab bag
Empty the corridor as much as possible
Stop all unnecessary traffic outside theatre, including porters.
ODP to make a small intubation trolley/tray with essential items close all the cupboard doors in the anaesthetic room and remove any non-essential items from surfaces, both in the anaesthetic room and on the ventilator in theatre.
Place a HSDU truck in the dirty utility room to put the trays straight in when used. The trays can be wrapped and sent to HSDU in the usual way as they use universal precautions for all trays and the main danger of infection is from aerosol contamination.
Consider operating on a trolley if possible
If diathermy is used smoke extraction is mandatory and should be prepared.
Access to the anaesthetic rooms is restricted to the anaesthetic team only.
The theatre corridors are all green areas, a surgical waterproof face mask is required in these areas.
Ensure the floor co-ordinator is aware of the case.
Bringing the patient to theatre
The patient should be escorted to theatre on their bed or trolley wearing a surgical face mask.
Consider the external circulators collecting the patient from the ward area rather than porters or ward staff to minimize staff in contact with the patient.
Staff escorting the patient should wear PPE, gloves, face mask, hat and plastic apron.
As far as possible make sure the corridor is clear of staff/patients while transporting the patient.
Receiving the patient
All theatre staff should don PPE before the patient arrives; this could be donned in the anaesthetic room or theatre using the guidance from IPC.
PPE is a plastic gown, a theatre gown, a hat, a FFP mask, a mask with eye visor, tuck in your hair and cover as much of your skin as possible.
Staffing in theatre should be as minimal as possible; ODP/SCRUB/CIRCULATOR /SURGEON (S) and Anaesthetist
Outside staff should ideally be an ODP or other person with anaesthetic knowledge.
The patient should be anesthetised in the theatre and all unnecessary staff should stay at least 2 meters away from the patient.
The whole internal theatre team should be available for transferring the patient if necessary so the surgical team should wait until the patient is transferred to the table and positioned before scrubbing.
During the procedure and recovery
Once transferred, the bed should stay in theatre but as far away as possible from the surgical field. The sheets should be changed prior to the patient returning to the bed.
Keep paperwork within theatre to a minimum, leave any patient notes including the consent form, once checked, in the anaesthetic room unless/until needed.
If possible and safe leave the care pathway in the anaesthetic room
The external staff should remain outside the main theatre and should be available to bring any items required once the operation starts to the anaesthetic room door. They should still wear PPE as described.
The patient should be recovered in theatre and not PACU and transferred back to the ward by the two external circulators after an appropriate handover. The patient if extubated should wear a surgical face mask to go to the ward
Post procedure
PPE should be doffed by the theatre team using the appropriate guidance and placed in the appropriate disposal bags inside the theatre in the designated doffing area.
Dispose of all rubbish and perform a red clean in theatre using HAZ tabs and Clinell wipes. Contaminated rubbish should be in orange bags.
The trays should be kept moist and put in a plastic bag before being placed in the HSDU buggy.
Change the anaesthetic circuit once the theatre is dry.
Request a RED clean, wall and floor clean for the area outside theatre. Ideally the theatre should then be left to rest but it can be used again after all the surfaces are dry and all equipment is cleaned and returned to theatre.
Surfaces in the anaesthetic room and theatres must be wiped down after each case.
Donning & Doffing
Donning: To be done in the theatre anaesthetic room area
Doffing:
Below the neck should be doffed in theatre by the sluice room door.
Above the neck should take place in the sluice area utilising the buddy system.
Staff who have been in theatre and had patient contact should not leave theatre without doffing their PPE in the appropriate area.
Standard Operating Procedure for the Management of Asymptomatic (Green) Patients Requiring Surgery During the Corona Virus Outbreak
Scope of SOP
Principles
General Guidance
Team brief
Donning & Doffing
Aerosol generating Procedures
Scenarios
Scope of SOP
The scope of this SOP is to provide clear guidance for the management of asymptomatic patients requiring surgery in theatre during the Corona virus outbreak. The purpose of this document is to provide staff with clear information on how these patients should be managed in theatre, including patient flow and use of PPE in different scenarios.
Principles
This document takes account of the latest PHE and Trust IPC guidelines on the correct use of PPE (03/04/2020) and is based on the following principles:
Staff and patient safety is of paramount importance at all times.
All patients could potentially have COVID-19 even if asymptomatic.
PPE is a valuable and limited resource and its use needs to be tailored depending on the risk involved and not used indiscriminately.
Those are low risk cases and need to be protected from confirmed or suspected patients.
This is an evolving situation and these guidelines are likely to change so flexible working practices and good communication is of paramount importance.
General Management
Staff entering the main theatre corridor require a surgical facemask and protective eyewear if within 2 meters of a suspected Covid patient.
Traffic along the theatre corridor should be kept to a minimum.
Staff in theatre should be the minimum number required to safely perform the procedure.
These are not teaching lists. Each case will take longer than usual and in order to maximise efficiency the most appropriate/senior member of the team should perform the procedure.
If diathermy is used smoke extraction is mandatory.
Access to the anaesthetic rooms is restricted to the anaesthetic team only.
Surfaces in the anaesthetic room and theatres must be wiped down after each case.
The theatre corridors are all green areas, a surgical waterproof face mask is required in these areas.
Clean air theatres to be used for all patients where possible, air changes are adequate to negate the need for a red clean.
Team Brief
During the team brief it is mandatory to identify the following:
What aerosol generating procedures AGP (if any) are to occur.
What level of PPE is required by which staff members.
That adequate PPE is available for each staff member that requires it.
Which staff should be present in theatre – minimum numbers only.
Which staff member will be the nominated runner where required.
Donning & Doffing
For the purposes of this document the following terms will be used for PPE:
PPE2 plastic apron/gloves/surgical water proof facemask/protective eyewear
PPE3 plastic apron/long-sleeved fluid resistant gown/gloves/FFP3 mask/protective eyewear
Donning: To be done in the theatre scrub area
Doffing:
Below the neck should be doffed in theatre by the sluice room door.
Above the neck should take place in the sluice area utilising the buddy system.
Responsibility of cleaning hoods is down to the individual who has used them.
Staff who have been in theatre and had but have finished patient contact should not leave theatre without doffing their PPE in the appropriate area.
Aerosol generating procedures (AGPs)
AGPs should be kept to a minimum and include the following:
Intubation, extubation and related procedures e.g. manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)
Tracheotomy/tracheostomy procedures (insertion/open suctioning/removal)
Bronchoscopy and upper ENT airway procedures that involve suctioning
Upper Gastrointestinal Endoscopy where there is open suctioning of the upper respiratory tract
Surgery and post mortem procedures involving high-speed devices
Some dental procedures (eg high-speed drilling)
Non-invasive ventilation (NIV) e.g. Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
High Frequency Oscillatory Ventilation (HFOV)
Induction of sputum
High flow nasal oxygen (HFNO)
Scenarios
Most theatre cases can be divided into 3 scenarios:
Anaesthesia is the sole AGP
Surgery involves an AGP
Neither anaesthesia or surgery involves an AGP
Anaesthesia as the sole AGP
Who
· Any patient having a GA
· No surgical AGP planned
Where
· Induction in the anaesthetic room
PPE
· PPE3 for all staff in anaesthetic room
· Theatre staff require PPE2 only
· PACU staff PPE2 only
Transfer
· HME filter used during transfer into theatre
· Theatre staff go outside theatre or into scrub area during transfer and only go into main theatre area after connection to anaesthetic circuit
Procedure
· Anaesthetic staff remain donned for duration of case
· Anyone leaving theatre who has patient contact needs to doff apron and gloves in the appropriate area
· At end of procedure all theatre staff vacate theatre leaving minimal anaesthetic staff only
Handover
· Handover to PACU should be done with PACU staff wearing PPE2
Doffing
· Staff should DOFF in appropriate areas and use correct disposal bins.
· Anaesthetic team DOFF below the neck in theatre and take patient to PACU and handover.
Surgical procedures involving an AGP
Who
· Use of power tools
· Laparoscopic surgery
· OGDs
· Airway surgery
Where
· Induction in the anaesthetic room
PPE
· PPE3 for all staff in anaesthetic room
· PPE3 for all staff in theatre
· PACU staff PPE2 only
Transfer
· HME filter used during transfer into theatre
Procedure
· All staff remain donned for duration of case
· A runner needs to be available outside theatre wearing PPE2
· At end of procedure all theatre staff vacate theatre leaving minimal anaesthetic staff only
Handover
· Handover to PACU should be done with PACU staff wearing PPE2
Doffing
· Anaesthetic team DOFF below the neck in theatre then take patient to PACU and handover.
· Staff should DOFF in appropriate areas and use correct disposal bins.
No anaesthetic or surgical AGP planned
Who
· Regional anaesthesia & no surgical AGP planned
Where
· Induction in the anaesthetic room or theatre
PPE
· PPE2 only for all staff
Handover
· Patient transferred to PACU by anaesthetic team at end of case
Doffing
· Doffing after handover of patient to PACU staff
· No requirement to stand theatres for 20 minutes
Standard Operating Procedure for visitors to theatre department during Covid outbreak
Scope of SOP
Principles
General Guidance
Green Routes
Red Routes
Social distance and grouping
Scope of SOP
The scope of this SOP is to provide clear guidance for staff and visitors to operating department during the Corona virus outbreak. The purpose of this document is to provide visitors to theatre with clear information on which PPE should be worn in which areas.
Principles
This document takes account of the latest PHE and Trust IPC guidelines on the correct use of PPE (03/04/2020) and is based on the following principles:
Staff and patient and visitor safety is of paramount importance at all times.
All patients could potentially have COVID-19 even if asymptomatic.
PPE is a valuable and limited resource and it’s use needs to be tailored depending on the risk involved and not used indiscriminately.
This is an evolving situation and these guidelines are likely to change, so flexible working practices and good communication is of paramount importance.
General Management
First principle should be not to come to theatre at all if there is an alternative.
Any Staff entering the main theatre corridor require a surgical facemask + protective eyewear if within 2 meters of a suspected Covid patient.
Traffic along the theatre corridor must be kept to a minimum.
Visitors to the department who are not going into theatre, IE HSDU/Pharmacy/external porters/medical physics and estates staff etc should avoid, wherever possible, patient contact and endeavour to be more than 2 metres away from any patients they encounter.
Staff who need to go into theatres should follow the same guidelines/SOPS as the theatre staff
Green Routes
Surgical fluid resistant face mask which are available on reception and at all entry points
Masks should be disposed of in orange clinical waste bags.
Red Routes
Red Routes will be identified by door signs
All staff who need to enter a designated red area for whatever reason should follow the appropriate SOP and consult with the theatre floor co-ordinater before entering to ascertain the level of PPE required.
Social distancing and grouping
All staff entering the department should be aware of social distancing requirements and not congregate in groups on the corridors
SOP for surgery in patient with suspected or confirmed COVID-19
(interim guidance prior to works to modify theatres to neutral ventilation)
Background
Surgical patients with proven or suspected COVID-19 will need to be managed differently to standard patients
The aim of this SOP is to illustrate how to deliver good patient care whilst avoiding:
Passing on infection to Staff members
Passing on infection to other patients
Contaminating surfaces which could then lead to infection
This is an evolving situation so some details may change
Personal Protective Equipment
Preparation
Theatre:
Should have short transit from gate to theatre
Should have its own sluice with negative pressure
Ventilation should not be linked other rooms
Anaesthetic room should not be connected through ventilation
No Laminar flow ,so need to understand theoretical increase risk of infection for implant surgery (eg #NOF)
Theatre team:
Theatre team will be composed of the minimum number of staff to allow safe surgery. This will be two teams
In-theatre team (full PPE with FFP mask)
Out-of-theatre team
Anaesthetist and ODP
2nd ODP
(also needs to wear full PPE with FFP mask)
Surgeon +/- assistant
Out of theatre runner
Scrub nurse
In-theatre runner
Team brief:
Will occur as normal in anaesthetic room prior to sending for patient
Will need to decide exactly what equipment is required and what may be needed to avoid staff leaving theatre suite to search for equipment
Verbal run-though of the plan for PPE and patient transfer, including role allocation
Write name/role on theatre hats to avoid confusion when everyone wearing PPE
Send for patient
Theatre preparation:
All equipment that is not anticipated to be used for the case needs to be removed from theatre to avoid contamination including:
positioning equipment (clamps, stirrups etc)
sutures
tourniquet machine
drip stands
theatre trays
Anaesthetist preparation:
Regional anaesthetic preferred if possible, to minimise airway manipulation (aerosol generating procedure)
If GA, needs to be intubation with RSI to minimise bagging (aerosol generating procedure)
Prepare drugs in anaesthetic room.
Once happy, don full PPE for aerosol generating procedure
Carry prepared drugs into Theatre and (except in emergencies) should no longer return
ODP preparation:
Prepare all airway equipment that is likely to be required on a tray to take into theatre
Have any rescue equipment ready in anaesthetic room for 2nd ODP to be able to handover easily (e.g. i-gel)
List: laryngoscope, size 7.0 or 8.0 ETT, gel, bougie, face mask, guedel, catheter mount, HME filter, 20ml syringe, tube tie, clamp
Scrub nurse preparation:
Get all required trays into theatre but do not open at this stage (unless emergency)
Any other equipment in clean prep room
Ensure PPE available
Ensure all staff identified &labelled
Theatre Runner full PPE
Scrub team and surgeon full PPE
Procedure for transferring patient from ward to theatre
Porters to go for patient as normal. They will have to don PPE outside patient’s room as required
Pre-op ward check:
Normal WHO checklist needs completing by nurse on ward with consent form as normal
Patient notes should be kept separate where possible to avoid contamination
Patient needs normal surgical mask for transfer (no visor)
HCA or other member of ward staff should carry notes & needs to lead patient/porters to theatre, scouting ahead to open doors and clear route
Take patient directly into theatre via theatre exit doors
Porters, ODP and anaesthetic transfer patient onto operating table
Bed is kept in corner of theatre as contaminated
Porters leave theatre and doff PPE in dirty sluice
Sign-in, Anaesthesia& Time Out
ODP and Anaesthetist complete WHO Sign-in as normal, HCA remains in theatre until this is completed
HCA gives notes to the out-of-theatre runner to keep in prep room (non-contaminated) and leaves, doffing PPE in dirty sluice
Anaesthesia commenced:
If GA, needs RSI and intubation without bagging if possible, to minimise aerosol generation
Therefore, pre-oxygenation important
Once intubated, inflate cuff before connecting to ventilator to minimise aerosol generation
Once patient intubated, Scrub nurse, Surgeon, & Assistant put on sterile gowns and gloves
Time Out as normal
End of surgery& Recovery
Sign Out as normal (specifically ask if anything could be improved about PPE)
Transfer patient back onto bed for recovery in theatre
ODP and Anaesthetist recover patient with scrub nurse for assistance
Surgeon, assistant and theatre runner can doff PPE in dirty sluice and leave theatre
Dispose of theatre trays as normal for infected case
Once recovered patient returned to ward by out-of-theatre runner and 2nd ODP but need HCA or porter to act as route runner for clearing path back to ward
Back on ward:
Connect patient’s oxygen cylinder back to wall
Clean oxygen cylinder with wipes and hand out
ODP & Runner doff PPE and return to theatres
Finally:
Red clean for theatre
Staff to change scrubs