Standard Operating Procedure for the pre-operative ...€¦ · Standard Operating Procedure for the...

Standard Operating Procedure for the pre-operative management of elective surgery patients during the

COVID-19 Pandemic

CATEGORY: Standard Operating Procedure

CLASSIFICATION: Clinical

PURPOSE

This procedure describes the process that should be followed for the pre-operative management of selected patient groups due to undergo major elective high risk surgery during the COVID-19 Pandemic.

Controlled Document Number: C115

Version Number: 2.0

Document Author: Martin Richardson Approved By: Medical Scientific Advisory Group (COVID-19)

Date / Time: 11/06/2020

Review Date: 30/09/2020

Distribution:

• Recommended Readingfor:

Clinicians, all non medical Prescribers, Pharmacists and nurses

• Information for: Wards Managers, Senior Nurses, ADNs, Divisional Directors C

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CDN: C115 V 2.0 Title: SOP for the pre-operative management of elective surgery patients during the COVID-19 Pandemic Issued 11/06/2020

Standard Operating Procedure for the pre-operative management of elective surgery patients during the COVID-19 Pandemic

1. High risk surgery

Scope

This procedure describes the process that should be followed for the pre-operative management of selected patient groups due to undergo major elective high risk surgery during the COVID-19 Pandemic. The procedure has been developed in order to mitigate the recognised risk of exacerbated respiratory complications and associated mortality when undertaking major surgery on undetected COVID positive patients.

The SOP applies to all patients about to undergo any of the below surgical interventions

• Cardiac & Thoracic surgery• Oesophago-gastric cancer resections & Major HPB surgery• Major sarcoma resections• Major vascular surgery• Major Head and Neck Surgery

Overarching Principals

• Patients to have undergone full pre-operative assessment and be considered fit to proceedprior to listing (questionnaire). Drive through testing agreed (or swabs are posted out).

• Patients (& all other household members) to strictly self-isolate for a minimum of 14 days• Patients to have 2 x COVID-19 swabs conducted (designated ‘clean’ area ) 48-96 hours prior

to planned TCI date (driver pick up if no transport or courier at 96 hours then pre-admissionif out of area)

• Surgical team to remain responsible for ensuring clear COVID-19 result prior to patientadmission to hospital

• The surgical site should remain a ‘cold’ elective centre to minimise risk to patient and staff

A central booking team contact number will be communicated to all patients in order to report symptoms of COVID-19 during the pre-operative isolation period.

Swab positivity or symptom reporting require deferral of surgery with revised patient pathway (see Appendix 1). Equivocal symptoms or clinical suspicion on morning of surgery require deferral or in exceptional circumstances may merit urgent Chest CT with ‘Hot’ reporting (cold scanner). Changes (including equivocal) on CT thorax require deferral.

V 2.0 CDN: C115 Title: SOP for the pre-operative management of elective surgery patients during the COVID-19 Pandemic Issued 11/06/2020

All patients due to undergo high risk surgical procedures (UHB or Private Provider)

• Drive through swab testing (SOL / QEH) – patient must stay isolated- Pre-booked slot, batch collection to BHH / QE lab

• Alternate home testing available if independent transport not available- Home Coronavirus Throat/Nasal swab – (clear instructions)

Day 13

Telephone call to the patient (Booking team):

• Check current POA and signed off (surgical team) as fit to proceed- Screening questionnaire

• Confirm no COVID symptoms in last 7 days (patient / family members)

• Advised to strictly self-isolate for next 14 days (patient definitely and all otherhousehold / family members preferably) - inform surgery will not go ahead if self-isolation broken (correspondence to emphasise importance)

• Date of self-isolation commencement to be recorded

Day 0

Day 11



Day 14 • Results to Booking team for Operating Surgical team review

• Telephone confirmation to patient with symptom & isolation check

• Out of area patients ONLY to be admitted to hospital for 2nd Covid swab

• Patient TCI day of surgery if negative for COVID-19Pre-admission area (questionnaire):

• Re-check results, asymptomatic, affirmation modified consent• If clinical doubt defer (or in exceptional cases CT thorax)

Admit to admissions area

Day 15

Day 12 Check swab 1 result, notify surgeon if positive result

Text message reminder to swab

Text message reminder to swab Day 10 • Out of area patients ONLY to completecourier swab (If unable to attend drivethrough)



2. Intermediate risk surgery

Scope

This procedure describes the process that should be followed for the pre-operative management of selected patient groups due to undergo intermediate to major elective surgery during the COVID-19 Pandemic. The procedure has been developed in order to mitigate the recognised risk of exacerbated respiratory complications and associated mortality when undertaking major surgery on undetected COVID positive patients.

The SOP applies to all patients about to undergo any of the below surgical interventions (expected inpatient stay >48 hours):

• Colorectal cancer surgery• Intermediate ENT / OMF surgery• Neurosurgery and major plastic surgery• Urology cancer surgery• Vascular surgery• Gynaecological oncology• Major arthroplasty (if not at ROH)• Any other procedures with >48 hrs LoS (excluding those covered in high risk category)



• Patients (& all other household members) to strictly self-isolate for a minimum of 14 days• Patients to have 2 x COVID-19 swabs conducted (designated ‘clean’ area ) 48-96 hours prior

to planned TCI date (driver pick up if no transport or courier at 96 hours then pre-admissionif out of area)

• Surgical team to remain responsible for ensuring clear COVID-19 result prior to patientadmission to hospital

• The surgical site should remain a ‘cold’ elective centre to minimise risk to patient and staff


Swab positivity or symptom reporting require deferral of surgery with revised patient pathway (see Appendix 1). Equivocal symptoms or clinical suspicion on morning of surgery require deferral

If single test result unavailable but single swab negative then proceed with surgery.


All patients due to undergo intermediate surgical procedures (UHB or Private Provider)



Day 13




• Advised to strictly self-isolate for next 14 days (patient definitely andall other household / family members preferably) - inform surgery willnot go ahead if self-isolation broken (correspondence to emphasiseimportance)


Day 0

Day 11





• Patient TCI day of surgery if negative for COVID-19Pre-admission area:

• Re-check results, asymptomatic, affirmation modified consent- If clinical doubt defer (or in exceptional cases CT thorax)

Admit to admissions area

Day 15

Check swab 1 result, notify surgeon if positive result

Day 12 Text message reminder to swab

Text message reminder to swab Day 10



3. Low risk surgery

Scope

This procedure describes the process that should be followed for the pre-operative management of selected patient groups due to undergo minor-intermediate elective surgery during the COVID-19 Pandemic. The procedure has been developed in order to mitigate the recognised risk of exacerbated respiratory complications and associated mortality when undertaking surgery on undetected COVID positive patients.

The SOP applies to all patients about to undergo day case or ambulatory surgery (expected length of stay <48 hours)



• Patients (& all other household members) to strictly self-isolate for a minimum of 14 days• Patients to have 1 x COVID-19 swabs conducted (designated ‘clean’ area ) 48 hours prior to

planned TCI date (driver pick up if no transport or courier at 72 hours if out of area)• Surgical team to remain responsible for ensuring clear COVID-19 result prior to patient

admission to hospital• The surgical site should remain a ‘cold’ elective centre to minimise risk to patient and staff


Swab positivity or symptom reporting require deferral of surgery with revised patient pathway (see Appendix 1).

Local anaesthetic procedures + Invasive Diagnostic Tests

These procedures do not require the above screening unless there is a documented chance they may be converted to GA peri-procedure (eg. spinal anaesthetics). If definite non-GA procedures it is recommended that these patients:

• Self-isolate for 7 days prior to procedure• Undergo symptomatic check questionnaire on day of procedure• Wear face masks when attending appointment


All patients due to undergo low risk surgical procedures (UHB or Private Provider)



Day 13




• Advised to strictly self-isolate for next 14 days (patient definitely andall other household / family members preferably) - inform surgery willnot go ahead if self-isolation broken (correspondence to emphasiseimportance)


Day 0



• Patient TCI day of surgery if negative for COVID-19Pre-admission area:

• Re-check results, asymptomatic, affirmation modified consentAdmit to admissions area

Day 15

Day 12 Text message reminder to swab


All patients due to undergo local anaesthetic surgical procedures or invasive diagnostic investigations (UHB or Private Provider)


• Check fit to proceed- Screening questionnaire


• Advised to strictly self-isolate for next 7 days (patient definitely andhousehold / family members where possible) - inform procedure willnot go ahead if self-isolation broken (correspondence to emphasiseimportance)


Day 0

Patient attends on day of procedure

Pre-admission area: • Re-check asymptomatic (questionnaire)

Admit for procedure • Wears surgical mask at all times• Social distancing maintained except for necessary interactions• Meticulous hygiene• Appropriate PPE for staff depending on procedure type

Day 8


Appendix 1 – Cancellation Actions

1. Cancellation for logistic reasons

a. Patient to be re-booked on next suitable list (where possible)

b. Patient to continue strict personal and household / family isolation

c. If delayed by over 7 days – repeat swabbing arranged at 48 hours prior torescheduled procedure

2. Cancellation for positive test

a. Patient suspended for 2 weeks but must continue self / household isolation, then re-contacted by booking team (questionnaire). If asymptomatic for past 7 days, cyclerestarts as per below. If booking team has doubts about response then refer tosurgical team for decision. Interval assessment repeated if remains equivocal /positive.

b. Patient to be re-booked on next suitable list (where possible)

c. Patient to continue strict personal and household / family isolation for 14 days

d. SOP as per original based on magnitude of surgery

3. Cancellation for equivocal symptoms / test

a. Patient suspended for 1 week but must continue self / household isolation, then re-contacted by booking team (questionnaire). If asymptomatic for past 7 days, cyclerestarts as per below. If booking team has doubts about response then refer tosurgical team for decision. Interval assessment repeated if remains equivocal.

b. Patient to be re-booked on next suitable list (where possible)

c. Patient to continue strict personal and household / family isolation for 14 days

d. SOP as per original based on magnitude of surgery

4. Cancellation on medical grounds

a. Referred for anaesthetic assessment (in conjunction with surgical team) with IDinput if required

b. Scheduling as per above based on decision or suspension / deferral if deemed(relative) contraindication to proceed


Appendix 2 – Pre-operative Assessment Process


Appendix 3 Booking Process

Patients added to Speciality Priority Waiting List as agreed by Directorate

Waiting List Coordinator / secretary contacts patient to confirm with them they are willing to follow the self-isolation instructions

Waiting List Coordinator / secretary schedules pre op assessment appointment on UltraGenda or Oceano – (this is not dependant on the patient having a TCI date)

Patient attends pre-operative assessment – this could be a telephone consultation or a face to face appointment – refer to appendix 2 for pre op process

Pre op nurses inform waiting list coordinator / secretary if patient is fit or not fit for surgery:

HGS UltraGenda updated as per current process

QEHB Waiting List Coordinator / Secretary updates as per current process

Patient unfit for surgery TCI cancelled.

If patient does not have a TCI date waiting list updated to reflect not fit to proceed at this time and medical suspension added

Patient fit for surgery waiting list updated to reflect pre op notes.

Waiting List Coordinator / Secretary contacts patient to offer a date and TCI’s patient on UltraGenda or Oceano

WLC / secretary to advise patient that should they experience or develop any COVID like symptoms they must inform the waiting list team immediately.

HGS contact number: 0121 424 4383 / 0121 424 2941

QEHB secretary to provide patient with contact number at time of booking.

Waiting List Coordinator / Secretary add patient to UltraGenda or Oceano swab clinic for days 11 & 13 this will activate the text remind service -

Patients without mobile number will need to be phoned by waiting list coordinators / secretary

Low risk patients as per the SOP need to be booked for a single swab on day 13

Central booking team check Portal for test results and notify surgeon / secretary of any patients who come back with a positive result

Patients with a positive result will be contacted by the waiting list coordinator / secretary and TCI will be cancelled

V 2.0

CDN: C115 Title: SOP for the pre-operative management of elective surgery patients during the COVID-19 Pandemic Issued 11/06/2020

Appendix 4 – Swabbing Process

• Clinic schedule and patient labels printed by Solihull ODP reception anddelivered to OPD nurses

• OPD nurses complete sample request forms and ensure enough swabsand PPE in swabbing unit

Day 10 & 12

• Patient arrives at allocated appointment time

• OPD nurse checks patient details correct

• OPD nurse takes swab sample and package as per instructions

• QE patient samples and HGS patient samples collated separately

Day 11 & 13

• Driver will collect samples at pre-agreed times from swabbing Unit anddeliver to relevant site laboratory for processing


Appendix 5 – Swab booking Instructions

There are 3 methods of arranging for patients to be swabbed.

1. Drive up (at Solihull Elective Screening Unit).

2. Self-swab at home via Hospital delivery

The default for patient swabbing is the drive up at option. Only if the patient is out of area or strictly has no means of getting to the hospital without compromising their isolation status should either the home or postal swabbing option be used.

How to book:

1. Drive up:

• Patients with a QE Registration are to be booked an appointment in Oceano clinic codeSW7

• Patients with a HGS Registration are to be booked an appointment in UltraGenda clinicDepartment pre-op, schedule COVID swab (Sol)

2. Self-swab (hospital delivery)

If the patient is unable to attend the Solihull Elective Screening Unit without compromising their isolation status or live out of area, book as per the following:

• Patients with a QE Registration are to be booked an appointment in Oceano clinic code2RE

• Patients with a HGS Registration are to be booked an appointment in UltraGenda clinicDepartment pre-op, schedule COVID swab (Home)

Use of the above Covid swabbing appointments will be subject to audit. Inappropriate use of these slots for patients not meeting the relevant criteria will result in future access being denied


Appendix 6

Draft COVID19 screening questionnaire for elective investigations and surgical procedures.

1) Have you been diagnosed with COVID19 disease or been suspected of having COVID19 disease?

No

Yes

If yes detail date of infection. If < 14 days since contact stop and arrange repeat screening phone call at day 14

If no proceed to next question.

2) Have you been in close contact with a known or suspected case of COVID19 disease?

No

Yes

If yes detail date of contact. If < 14 days since contact stop and arrange repeat screening phone call at day 14.

If no proceed to symptom screening question

3) Have you had any of the following COVID19 symptoms in the last 14 days?

Yes No

• Fever – temperature measured >37.8 degrees

• Sore throat

• Cough that persists

• Difficulty breathing

• Muscle pains or headache

• Loss of taste or smell

• Nausea or vomiting

• Diarrhoea

If the answer is no to all of the above patient proceeds to elective investigations and surgical procedures

If answer yes to any of the questions refer to clinician for follow-up and further risk assessment.

Patient demographics


Appendix 7

TRANSPORT

In order of preference:

1. Brought in family / household car by family member (family have all self-isolated) – same asfor swab attendance

2. Brought in family / household car by household member (patient only has self-isolated) –same as for swab attendance – patient + driver wear mask, car cleaned before journey

3. Brought in friend’s car or taxi (patient +/- family have self-isolated) – same as for swabattendance – patient + driver wear mask, car cleaned before journey

Patients need to be strongly advised that 1 is very much the safest.

Patients will be issued 2 x surgical masks when they attend for their COVID swabs (or given at pre-operative assessment if they do not have transport)

Patient and driver to wear surgical mask at all times on way to hospital for admission (this includes if a taxi is required due to no car)

Appropriate hand washing and vehicle hygiene measures apply.


Covid-19 Pre-operative Information

Your surgeon has discussed with you that you require a surgical procedure. This information sheet outlines the information you need to know and understand when agreeing to surgery during the Covid-19 pandemic.

What is Covid-19? Covid-19 is an infectious disease caused by a newly discovered coronavirus. Most people infected with the Covid-19 virus will experience mild to moderate respiratory illness and recover without requiring special treatment.

What is the risk of having surgery at this time? As this is still a relatively new disease, there is limited information available about the exact risks of having surgery at this time. There has always been a risk of major respiratory (breathing) complications after an operation where a general anaesthetic is used. If you have Covid-19 at the time of a general anaesthetic, the risk of developing respiratory complications is at least twice as great as those who do not have the virus. Where Covid-19 causes post-operative respiratory complications, we know significantly more patients could die. This risk appears to be four times greater than normal.

What actions have the hospitals taken to reduce the risks? Recognising the risks of undertaking surgery at this time, University Hospitals Birmingham has implemented the following steps to reduce the risk to each patient:

• Converted areas of the hospitals into elective surgery only units, therefore your surgicalprocedure will determine the hospital site you will be admitted to

• Implemented patient screening processes both on the day and prior to admission• Reduced the number of times a patient needs to attend the hospital• Visiting is no longer allowed on any of our hospital sites (except in exceptional

circumstances)

What actions do patients need to take? Should you agree to proceed with your surgery, you will be required to follow the below pre-admission instructions:

• You and all members of your household will be required to fully self-isolate for a period of14 days immediately prior to your admission. This means you and your household memberswill not be able to leave your property even for the essential activities allowed by theGovernment.

• Before you can be admitted to the hospital for your operation, you will be tested (using athroat swab) either once or twice (depending on your surgical procedure) during a 14 dayperiod to see whether you have the Covid-19 virus. Providing you have clear results fromthese tests and have followed the 14 day isolation, your surgery will be able to take place.


Should you agree to follow these instructions and proceed with your surgery at this time, you will be contacted in due course to arrange your pre-operative assessment and admission date. You will be provided with further information at each of these stages.


Pre-operative information sheet

You are due to have your surgery soon and this information sheet provides you with more detail on the processes you are required to undertake in readiness for your admission and surgery. You will be telephoned by a Booking Clerk who will provide you with the dates to fill in on this sheet. Please do not lose this sheet as you will need to refer to it in the days prior to your surgery.

As previously stated, a number of steps have been put into place to preserve your safety as much as possible from Covid-19; this includes the requirement for you and your household to isolate and not go outside of your property prior to the surgery. You will have one or two swabs (depending on your planned operation) to check for the Covid-19 virus and your surgery will take place at one of our hospital sites that you may not be familiar with.

Please fill in the following when you receive your call from our Booking Clerk:

Your operation date is:

You will have your Covid-19 swabs on:

1 2

You will need to attend the Elective Admissions Unit at Solihull Hospital on: Please arrive at:

You must not eat anything after:

You can only drink clear* fluids until:

Nothing to be taken orally after: Once you are nil by mouth you cannot use chewing gum or suck/eat boiled sweets or your operation will be cancelled. *clear fluids are fluids that when in a glass you can read a newspaper through.

If you develop any symptoms (Covid or non-Covid) while waiting for admission date, please contact the Elective Admissions Unit on 0121 424 xxxx

Day of admission process Your family/carer/friend will need to bring you to Solihull Hospital; the post code is B91 2JL. They will need to enter the hospital via Union Road (opposite House of Fraser). There will be signs to a barrier, please press the buzzer to be given entry.

Please follow the signs to the parking bays near the Elective Admissions Unit entrance. Your relative/carer/friend will not be allowed into the hospital, but will need to remain in the care whilst we check that you are symptom free and able to be admitted. The nursing staff will inform your designated driver when they are able to leave the site.


As you enter the Elective Admissions Unit you will be asked to apply a mask, have your temperature taken and be given a questionnaire for you to complete. The nursing staff can help you with this if you need them to. The questionnaire is to check your risk factors for exposure to Covid-19. It is important when completing this questionnaire that you are honest as this is for your own safety.

You will be expected to wear a mask for the duration of your hospital stay, all staff on the wards will also have them on, this is precautionary and there is no need to be alarmed.

Should it be identified that you are at a higher risk of harm due to Covid-19, you will be asked to leave the site and your operation will have to be rearranged; this is why it is important that you have followed the isolation instructions prior to this date.

Once determined that your surgery will proceed, you will be taken to an admissions area where you may need to wait a little prior to the operation. During this time you will meet your surgeon and your anaesthetist who will confirm your fitness for surgery and you will be prepared for your operation.

Following your operation, a member of staff will ring your designated next of kin to inform them that you have had your surgery, what ward you are on and the telephone number. During your stay you may be moved from one ward to another, this is normal and nothing to worry about. Please feel free to bring a mobile ‘phone and charger with you to enable you to talk to your family during your stay.

Other information • Please bring with you your current medication and ensure you take your normal tablets in

the morning as advised by the pre-operative nurse.

• Due to the pandemic, University Hospitals Birmingham has stopped visitors on all sites. Thisis for the protection of patients, your family and our staff.

• Due to limited storage and to reduce any possible contamination and any losses, please onlybring essential items into the hospital; dressing gown, slippers, glasses, hearing aids andtoiletries. It is unlikely you will require much money, therefore for security reasons; pleaseleave your money at home.

• Please ensure that your designated driver is available on both your admission and yourdischarge. They will be contacted prior to your discharge to give a time to collect you andthis will depend on any tests or investigations and your discharge medication.

• After discharge you should continue to isolate for a further 14 days from your operationdate; this is for your personal safety.


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