As CMS had advised , “ Non-COVID-19 care should be offered to patients as clinically appropriate and within a state , locality , or facility that has the resources to provide such care and the ability to quickly respond to a surge in COVID-19 cases , if necessary . Decisions should be consistent with public health information and in collaboration with state public health authorities . Careful planning is required to resume in-person care of patients requiring non-COVID-19 care , and all aspects of care must be considered , including adequate facilities , workforce , testing , and supplies ; and adequate workforce across phases of care ( such as availability of clinicians , nurses , anesthesia , pharmacy , imaging , pathology support , and post-acute care ).” General considerations issued by CMS included :
● In coordination with state and local public health officials , evaluate the incidence and trends for COVID-19 in the area where re-starting in-person care is being considered .
● Evaluate the necessity of the care based on clinical needs . Providers should prioritize surgical / procedural care and high-complexity chronic disease management ; however , select preventive services may also be highly necessary .
● Consider establishing Non-COVID Care ( NCC ) zones that would screen all patients for symptoms of COVID-19 , including temperature checks . Staff would be routinely screened as would others who will work in the facility ( physicians , nurses , housekeeping , delivery and all people who would enter the area ).
● Sufficient resources should be available to the facility across phases of care , including PPE , healthy workforce , facilities , supplies , testing capacity , and post-acute care , without jeopardizing surge capacity .
CMS also reiterated the Centers for Disease Control and Prevention ( CDC )’ s PPE recommendations on staff wearing surgical face masks at all times , and for procedures with a higher risk of aerosol transmission , staff should utilize appropriate respiratory protection such as N95 masks and face shields . And patients should wear surgical masks or cloth face coverings . The recommendations of social distancing as well as sanitation protocols relating to thorough cleaning and disinfection were also advised .
In December 2020 , the American Society of Anesthesiologists ( ASA ) and the Anesthesia Patient Safety Foundation ( APSF ) issued a joint statement on performing elective surgery and anesthesia for patients following COVID-19 infection . As the ASA / APSF statement acknowledged , “ Since hospitals are able to continue to perform elective surgeries while the COVID-19 pandemic continues , determining the optimal timing of procedures for patients who have recovered from COVID-19 infection and the appropriate level of preoperative evaluation are challenging given the current lack of evidence or precedent .”
It stated that “ all non-urgent procedures should be delayed until the patient has met criteria for discontinuing isolation and COVID-19 transmission precautions and has entered the recovery phase . Elective surgeries should be performed for patients who have recovered from COVID-19 infection only when the anesthesiologist and surgeon or proceduralist agree jointly to proceed .”
Given that the evidence is evolving almost daily , what determines when a patient confirmed to have COVID-19 is no longer infectious ? Especially since patients infected with
SARS-CoV-2 , as confirmed by reverse transcriptase-polymerase chain reaction ( RT-PCR ) testing of respiratory secretions , may be asymptomatic or symptomatic . Symptomatic patients have been sub-classified into groups depending upon symptom severity :
● Patients with mild to moderate symptoms ( generally those without viral pneumonia or oxygen saturation below 94 percent )
● Patients who experienced severe or critical illness due to COVID-19 ( e . g ., pneumonia , hypoxemic respiratory failure , septic shock ).
● Severely immunocompromised patients , whether suffering from asymptomatic or symptomatic COVID-19 , are considered separately .
The ASA / APSF statement noted , “ Current data indicate that , in patients with mild to moderate COVID-19 , repeat RT-PCR testing may detect SARS-CoV-2 RNA for a prolonged period after symptoms first appear . However , in these patients , replication-competent virus has not been recovered after 10 days have elapsed following symptom onset . Considering this information , the CDC recommends that physicians use a time- and symptom-based strategy to decide when patients with COVID-19 are no longer infectious .”
For patients with confirmed COVID-19 infection who are not severely immunocompromised and experience mild to moderate symptoms , the CDC recommends discontinuing isolation and other transmission-based precautions when :
● At least 10 days have passed since symptoms first appeared .
● At least 24 hours have passed since last fever without the use of fever-reducing medications .
● Symptoms ( e . g ., cough , shortness of breath ) have improved .
For patients who are not severely immunocompromised and have been asymptomatic throughout their infection , isolation and other transmission-based precautions may be discontinued when at least 10 days have passed since the date of their first positive viral diagnostic test . The ASA / APSF statement notes , “ In approximately 95 percent of severely or critically ill patients ( including some with severe immunocompromise ), replication-competent virus was not present after 15 days following the onset of symptoms . Replication-competent virus was not detected in any severely or critically ill patient beyond 20 days after symptom onset .”
Another key issue is the appropriate length of time between recovery from COVID-19 and surgery with respect to minimizing postoperative complications . As the ASA / APSF statement explains , “ The preoperative evaluation of a surgical patient who is recovering from COVID-19 involves optimization of the patient ’ s medical conditions and physiologic status . Since COVID-19 can impact virtually all major organ systems , the timing of surgery after a COVID-19 diagnosis is important when considering the risk of postoperative complications . There are limited data now that address timing of surgery after COVID-19 infection . One study found a significantly higher risk of pulmonary complications within the first four weeks after diagnosis . An upper respiratory infection within the month preceding surgery has previously been found to be an independent risk factor for postoperative pulmonary complications . Patients with diabetes are more likely to have severe COVID-19 disease and are more likely to be hospitalized . Studies conducted during the 2009 influenza A H1N1 pandemic found that pulmonary function continues to recover up to three months after ARDS . Given this current knowledge base , wait times before surgery can be reasonably extrapolated and are a
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