Access Now: AORN COVID-19 Clinical Support

COVID-19 FAQs

Updated: March 27, 2020.

AORN is here to support the entire perioperative community during this novel coronavirus (COVID-19) pandemic. We will continue to update this page as issues and questions arise.

Surgical Precautions

  • Is there any information or guidance for intraoperative care of patients who are positive for COVID-19 that will protect staff and prevent transfer of the virus?

    Answer: Minimizing the amount of equipment, supplies and personnel in room is one proven action to prevent transmission. However, each facility will need to develop their own protocol based on the number of operating rooms, negative pressure or airborne infection isolation rooms (AIIR), prevalence of disease in their region, and the availability of equipment and supplies.  When surgeries for patients who do not have COVID-19 are performed in the same surgical suite, every effort should be taken to distance these patients.

    Some guidelines and protocols have been published by the American College of Surgeons, The Canadian Anesthesiologists Society, and Nebraska Medicine which include:

    • Developing a dedicated COVID-19 OR
    • Maintaining supply of proper personal protective equipment
    • If available, utilizing a negative pressure anteroom with separate entrance between OR and main hallway that is used for:
      • Donning and doffing PPE
      • Placing supplies that are needed after the case begins
    • Dedicated equipment, anesthesia and medication carts
    • Dedicated OR team for COVID-19 patients
    • Detailed education of perioperative team on infection prevention strategies, including visual reminders
    • Defined roles and responsibilities of each team member
    • Thoughtful and judicious preparation for procedure, with removal of all items not needed before patient enters room
    • Runner outside OR who will retrieve medications, instrumentation and other supplies
    • Utilization of mobile telephones to request needed items from runner and when they are available for circulator
    • Double-bag specimens

    Resources:

  • Which surgical procedures would have additional infection risks related to COVID-19?

    Answer: According to limited data from the CDC, COVID-19 has been detected in blood specimens, and it is unknown whether the virus is viable or infectious in extrapulmonary (outside the lungs) specimens. There have been some reports that COVID-19 is present in stool and may be transmissible through the fecal-oral route.

    Bronchoscopy, tracheostomy, and thoracic cases may have a higher risk for airborne transmission of COVID-19 because the nature of the procedures involve the respiratory tract, which could lead to aerosolization of the virus. Because the risk of transmission of COVID-19 through aerosolized blood and body fluids is unknown, precautions should be taken to prevent transmission out of an abundance of caution. Procedures that may aerosolize blood and body fluids during surgery may include:

    • Electrocautery of blood or gastrointestinal tissue
    • Laparoscopy
    • Endoscopy
    • Use of intraoperative debridement devices with irrigation (eg, hydrosurgery, pulse lavage, low frequency ultrasonic debridement)
    • Use of high-speed powered equipment (eg, saws, drills)

    For information about the risks associated with surgical smoke, see COVID FAQ: “Is the COVID-19 virus in surgical smoke?”

    Resources:

    Updated March 27, 2020

  • Should COVID-19 precautions be taken for all surgical patients?

    Answer: Depending on your local situation and patient population, it may be ideal to have everyone in the OR wear respiratory protection for all patients regardless of COVID-19 status, but this decision should take into account not only your N95 supply in the present time but also your projected usage, as this shortage is expected to continue for months. While there have been concerns about lab testing and asymptomatic patients, many places simply do not have the resources to use N95 respirators as a universal approach for all surgical patients. The CDC currently only recommends N95 use for known or suspected COVID patients, and use of N95s should be prioritized for these patients.

    Resources:

    Updated March 27, 2020

  • Should surgery on a COVID-19 patient be done in a negative pressure (AIIR) OR?

    Answer: Normally, the direction of airflow should be from the operating room (OR) to the hallway (positive pressure) to minimize contamination of the surgical field. In some hospitals there are ORs with reversible airflow or pressure, whereas others have positive-pressure rooms with a negative pressure anteroom.

    Precautions should be taken when performing aerosol-generating procedures such as intubation, extubation, bronchoscopy and suctioning of airways. CDC states that AGPs should ideally take place in an airborne infection isolation room (AIIR), but this negative pressure can put patients who are having surgery at risk for surgical site infections. A risk assessment should be performed by an interdisciplinary team to determine if COVID-19 suspected or confirmed positive patient’s surgery can be postponed until they are no longer infectious.

    If it is determined that an AII room will be used for a surgical procedure, keep the doors to the AIIR or OR closed, and minimize traffic into and out of the room. When possible, perform the procedure when the fewest people are in the surgical suite. After the procedure, leave the room vacant while the OR air exchanges clear any airborne contaminants that may remain in the room.  Air exchanges that remove airborne contaminants should occur before anyone who is not wearing respiratory protection enters the room, and before environmental cleaning is done.

    If you are considering conversion of the OR to negative pressure, consult with your engineering and maintenance team. It is important to evaluate whether altering the pressure to be negative in one or more ORs will affect the air balancing in adjacent areas.

     Resources:

    • Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.

    https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html

    • Airway/OR Management in Patient with Confirmed or Suspected COVID-19.

    https://www.nebraskamed.com/for-providers/covid19. Accessed March 27, 2020.

    • AORN Guideline for Transmission Based Precautions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • The Use of Personal Protective Equipment by Anesthesia Professionals during the COVID-19 Pandemic.

     https://www.asahq.org/about-asa/newsroom/news-releases/2020/03/the-use-of-personal-protective-equipment-by-anesthesia-professionals-during-the-covid-19-pandemic Accessed March 27, 2020.

    Accessed March 26, 2020

     

     

    Updated March 27, 2020

  • Can surgery on a COVID-19 patient be done in a positive pressure OR?

    Answer: Yes, an interdisciplinary team may decide to use a positive pressure room for a procedure on a COVID-19 patient when there is an increased risk for SSI or converting the OR to negative pressure is not feasible. If possible, perform the procedure when the least amount of people are in the surgical suite.  In other words, this is a risk versus benefit decision that will be specific to the situation, patient needs, and proximity of other patients in the operating room.

    During the procedure:

    • Limit traffic during procedure and only open the door if it is absolutely necessary.
    • If you use a runner or an additional circulating RN outside the OR to secure supplies, that person may wear a surgical mask but should not enter the OR. If you have an anteroom or substerile room this can be used as a drop off point, making sure one door is closed before the other is opened.

    When performing intubation and/or extubation in a positive pressure OR:

    • Ideally intubate patients in an AII room and then transfer them to the positive pressure OR (once intubated they are considered low risk because it is a closed system). Also consider transferring the patient to an AII room for extubation.
    • Only essential personnel wearing respiratory protection, such as an N95 respirator or PAPR, should be in the OR when intubation and extubation occur, including the RN Circulator. A time should be established for when it is safe for other team members who do not have respiratory protection can enter the room after intubation or extubation. This time should be determined in conjunction with facilities personnel who can provide information about number of air exchanges. Also, if extubation is performed in the OR, the scrubbed person should prioritize point of use treatment of surgical instruments to reduce the drying of bioburden on them before extubation occurs and they leave the room.  This can be achieved by using the method that your facility has chosen to keep instruments moist until decontamination in the sterile processing area occurs.
    • A portable high-efficiency particulate air (HEPA) filtration unit may be used by
      • positioning the unit near the patient’s breathing zone,
      • obtaining engineering consultation to determine the correct placement, and
      • switching the portable unit off during the surgical procedure.
    • A portable anteroom system (PAS)-HEPA combination unit may also be used.

     

    After the procedure:

    • Adequate air exchanges should occur before environmental services enters the room for cleaning. With 15-20 air exchanges it will be around 30 minutes.

    Resources:

    • Guidelines for Environmental Infection Control in Health-Care Facilities (2003), Appendix B. Air. Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/environmental/appendix/air.html#tableb1 Accessed March 27, 2020.
    • AORN Guideline for Environmental Cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • AORN Guideline for Transmission-Based Precautions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • AORN Guideline for Design and Maintenance of the Surgical Suite. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Airway/OR Management in Patient with Confirmed or Suspected COVID-19.https://www.nebraskamed.com/for-providers/covid19 Accessed March 27, 2020.

    Updated March 27, 2020

     

PPE

  • We have a shortage of surgical masks and/or respiratory protection, what should we do?

    Answer:

    Before considering any of the strategies in the tool below, the CDC recommends that your facility should

    • be aware of facemask and respirator inventory, supply chain, and utilization rate;
    • be in communication with local healthcare coalitions, federal, state, and local public health partners regarding need for additional supplies;
    • have already implemented other engineering and administrative control measures including:
      • Reducing the number of patients going to the hospital or outpatient settings
      • Excluding HCP not essential for patient care from entering their care area
      • Reducing face-to-face HCP encounters with patients
      • Excluding visitors to patients with confirmed or suspected COVID-19
      • Cohorting patients and HCP
      • Maximizing use of telemedicine; and
    • have provided HCP with fit testing for N95 respirators and required education and training, including having them demonstrate competency with donning and doffing.

    Your facility should perform a risk assessment to help prioritize strategies for implementation. Though some interventions may not be ideal, it is necessary to constantly assess and stratify risks in a fluctuating supply shortage situation. When determining which measures to implement, a risk assessment can guide the interdisciplinary team in determining how to manage the resources available. At all times it is the responsibility of the institution and decision makers to include key stakeholders in the decision process, including infection preventionists and healthcare epidemiologists. To assist the interdisciplinary team in conducting a risk assessment, there are commonly used risk assessment templates that can be adapted for the current COVID-19 pandemic. Factors to consider are the impact of the risk occurring, the probability of it occurring, and the resources available. Selection of PPE is a real time event and should be determined based on the real time resources. When resources again become available, the risks should be re-evaluated, and selection of PPE adjusted back toward conventional practices.

    Updated March 25, 2020

    Choose the level of shortage below:

    Source

    Strategy

    Comments/Recommendations

     Conventional Capacity

    Measures consist of providing patient care without any change in daily contemporary practices. This set of measures, consisting of engineering, administrative, and personal protective equipment (PPE) controls should already be implemented in general infection prevention and control plans in healthcare settings.

    CDC

    Use facemasks according to product labeling and local, state, and federal requirements.

    ·       FDA-cleared surgical masks are designed to protect against splashes and sprays and are prioritized for use when such exposures are anticipated, including surgical procedures.

    ·       Facemasks that are not regulated by FDA, such as some procedure masks, which are typically used for isolation purposes, may not provide protection against splashes and sprays.

    AORN

    Use masks in accordance with AORN Guidelines for Perioperative Practice.

    ·       Select the type of surgical mask needed according to the ASTM barrier level as stated on the label. (Guideline for Transmission Based Precautions, 2.6.4)

    ·       Higher barrier levels provide more protection to the wearer. The label “surgical mask” on a product does not necessarily indicate that the product underwent the FDA-recommended fluid-resistance testing. The FDA recommends that mask manufacturers test the masks for risks to the health of the wearer, including the risk for inadequate fluid resistance, inadequate barrier for bacteria (ie, particulate filtration efficiency, bacterial filtration efficiency), inadequate air exchange (ie, differential pressure), and flammability.

    Medical face mask barrier levels

    ·       Select the mask attachment that provides the best fit (eg, ties, ear loop, elastic). (Guideline for Transmission Based Precautions, 2.6.6)

    ·       Wear a clean mask for each new procedure. (Guideline for Transmission Based Precautions, 2.6.7)

    ·       Wear a clean surgical mask when open sterile supplies are present. (Guideline for Sterile Technique, 1.3)

    ·       Wear a mask when nose or mouth contamination can be reasonably anticipated. (Guideline for Transmission Based Precautions, 2.6)

    ·       Wear a mask or a full-face shield in the decontamination area. (Guideline for Cleaning and Care of Surgical Instruments, 6.2)

    ·       Wear the mask completely over the mouth, nose, and chin and fit snugly in a manner that prevents gaps at the sides of the mask. (Guideline for Transmission Based Precautions, 2.6.5)

    ·       Discard the mask when it becomes wet or soiled. The filtering capacity of a surgical mask may become compromised when it is wet or soiled. (Guideline for Transmission Based Precautions, 2.6.8)

    ·       Remove the mask without touching the front of the mask. (Guideline for Transmission Based Precautions, 2.6.10)

    ·       Do not wear used masks hanging around the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross contaminate the attire when the mask is worn hanging around the neck. (Guideline for Transmission Based Precautions, 2.6.11)

    CDC

    Use respirators according to product labeling and local, state, and federal requirements.

    ·       Surgical N95 respirators (sometimes called medical respirators) are recommended only for use by HCP who need protection from both airborne and fluid hazards (e.g., splashes, sprays). These respirators are approved by NIOSH and regulated by the FDA and are not used or needed outside of healthcare settings.

    ·       Use alternatives to N95 respirators where feasible. These include other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air purifying respirators, powered air purifying respirators (PAPRs) where feasible. All of these alternatives will provide equivalent or higher protection than N95 respirators when properly worn. NIOSH maintains a searchable, online version of the certified equipment list identifying all NIOSH-approved respirators.

    AORN

    Use N95 respirators and PAPRs in accordance with AORN Guidelines for Perioperative Practice.

    ·       When respiratory protection is needed, wear a NIOSH-approved, fit-tested, surgical N95 respirator or higher-level respirator. (Guideline for Transmission Based Precautions, 2.7)

    ·       Don respiratory protection before entering the room of a COVID-19 patient in accordance with the manufacturer's instructions and perform a user seal check (ie, fit check) for each use. (Guideline for Transmission Based Precautions, 2.7.1, 2.7.2, 2.7.4)

    ·       Facial hair should not cross under the seal of a fit-tested N95 respirator. (Guideline for Transmission Based Precautions, 2.7.5)

    ·       Remove the respirator after leaving the patient's room and closing the door. (Guideline for Transmission Based Precautions, 2.7.6)

    ·       Remove the surgical N95 respirator in accordance with the manufacturer’s written IFU by touching only the ties and without touching the front of the respirator. Discard it in a waste receptacle and perform hand hygiene. (Guideline for Transmission Based Precautions, 2.7.8)

    ·       An interdisciplinary team that includes an infection preventionist and an occupational health professional should determine whether powered air-purifying respirators (PAPRs) may be used for respiratory protection in the perioperative environment when a sterile field is present. (Guideline for Sterile Technique, 1.4)

    ·       If PAPR use is allowed, create a standardized procedure for perioperative PAPR use and protection of the sterile field from contamination (eg, portions of the sterile field to be covered; direction of the blower exhaust; type of PAPR allowed, such as loose-fitting, full face piece, hood style).  (Guideline for Sterile Technique, 1.4.1)

    Source

    Strategy

    Comments/Recommendations

     Contingency Capacity

    Strategies may change daily standard practices but may not have any significant impact on the care delivered to the patient or the safety of healthcare personnel (HCP). These practices may be used temporarily during periods of expected facemask shortages.

    CDC

    Remove facemasks for visitors in public areas.

    ·       Facemasks can be available to provide to symptomatic patients upon check in at entry points.

    ·       All facemasks should be placed in a secure and monitored site, especially in high-traffic areas like emergency departments.

    CDC

    Implement extended use of facemasks.

    ·       Extended use of facemasks is the practice of wearing the same facemask for repeated close contact encounters with several different patients, without removing the facemask between patient encounters.

    ·       Remove and discard the mask if soiled, damaged, or hard to breathe through.

    ·       HCP should leave patient care area if they need to remove the facemask.

    ·       A cleanable face shield over the facemask is the preferred method to reduce surface contamination.

    ·       Take care not to touch the mask. If touched or adjusted, immediately perform hand hygiene.

     

    Note The AORN recommendation to wear a clean mask for each new procedure will not be met. (Guideline for Transmission Based Precautions, 2.6.7) Care should be taken to avoid wearing used masks hanging around the neck (Guideline for Transmission Based Precautions, 2.6.11) and to not touch the front of the mask. (Guideline for Transmission Based Precautions, 2.6.10) This strategy may increase the patient's risk for surgical site infection when performed in an operating room.

    CDC

    Implement extended use of N95 respirators.

    ·       Extended use of N95 respirators is the practice of wearing the same respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters.

    ·       Remove and discard the N95 respirator if soiled, damaged, or hard to breathe through.

    ·       HCP should leave patient care area if they need to remove the respirator.

    ·       A cleanable face shield over the N95 respirator is the preferred method to reduce surface contamination.

    ·       Take care not to touch the respirator. If touched or adjusted, immediately perform hand hygiene.

    ·       https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html#risksextended

     

    Note The AORN recommendation to wear a clean mask for each new procedure will not be met. (Guideline for Transmission Based Precautions, 2.6.7) Care should be taken to avoid wearing used respirators hanging around the neck (Guideline for Transmission Based Precautions, 2.6.11) and to not touch the front of the respirator. (Guideline for Transmission Based Precautions, 2.6.10) This strategy may increase the patient's risk for surgical site infection when performed in an operating room.

     

    CDC

    Use respirators approved under standards used in other countries that are similar to NIOSH-approved N95 respirators

    ·       Other countries approve respirators for occupational use and approve respirators to these standards. These products are evaluated using some methods similar to those used by NIOSH, and some methods that are different, but are expected to protect HCPs. These respirators are expected to provide protection to workers.

    ·       See the CDC website for list of countries and performance standards: https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/crisis-alternate-strategies.html

    CDC

    Restrict facemasks to use by HCP, rather than patients for source control.

    ·       Have patients with symptoms of respiratory infection use tissues or other barriers to cover their mouth and nose.

    CDC

    Selectively cancel elective and non-urgent procedures and appointments for which a facemask is typically used by HCP.

    Note Refer to the following resources for triage of non-emergent surgical procedures:

    ·       American College of Surgeons: https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage

    ·       Ambulatory Surgery Center Association: https://www.ascassociation.org/asca/resourcecenter/latestnewsresourcecenter/covid-19

    ·       Centers for Medicare & Medicaid Services: https://www.cms.gov/files/document/31820-cms-adult-elective-surgery-and-procedures-recommendations.pdf

    AORN

    Review types of procedures that masks are worn for and reduce nonessential use.

    ·       A mask may not be necessary for some bedside procedures, including the following:

    o   Clean (eg, nasogastric tube insertion, chronic wound care without sharp debridement, endotracheal intubation, intrauterine device placement or removal, endometrial biopsy)

    o   Aseptic (eg, venipuncture, peripheral IV line placement, fine needle aspirations, arterial blood gas measurements, skin biopsies)

    o   Sterile‐superficial (eg, bone marrow biopsies, urinary catheter insertion)

    ·       Masse V, Edmond MB, Diekema DJ. Infection prevention strategies for procedures performed outside operating rooms: a conceptual integrated model. Am J Infect Control. 2018;46(1):94‐96.

    ·       Cahn, J. Clinical Issues-Preventing sterile field contamination during bedside procedures. AORN J. 2019;110(6):663-671.

    AORN

    Use work practice controls to prevent contamination of surgical masks being worn for extended use and to prevent airborne transmission of SARS-CoV-2.

    ·       Use a smoke evacuation system (eg, smoke evacuator, in-line filter) to evacuate all surgical smoke. (Guideline for Surgical Smoke Safety, 2.2)

    ·       When using intraoperative debridement devices with irrigation (ie, hydrosurgery, pulse lavage, low-frequency ultrasonic debridement), implement interventions such as covering the active hand piece with a clear sterile drape and using manufacturer’s recommendations for power, irrigation, and suction settings that limit mist, splatter, or spray, if patient care allows. (Guideline for Sterile Technique, 6.6)

    AORN

    Use engineering controls to reduce the patient's risk for surgical site infection.

    ·       Use positive pressure ventilation systems to reduce the risk of surgical site infection for patients who are not known or suspected of having COVID-19.

    AORN

    Use engineering controls to prevent the transmission of SARS-CoV-2.

    ·       Use negative pressure ventilation systems to reduce the risk of infection transmission to people outside the room.

    ·       May use portable HEPA filtration units in the OR to turn on during the surgical procedure to minimize the risk for surgical site infection. (Guideline for Transmission Based Precautions, 5.6.1)

    AORN

    Implement strategies to prevent having to remove the mask or respirator.

    ·       Call for help or have a team member stationed outside the room to bring supplies, medications, or equipment as needed.

    AORN

    If available, consider using a higher level of respiratory protection (ie, surgical N95, PAPR).

    ·       If surgical N95 respirators are not available, and there is a risk that the worker may be exposed to high velocity splashes, sprays, or splatters of blood or body fluids, then a face shield should be worn over the standard N95 respirator.

    ·       The use of PAPRs in the perioperative setting may contaminate the sterile field. An interdisciplinary team that includes an infection preventionist and an occupational health professional should determine whether PAPRs may be used for respiratory protection in the perioperative environment when a sterile field is present. (Guideline for Sterile Technique, 1.4) If allowed, create a standardized procedure for perioperative PAPR use and protection of the sterile field from contamination (eg, portions of the sterile field to be covered; direction of the blower exhaust; type of PAPR allowed, such as loose-fitting, full face piece, hood style). (Guideline for Sterile Technique, 1.1.4)

    AORN

    If available, consider using a surgical helmet system for care of surgical patients who do not require droplet or airborne precautions.

    ·       Surgical helmet systems are already being used for care of surgical patients and do not increase the patient's risk for surgical site infection. (Guideline for Sterile Technique, 2.6)

    o   Young  SW, Zhu  M, Shirley  OC, Wu  Q, Spangehl  MJ. Do “surgical helmet systems” or “body exhaust suits” affect contamination and deep infection rates in arthroplasty? A systematic review. J Arthroplasty. 2016;31(1):225–233. 

    ·       A mask may not be needed underneath the helmet unless otherwise specified by the manufacturer’s instructions for use. 

    ·       Surgical helmet systems do not filter the air that circulates in the helmet and are not considered respiratory protection.

    AORN

    If available, consider using an isolation mask or other non-surgical mask.

    ·       In the absence of surgical masks, consider using isolation masks (if available) for procedures with low-fluid exposure and low SSI risk.

    AORN

    Consider using elastomeric respirators in the decontamination area of sterile processing.

    ·       Elastomeric respirators are sometimes referred to as reusable respirators because the facepiece is cleaned and reused but the filter cartridges are discarded and replaced when they become unsuitable for further use. Similar to N95 respirators, elastomeric respirators require annual fit testing.

    ·       Facilities using elastomeric respirators and PAPRs should have up to date cleaning/disinfection procedures, which are an essential part of use for protection against infectious agents. (CDC NIOSH)

    Source

    Strategy

    Comments/Recommendations

    Crisis Capacity

    Strategies that are not commensurate with U.S. standards of care. These measures, or a combination of these measures, may need to be considered during periods of known facemask shortages.

    CDC

    Cancel all elective and non-urgent procedures and appointments for which a facemask is typically used by HCP.

    Note Refer to the following resources for triage of non-emergent surgical procedures:

    ·       American College of Surgeons: https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage

    ·       Ambulatory Surgery Center Association: https://www.ascassociation.org/asca/resourcecenter/latestnewsresourcecenter/covid-19

    ·       Centers for Medicare & Medicaid Services: https://www.cms.gov/files/document/31820-cms-adult-elective-surgery-and-procedures-recommendations.pdf

    CDC

    Use facemasks beyond the manufacturer-designated shelf life during patient care activities.

    ·       If there is no date available on the facemask label or packaging, contact the manufacturer.

    ·       Visually inspect the product prior to use and, if there are concerns (such as degraded materials or visible tears), do not use the product.

    CDC

    Implement limited re-use of facemasks.

    ·       Limited re-use of facemasks is the practice of using the same facemask by one HCP for multiple encounters with different patients but removing it after each encounter. As it is unknown what the potential contribution of contact transmission is for SARS-CoV-2, care should be taken to ensure that HCP do not touch outer surfaces of the mask during care, hand hygiene is performed, and that mask removal and replacement be done in a careful and deliberate manner.

    ·       The facemask should be removed and discarded if soiled, damaged, or hard to breathe through.

    ·       Not all facemasks can be re-used.

    ·       Facemasks that fasten to the provider via ties may not be able to be undone without tearing and should be considered only for extended use, rather than re-use.

    ·       Facemasks with elastic ear hooks may be more suitable for re-use.

    ·       Facemask materials degrade when they are worn and degrade more quickly in the presence of increased moisture.  Information about duration of safe mask wear can be obtained from the manufacturer of the mask.

    ·       HCP should leave patient care area if they need to remove the facemask.

    ·       Facemasks should be carefully folded so that the outer surface is held inward and against itself to reduce contact with the outer surface during storage. The folded mask can be stored between uses in a clean sealable paper bag or breathable container.

     

    Note The AORN recommendations to not touch the front of the mask (Guideline for Transmission Based Precautions, 2.6.10) or wear a clean mask for each new procedure will not be met. (Guideline for Transmission Based Precautions, 2.6.7) Care should be taken to avoid wearing used masks hanging around the neck. (Guideline for Transmission Based Precautions, 2.6.11) This strategy may increase the patient's risk for surgical site infection when performed in an operating room. This strategy may also place HCP who are not wearing a mask at risk for acquiring bloodborne, contact, droplet, and airborne transmissible infections, such as COVID-19.

    CDC

    Implement limited re-use of N95 respirators.

    ·       The maximum number of safe reuses cannot be assigned as a generic number because safe reuse is dependent on contamination over time.

    ·       Use of a cleanable face shield over the N95 is preferred over a surgical mask to reduce surface contamination.

    ·       Between uses, respirators should be hung in designated storage area or kept in clean breathable container such as a paper bag.

    ·       Clean non-sterile gloves should be used when redonning used N95 respirator and performing a user seal check.

    ·       N95 respirator materials degrade when they are worn and can degrade more quickly in the presence of increased moisture.  Information about duration of safe mask wear can be obtained from the manufacturer of the mask. 

    ·       https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html#risksextended

     

     

    Note The AORN recommendations to not touch the front of the mask (Guideline for Transmission Based Precautions, 2.6.10) or wear a clean mask for each new procedure will not be met. (Guideline for Transmission Based Precautions, 2.6.7) Care should be taken to avoid wearing used respirators hanging around the neck. (Guideline for Transmission Based Precautions, 2.6.11) This strategy may increase the patient's risk for surgical site infection when performed in an operating room. This strategy may also place HCP who are not wearing a mask at risk for acquiring bloodborne, contact, droplet, and airborne transmissible infections, such as COVID-19.

    CDC

    Prioritize the use of facemasks by activity type.

    ·       Prioritize facemask use for the following activities:

    o   For provision of essential surgeries and procedures

    o   During care activities where splashes and sprays are anticipated

    o   During activities where prolonged face-to-face or close contact with a potentially infectious patient is unavoidable

    o   For performing aerosol generating procedures, if respirators are no longer available

    CDC

    Prioritize the use of N95 respirators by activity type.

    ·       The use of N95s or PAPRs should be prioritized for HCP with the highest potential exposures including being present in the room during aerosol generating procedures performed on symptomatic persons.

    Facemask or respirator determination

    CDC

    Use respirators beyond the manufacturer-designated shelf life during patient care activities.

    ·       Over time, components such as the straps and nose bridge material may degrade, which can affect the quality of the fit and seal. Many models found in U.S. stockpiles and stockpiles of healthcare facilities have been found to continue to perform in accordance with NIOSH performance standards. However, fluid resistance and flammability were not assessed.

    ·       It is particularly important that HCP perform the expected seal check, prior to entering a patient care area.

    ·       CDC does not recommend using N95s beyond the manufacturer-designated shelf life in surgical settings.

     

    Note This strategy may increase the patient's risk for surgical site infection when performed in an operating room.

    AORN

    Consider using elastomeric respirators for nonscrubbed team members.

    ·       Elastomeric respirators are sometimes referred to as reusable respirators because the facepiece is cleaned and reused but the filter cartridges are discarded and replaced when they become unsuitable for further use. Similar to N95 respirators, elastomeric respirators require annual fit testing.

    ·       Elastomeric respirators should not used in surgical settings due to concerns that air coming out of the exhalation valve may contaminate the sterile field. (CDC NIOSH)

    ·       An interdisciplinary team that includes an infection preventionist and an occupational health professional should determine whether elastomeric respirators may be used for respiratory protection by nonscrubbed team members in the perioperative environment when a sterile field is present. If allowed, create a standardized procedure for use and protection of the sterile field from contamination.

    ·       Facilities using elastomeric respirators and PAPRs should have up to date cleaning/disinfection procedures, which are an essential part of use for protection against infectious agents. (CDC NIOSH)

     

    Note This strategy may increase the patient's risk for surgical site infection when performed in an operating room.

    AORN

    Consider prioritizing mask use for scrubbed team members during care of surgical patients who do not require droplet or airborne precautions.

    ·       Consider only requiring scrubbed team members to wear a mask for procedures with low risk for SSI and low exposure to blood and body fluids.

    ·       An interdisciplinary team that includes an infection preventionist should determine whether nonscrubbed team members may not wear a mask.

    o   Vincent  M, Edwards  P. Disposable surgical face masks for preventing surgical wound infection in clean surgery. Cochrane Database Syst Rev. 2016;4:CD002929.

    ·       If nonscrubbed team members are not wearing a mask, they should stay as far away from the sterile field as possible. A drape may be used to provide a barrier to the anesthesia work area.

     

    Note The AORN recommendation to wear a clean surgical mask when open sterile supplies are present will not be met. (Guideline for Sterile Technique, 1.3) This strategy may increase the patient's risk for surgical site infection.

    Source

    Strategy

    Comments/Recommendations

    When No Facemasks or Respiratory Protection are Available

    CDC

    Exclude HCP at higher risk for severe illness from COVID-19 from contact with known or suspected COVID-19 patients.

    ·       During severe resource limitations, consider excluding HCP who may be at higher risk for severe illness from COVID-19, such as those of older age, those with chronic medical conditions, or those who may be pregnant, from caring for patients with confirmed or suspected COVID-19 infection.

    CDC

    Designate convalescent HCP for provision of care to known or suspected COVID-19 patients.

    ·       It may be possible to designate HCP who have clinically recovered from COVID-19 to preferentially provide care for additional patients with COVID-19.

    ·       Individuals who have recovered from COVID-19 infection may have developed some protective immunity, but this has not yet been confirmed.

     

    Note This strategy may increase the patient's risk for surgical site infection when performed in an operating room because the personnel are not wearing a mask. This strategy may also place HCP at risk for acquiring bloodborne, droplet, and airborne transmissible infections, such as COVID-19.

    AORN

    Consider using a surgical helmet system for care of COVID-19 patients.

    ·       Surgical helmet systems are not certified by NIOSH for respiratory protection. Depending on the type of device, the system may provide some protection to the wearer by positive-pressure ventilation, although the incoming air may not be filtered to the level required to be classified as respiratory protection. Contact the manufacturer for product information and follow the manufacturer's instructions for use.

    ·       An interdisciplinary team that includes an infection preventionist and an occupational health professional should determine whether surgical helmet systems may be used for respiratory protection in the absence of certified equipment.

    ·       For scrubbed team members, the helmet system should be donned before entering the OR:

    o   Don the unsterile helmet before performing surgical hand antisepsis. (Guideline for Sterile Technique, 2.6.1)

    o   Don the sterile visor hood or toga that covers the unsterile helmet before donning the sterile gown and gloves. (Guideline for Sterile Technique, 2.6.2)

    o   Turn the fan in the unsterile helmet on after gowning is completed. (Guideline for Sterile Technique, 2.6.4)

    o   Enter the operating room, taking

     

    Note This strategy may place HCP at risk for acquiring airborne transmissible infections, such as COVID-19. This strategy may increase the patient’s risk for surgical site infection when performed by scrubbed team members in an operating room because there may be a risk for contamination of the sterile gown and gloves when donning the helmet system outside of the OR. Also, the AORN recommendation to wear a surgical mask when performing surgical hand antisepsis (Guideline for Sterile Technique, 2.6.1) and remain close to the sterile field (Guideline for Sterile Technique, 7.2) will not be met.

    CDC

    Use a face shield that covers the entire front and sides of the face with no facemask.

    ·       The face shield should extend to the chin or below.

     

    Note This strategy may increase the patient's risk for surgical site infection when performed in an operating room. This strategy may also place HCP who are not wearing a mask at risk for acquiring bloodborne, droplet, and airborne transmissible infections, such as COVID-19.

    CDC

    Consider use of expedient patient isolation rooms for risk reduction.

    ·       Portable fan devices with high-efficiency particulate air (HEPA) filtration that are carefully placed can increase the effective air changes per hour of clean air to the patient room, reducing risk to individuals entering the room without respiratory protection. NIOSH has developed guidance for using portable HEPA filtration systems to create expedient patient isolation rooms. The expedient patient isolation room approach involves establishing a high-ventilation-rate, negative pressure, inner isolation zone that sits within a “clean” larger ventilated zone.

     

    Note This strategy may increase the patient's risk for surgical site infection when performed in an operating room. This strategy may also place HCP who are not wearing a mask at risk for acquiring bloodborne, droplet, and airborne transmissible infections, such as COVID-19.

    CDC

    Consider use of ventilated headboards.

    ·       NIOSH has developed the ventilated headboard that draws exhaled air from a patient in bed into a HEPA filter, decreasing risk of HCP exposure to patient-generated aerosol. This technology consists of lightweight, sturdy, and adjustable aluminum framing with a retractable plastic canopy. The ventilated headboard can be deployed in combination with HEPA fan/filter units to provide surge isolation capacity within a variety of environments, from traditional patient rooms to triage stations, and emergency medical shelters.

     

    Note This strategy may not be feasible and may increase the patient's risk for surgical site infection when performed in an operating room. This strategy may also place HCP who are not wearing a mask at risk for acquiring bloodborne, droplet, and airborne transmissible infections, such as COVID-19.

    CDC

    Consider use of homemade masks.

    ·       In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort.

    ·       However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option.

    ·       Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face.

     

    Note This strategy may increase the patient's risk for surgical site infection when performed in an operating room. This strategy may also place HCP at risk for acquiring bloodborne, droplet, and airborne transmissible infections, such as COVID-19.

    AORN

    Consider use of masks made from sterilization wrap.

    ·       As with all homemade masks, this is a last resort strategy.

    ·       It is unknown whether masks made sterilization wrap provide any protection as PPE. Using a mask made of sterilization wrap may provide false reassurance of protection.

    ·       While sterilization wrap may provide a higher level of bacterial filtration and fluid resistance than cloth masks, it is unknown whether this would provide any protection when worn as a mask.

     

    Note This strategy may increase the patient's risk for surgical site infection when performed in an operating room. This strategy may also place HCP at risk for acquiring bloodborne, contact, droplet, and airborne transmissible infections, such as COVID-19.

    AORN

    Consider use of cloth masks.

    ·       As with all homemade masks, this is a last resort strategy.

    ·       Cloth masks do not provide any protection as PPE. Using a cloth mask may provide false reassurance of protection.

    o   MacIntyre CR, Seale H, Dung TC, et al. A cluster randomised trial of cloth masks compared with medical masks in healthcare workers. BMJ Open 2015;5:e006577. doi: 10.1136/bmjopen-2014-006577

    ·       Cloth masks do not provide any level of fluid protection, are flammable, and may introduce lint into the sterile field.

    ·       The poor bacterial filtration of cloth masks may increase the patient's risk for SSI.

    ·       Cloth masks should be laundered at a health care–accredited laundry facility, the health care organization according to state regulatory requirements, or the health care organization according to Centers for Disease Control and Prevention recommendations for laundering in the absence of state requirements.

    ·       Sterilization instructions may not be available for cloth masks, and as such sterilization cannot be guaranteed.

     

    Note This strategy may increase the patient's risk for surgical site infection when performed in an operating room. This strategy may also place HCP at risk for acquiring bloodborne, contact, droplet, and airborne transmissible infections, such as COVID-19.

    AORN

    Consider disinfection and/or sterilization of single-use masks and N95 respirators.

    ·       Single-use masks and N95 respirators may not have been validated by the manufacturer for reprocessing.

    ·       It may not be possible to clean single-use masks and N95 respirators.

    ·       Sterilization instructions may not be available for single-use masks and N95 respirators, and as such sterilization cannot be guaranteed.

    ·       Single-use products may not be able to withstand multiple uses, and may not provide any protection to the wearer with disinfection and/or sterilization.

    ·       There is limited evidence about UV disinfection of single-use N95 respirators. See Nebraska Medicine for protocol: https://www.nebraskamed.com/for-providers/covid19

    ·       Sterilization experts, government agencies, and public health officials are working together to determine whether reprocessing by third party vendors is feasible and can be done safely and effectively. Unfortunately, it is currently unknown whether reprocessing single-use N95s may damage the materials and how much that may affect their effectiveness, but these questions are being answered in a laboratory setting.  AORN is participating in these meetings and we are advocating for safe and effective solutions that may include reprocessing N95 respirator - when the scientific community, FDA, and CDC agree that it can be safely done.  In the meantime, please understand that some disinfection and sterilization methods could damage the mask and render it less effective or ineffective at filtering airborne particles.  The last thing we want for health care workers is for there to be a false sense of security when wearing an N95 respirator that is not providing protection.

     

    Note This strategy may increase the patient's risk for surgical site infection when performed in an operating room. This strategy may also place HCP at risk for acquiring bloodborne, contact. droplet, and airborne transmissible infections, such as COVID-19. Wearing a mask that was not adequately cleaned may expose the HCP to infections from the previous wearer.

  • What PPE should perioperative team members don when caring for a patient with COVID-19?

    Answer: In addition to standard precautions, the CDC currently recommends use of a respirator (preferred) or facemask, gown, gloves, and eye protection when caring for a patient with known or suspected COVID-19. When scrubbed, a sterile gown and gloves should be worn. The World Health Organization recommends using an N95 or equivalent respiratory protection if aerosol-generating procedures (eg, intubation) are performed. Refer to the CDC, your local health authority, and your organization’s policies and procedures for the latest guidance.

    Resources:

     

    Updated March 27, 2020

  • Where should donning and doffing of PPE occur?

    Answer: Donning of PPE should occur outside the OR. For scrubbed team members, respiratory protection and eye protection or a face shield should be donned outside of the room, but the sterile gown and gloves should be donned inside the room after surgical hand antisepsis.

    Doffing of the PPE should occur inside the OR, but the N95 respirator should be removed after exiting and closing the door to the OR. 

    Resources:

     

    Updated March 27, 2020

  • What are the recommendations for PPE when performing intubation and extubation in the OR for COVID-19 patients?

    Answer: A joint statement by the American Society of Anesthesiologists (ASA), American Association of Nurse Anesthetists (AANA) and the Anesthesia Patient Safety Foundation (APSF) states that when performing intubation and other aerosol generating procedures there should be minimal personnel at head of bed and they should wear properly fitted N95 respirators, eye protection, gowns and gloves. However, ASA, AANA, and APSF recognize that the population density, hospital size and resources, location, and access to supply chains presents unique challenges and therefore endorses the temporary mitigation plans as outlined by CDC for limited reuse of N95 respirators.

    Resources:

     

     

    Updated March 23, 2020

  • What is the recommendation on use of PAPRs in the OR during the COVID-19 pandemic?

    Answer: A facility interdisciplinary team including an infection preventionist and occupation health professional should determine whether a PAPR may be used for respiratory protection in the perioperative environment when a sterile field is present. It is important to note that the Centers for Disease Control and Prevention does not recommend that PAPRs with exhalation valves be used during invasive procedures when a sterile field is present. If the interdisciplinary facility team determines that PAPR use is allowed, a standardized procedure should be created that outlines perioperative PAPR use and how the sterile field will be protected from contamination. These measures may include covering portions of the sterile field and designating the direction that the blower will be exhausted.

    Resources:

    • Jensen PA, Lambert LA, Iademarco MF, Ridzon R. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health‐care settings, 2005. MMWR Recomm Rep. 2005;54(RR17):1‐141.
    • AORN Guideline for Sterile Technique. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated March 23, 2020

  • Does AORN have guidance on extended use of N95s? Can N95s be covered to extend their use?

    Answer: The CDC and NIOSH have released guidance on extended use of N95s; however, implementation of this strategy should be determined by occupational health, infection prevention, and professionals managing respiratory protection program and should be based on prevalence of disease in region, severity of illness as well as local conditions (eg, number of disposable respirators available, current respirator use). Extended use is preferred over reuse as it involves less touching of respirator. However, for safe extended use the N95 must maintain its fit and function and a cleanable face shield over the N95 is the preferred method to reduce surface contamination. The CDC guidance can be used to formulate clear written procedures for advising staff on steps to reduce contact transmission.

    Resources:

     

    Updated March 23, 2020

  • Does AORN have guidance on reuse of N95 respirators?

    Answer: Reuse of N95 respirators is not safe nor commensurate with standards of care, and should only be considered in a crisis situation when other strategizes to optimize respirator use have failed. The CDC provides guidance on the reuse of N95 respirators. However, the maximum number of safe reuses cannot be assigned as a generic number because safe reuse is dependent on contamination over time. Use of a cleanable face shield over the N95 is preferred over a surgical mask to reduce surface contamination. Between uses, respirators should be hung in designated storage area or kept in clean breathable container such as a paper bag. Clean non-sterile gloves should be used when redonning used N95 respirator and performing a user seal check.

    Resources:

     

    Updated March 23, 2020

  • Can we use expired N95 respirators or respirators that are not certified by NIOSH?

    Answer: Use of N95 respirators beyond the manufacturer-designated shelf life, as well as use of respirators approved under standards in other countries may be necessary during periods of expected or known N95 respirator shortages. However, respirators beyond the manufacturer-designated shelf life may not perform to the requirements for which they were certified. Over time, components such as the straps and nose bridge material may degrade, which can affect the quality of the fit and seal.

    Resources:

     

    Updated March 23, 2020

  • Can masks with ear loops be utilized in OR when caring for patients suspected or confirmed with COVID-19?

    Answer: Surgical masks with ear loops may be worn in the OR, provided that the mask completely covers the mouth, nose, and chin and fits snugly in a manner that prevents gaps at the sides of the mask. The wearer’s facial shape will determine which mask attachment (eg, ties, ear loops, elastic) provides the best fit. Masks with ear loops may not have been designed and intended for use as surgical masks. The type of surgical mask needed for the procedure should be selected according to the barrier level as stated on the product label. The level of protection provided by the mask may be determined by the ASTM barrier level as stated on the product label, with higher barrier levels providing more protection to the wearer.

    Resources:

    • AORN Guideline for Transmission-Based Precautions. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • ASTM F2100-11(2018): Standard Specification for Performance of Materials Used in Medical Face Masks. West Conshohocken, PA: ASTM International; 2018.

     

    Updated March 23, 2020

  • What is AORN’s guidance on extended use of facemasks?

    Answer: The decision to implement extended use of face masks should be determined by occupational health, infection prevention, and professionals managing respiratory protection program and should be based on prevalence of disease in region, severity of illness as well as local conditions (eg, number of disposable face masks available, current face mask use). The CDC recommendations for extended use involve the wearing of same facemask for repeated close contact with several different patients without removing the facemask between patients. However, the facemask should be removed and discarded if soiled or damaged after healthcare provider (HCP) leaves patient care area. The HCP should make every effort not to touch or readjust facemask, but if that occurs, they must immediately perform hand hygiene.

    Resources:

     

    Updated March 23, 2020

     

  • What is AORN’s guidance on reuse of facemasks?

    Answer:  Reuse of facemasks is not safe nor commensurate with standards of care, and should only be considered in a crisis situation when other strategies to optimize mask use have failed. The decision to implement reuse of face masks should be determined by occupational health, infection prevention, and professionals managing respiratory protection program and should be based on prevalence of disease in region, severity of illness as well as local conditions (eg, number of disposable face masks available, current face mask use). The CDC recommendations for reuse of facemasks involves one healthcare provider (HCP) using the same facemask for multiple patient encounters and removing it after each encounter. It is important to note that not all facemasks can be reused. Facemasks with ties may not be able to untie without tearing, so may be better suited for extended use and facemasks with ear loops may be better choice for reuse. HCP should leave patient area to remove mask and it should be carefully folded so that outer surface is folded inward against itself to reduce contact with outer surface. The folded mask should then be stored in a clean closed paper bag or breathable container. If masks become soiled or damaged, they should be discarded.

    Resources:

     

    Updated March 23, 2020

  • What is AORNs position regarding “cloth mask use” if we run out of surgical masks?

    Answer: Cloth masks do not provide any protection as PPE and should not be worn by any health care professional (HCP) unless there are absolutely no masks or other respiratory protection left.  Wearing a cloth mask may provide false reassurance as protection. Cloth masks are the very last option in the CDC’s recommendations and are intended for a facility that does not have any facemasks available and cannot get any more and should only be utilized after all other options provided by the CDC have been exhausted. Cloth masks do not provide respiratory protection and are not considered PPE because their ability to protect HCP from blood and body fluids is unknown. On March 24th, the American Nurses Association (ANA) released a position statement saying that “evidence does not support the notion that cloth masks are safe for HCP providing care to patients with coronavirus …as they do not afford the wearer any significant protection.”

    Furthermore, the poor bacterial filtration of cloth masks may increase the patient's risk for surgical site infection. For further guidance please see our COVID-19 FAQ "We have a shortage of surgical masks and/or respiratory protection, what should we do?"

    Resources:

     

    Updated March 27, 2020

  • What is AORNs position regarding disinfecting surgical masks using UV light?

    Answer: Ultraviolet light is designed to disinfect surfaces once the bioburden (ie, blood, dirt) has been removed. The manufacturers of single-use masks do not provide cleaning or disinfection instructions, as the masks are intended for single-use. Additionally, the permeability of mask material can make effective cleaning difficult. There are limited clinical studies on UV application to surgical masks and the effect of UV on material strength or particle penetration. UV may be safe to use on some materials for a limited amount of time, but may degrade the materials rendering them ineffective. Therefore, this strategy should be the absolute last resort as it can place HCP at risk for acquiring bloodborne, contact, droplet, and airborne transmissible infections, such as COVID-19, and may increase the patient's risk for surgical site infection when these processed masks are worn in an operating room. Another potential harm if the UV light has not adequately inactivated the coronavirus is potential transfer of infection from the previous wearer to new wearer donning the processed mask.

    Resources:

    Updated March 27, 2020

  • Can reusable gowns be used? What are recommendations for reusable gown material (ie, thread count, type of cloth)?

    Answer: When supplies of isolation and surgical gowns are depleted, gown use can be shifted to cloth isolation gowns which are usually made of polyester or polyester-cotton fabrics. Gowns made of these fabrics can be laundered, but additional laundry operations and personnel may be needed due to increased loads and cycles. Systems should also be in place to routinely inspect and maintain the gowns. The CDC’s guidance for Considerations for Selecting Protective Clothing used in Healthcare for Protections against Microorganisms in Blood and Body Fluids outlines the evidence and standards, test methods, and specifications for fluid-resistant and impervious gowns and can serve as guide to selection of reusable gown material.

    Resources:

    Updated March 23, 2020

Transmission-Based Precautions

  • Is the COVID-19 virus in surgical smoke?

    Answer:  AORN recommends the evacuation of all surgical smoke as it contains hazardous chemicals, ultra-fine particles, viruses, bacteria, and cancer cells. During higher-risk, aerosol generating procedures or procedures with known or suspected aerosol transmissible diseases, such as tuberculosis, the perioperative team should wear a fit-tested surgical N95 filtering face piece respirator in addition to using a smoke evacuator. Wearing a fit-tested surgical N95 filtering face piece respirator is secondary protection against residual surgical smoke.

    The earliest detected case of COVID-19 was in China on November 17, 2019. As such, there is currently no research on transmission of the virus through surgical smoke. However, there is no indication or proof that COVID-19 is not transmissible through surgical smoke.

    Research studies have demonstrated the presence of viruses (e.g., human papilloma virus) in surgical smoke with documented transmission to health care providers. According to limited data from the CDC, SARS-CoV-2 RNA has been detected in blood specimens, and it is unknown whether the virus is viable or infectious in extrapulmonary (outside the lungs) specimens. In similar coronaviruses, viable and infectious SARS-CoV was isolated from blood specimens, although infectious MERS-CoV was only isolated from the respiratory tract.

    Consult with your infection preventionist on measures (eg, smoke evacuation, fit-tested surgical N95) to take when performing surgery on a patient with known or suspected COVID-19. Consistent smoke evacuation is recommended for all surgical patients, particularly if fit-tested surgical N95 protective masks are unavailable.

    Resources

Environmental Cleaning

  • How should the operating rooms be decontaminated following surgery on a COVID-19 patient?

    Answer: The current CDC guidance states that routine cleaning and disinfection procedures using an EPA-registered, hospital-grade disinfectant from List N, are appropriate for SARS-CoV-2 in healthcare settings. Upon patient leaving the room, entry should be delayed until sufficient time has elapsed for enough air changes to remove aerosolized infectious particles. The AORN Guideline for Environmental Cleaning outlines recommended cleaning procedures that should be monitored for quality and consistency.  Linen and medical waste should follow the routine established practices as outlined by local, state and federal regulations.

     

    Resources:

    Updated March 23, 2020

  • What PPE should individuals don when cleaning the OR after surgery on a COVID-19 patient?

    Answer: Once sufficient time has elapsed to remove infectious particles, individuals performing cleaning should perform hand hygiene and don a gown, gloves. A facemask and eye protection should also be worn if splash or sprays are anticipated during cleaning or if they are required by disinfectant instructions for use. Shoe covers are not necessary as part of PPE.

     

    Resources:

     

    Updated March 23, 2020

  • Our hospital grade EPA-registered disinfectant supply is running low and we will not receive another shipment for two weeks. Is there an alternative EPA-registered disinfectant or can we make our own?

    Answer: The EPA website has a list of disinfectants that have qualified under EPA’s emerging pathogen viral pathogens program for use against SARS-CoV-2. Reviewing this list for products that could be obtained from other vendors may be an option. Contact your local health authority for guidance or access to stockpile resources.

    When EPA-registered product is not available, the CDC allows the use of generic sodium hypochlorite solutions, using a 1:100 dilution (500-615ppm). However, it is important to note that this solution is not a cleaning agent and can be both caustic and corrosive, especially on stainless steel surfaces. Therefore, cleaning with detergent and water must occur before using the solution. Use of any alternative solutions should be discontinued once List N EPA-registered disinfectants are obtained.

     

    Resources:

     

    Updated March 23, 2020

  • How long does SARS-CoV-2 survive on surfaces?

    Answer: SARS-CoV-2, the virus that causes COVID-19 can survive up to three hours in aerosols when air is not circulated or moving, and up two to three days on plastic and stainless steel. Therefore, sufficient air exchanges need to occur before cleaning begins and why thorough cleaning and disinfection of high touch stainless steel surfaces is so important.

    In their recommendation on care of COVID-19 patient, the American Society of Anesthesiologists (ASA) suggests that it may be beneficial to utilize disposable covers (eg, plastic sheets for surfaces) to reduce droplet and contact contamination of equipment and surfaces. Wearing proper PPE, the sheets could be discarded prior to cleaning and disinfection of surfaces.

     

    Resources:

    Updated March 27, 2020

     

  • What is the frequency of high-touch surface disinfection that AORN is recommending for hospitals where a COVID-19 infection has been confirmed or is suspected?

    Answer: The current CDC guidance states that routine cleaning and disinfection procedures using an EPA-registered, hospital-grade disinfectant from List N, are appropriate for SARS-CoV-2 in healthcare settings.  However, it is important that all items touched during patient care, as well as high touch surfaces within the operating room are cleaned and disinfected after the surgical procedure due to potential spray of blood and body fluids. The AORN Guideline for Environmental Cleaning provides examples of high-touch objects, such as, mobile devices, anesthesia equipment, door handles and computer accessories, as well as areas to concentrate on when performing cleaning like control panels, knobs and switches.  Facilities may already have a policy and procedure for room cleaning following transmission-based precaution procedures which can be used, or an interdisciplinary team can be established to identify which surfaces to include and the frequency they will be cleaned.  The AORN Guideline for Environmental Cleaning is available on the AORN COVID support page where you can find more detail on this topic.

    Resources:

    Updated March 27, 2020

Leadership

  • Perioperative RNs are being re-deployed in our hospital. Should we keep a few “clean” teams to decrease the risk of carrying COVID-19 to surgical patients?

    Answer: A facility should perform a risk assessment that takes into account perioperative personnel available, appropriate PPE is provided and worn, or if there are perioperative personnel who are in the high-risk category due to morbidities, or age. According to the CDC, wearing appropriate PPE, that is gown, gloves, eye protection and a respirator, should protect HCP having prolonged close contact with patients infected with COVID-19. However, to account for any inconsistencies, or human error, HCP should still perform self-monitoring and report any signs of illness and isolate themselves if ill.

    Resources:

     

    Updated March 27, 2020

  • Is there any guidance for cancelling elective and nonurgent surgeries?

    Answer: The American College of Surgeons (ASC) recommends the following:

    Hospitals and surgery centers should consider the patient’s needs, and the ability of the facility to meet those needs at the real time the decision is being made. For example, during a surge in a facility of COVID-19 patients, ORs may become ICUs, resources may be limited.

    The risk to the patient should include an aggregate assessment of the real risk of proceeding and the real risk of delay, including the possibility that a delay of 6-8 weeks could be required to a time COVID-19 is less prevalent.

    Resources:

    Updated March 27, 2020

  • What are hospitals around the country defining as “urgent/emergency” surgery?

    Answer: According to the American Medical Association, emergency surgery is performed to relieve or eliminate emergency medical conditions, such as those causing serious jeopardy to the health of a patient, impairment of bodily functions or dysfunction of bodily organs or parts. A 2017 study published in JAMA on the risks associated with urgent surgery versus elective and emergency surgery, the authors took a simple but reasonable approach and defined urgent procedures as those "not elective but not emergent."

    Each hospital may already have established definitions that are part of their protocol for scheduling procedures. However, the urgency of a surgery must be evaluated on an individual basis by the surgeon, with consideration of the patient’s medical risks if surgery were to be delayed, geographical location (eg, area of high community spread) and facility resources (ie, beds, staff, equipment, supplies).

    On March 24th ACS, ASA and AORN released a joint statement calling for the creation of a surgical review committee, composed of representatives from surgery, anesthesia, and nursing leadership that would meet on a daily basis to conduct surgical triage decisions regarding scheduled surgery, that was preferably no later than the day before scheduled surgery. To assist in the committee’s decisions, the American College of Surgeons, in conjunction with associated surgical specialty societies, has developed triage criteria according to specialty which can be found on the ACS website.

    Resources:

     

    Updated March 27, 2020

ASCs

  • Should ambulatory surgery centers be restricting type of cases being done?

    Answer. Ambulatory Surgery Center Association (ASCA) concurs with ACS that “the risk to the patient should include an aggregate assessment of the real risk of proceeding and the real risk of delay, including the expectation that a delay of 6-8 weeks or more may be required to emerge from an environment in which COVID-19 is less prevalent”

    Examples of procedures that might still need to proceed include:

    • acute infection
    • acute trauma that would significantly worsen without surgery
    • potential malignancy
    • uncontrollable pain that would otherwise require hospital admission
    • a condition where prognosis would significantly worsen with a delay in treatment

    According to ASCA, ASCs need to be prepared for the possibility that the pandemic may proceed to a point that strains the system such that hospitals will need to shift necessary surgeries to ASCs and/or hospitals may need the ASCs resources.

    Resources:

    Updated March 27, 2020

  • What are the recommendations for continued cleaning of ASCs while closed due to Coronavirus?

    Answer: ORs can be cleaned before shutdown. Likely it is unknown when a center will reopen, and facility staff may not be allowed to return until restrictions due to COVID-19 have been lifted. When it does reopen ORs should be terminally cleaned and supplies and equipment should be evaluated for signs of contamination. 

    Resources:

    • AORN Guideline for Environmental Cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

     

    Updated March 27, 2020

  • What should ASCs consider when closing due to COVID-19?

    Answer: There are several things to consider before shutting down an ASC. If it will be shut down for an indefinite period, take inventory of equipment and supplies and include expiration dates. This will assist you in determining supplies that could be used by a hospital in the event of shortages and will assist you when occupancy is restored for supplies that may need to be restocked or retrieved. ASCA has developed a checklist for this. Some of you may be part of your community emergency preparedness program and may be asked to provide resources and this could also include using your facility if and when a surge of COVID-19 patients occur.

    Before utilities are shutdown, conduct a risk assessment and consider the following:

    • Determine if equipment or supplies will be affected by temperature and humidity per manufacturer’s IFU. If a set back method is used, perform the same evaluation.
    • If utilities are shut down, determine if freezers that contain tissue and refrigerators that contain medications will be transferred to another facility.
    • Autoclaves will have to be brought back- up before procedures can be begin again and qualification testing may need to be conducted per manufacturer’s IFU and may involve industry service technicians.
    • Before HVAC is restored, the facility will need to be cleaned, if dust is found on surfaces it can be dispersed into the air after HVAC is restored. After a complete air exchange has occurred, a terminal cleaning will need to be done and supplies evaluated for contamination.
    • If utilities are not shut down, HVAC is monitored for variances in temperature and humidity.
    • AORN guidelines on Design and Maintenance of the surgical suite address utility and HVAC disruptions.
    • Environmental Cleaning Guideline addresses cleaning after utility disruptions.
    • Sterilization guideline addresses the processes for performance testing following shutdown of autoclaves and other sterilization equipment. Manufacturer’s IFU should be followed and facility management personnel consulted, when determining how to shut down and bring back up utilities and HVAC after a prolonged closure.

    Resources:

    • AORN Guideline for Sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • AORN Guideline for Environmental Cleaning. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • AORN Guideline for Design and Maintenance of the Surgical Suite. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html#infection_control

Converting OR/Ventilators

  • Should ambulatory surgery centers be restricting type of cases being done?

    Answer: This is a decision that should be made by an interdisciplinary team that includes at the least an infection preventionist, anesthesia provider, and a facility management representative that is familiar with the air handling in the perioperative department. Factors to consider are

    • Whether or not the positive pressure operating rooms can be converted to a negative pressure room
    • Whether adjacent ORs share the same air handling system
    • How close to the converted ICU room is to operating rooms still being used for non-COVID surgery

    Resources:

    • Ventilator Supply Mitigation Strategies: Letter to Health Care Providers

    https://www.fda.gov/medical-devices/letters-health-care-providers/ventilator-supply-mitigation-strategies-letter-health-care-providers

     

     

    Updated March 27, 2020

  • Can you provide guidance on converting anesthesia machines to use as ventilators in the event of a shortage?

    Answer:  The US Food & Drug Administration has provided guidance to health care providers on ventilator supply mitigation strategies.  The FDA Letter to Health Care Providers provides recommendations for health care providers and facilities, based on the recently issued guidance, regarding use of devices with patients who develop respiratory compromise from COVID-19 or other respiratory disorders.  The recommendations are intended to compliment the CDC COVID-19 recommendations.  Health care organizations should have, as part of their pandemic planning, a procedure for use of anesthesia machines when the supply of ventilators does not meet the demand.  This procedure should be defined by an interdisciplinary team including anesthesia professional(s), perioperative RN leaders, health care administrator(s), infection preventionist(s), and other stakeholders defined by the organization.  This work should be informed by clear information from the anesthesia machine manufacturer about how functionality may be safely optimized for use as a critical care ventilator. The team should also establish a plan for and assess the availability of an anesthesia professional to put these machines into service and to manage them while in use. The Anesthesia Patient Safety Foundation provides FAQs on anesthesia machine use, protection, and decontamination during the COVID-19 pandemic.

    Resources:

     

    Updated March 27, 2020

  • Should our hospital convert our PACUs into makeshift ICUs?

    Answer: ASA provides guidance on conversion of PACUs into ICUs:

    If the pandemic overcomes the capacity of a hospital ICUs, the PACUs can serve as overflow. Given the fact that PACUs are open units, the institution must decide if all the patients housed in the PACU will have COVID19 or non-COVID19 patients (but not both). Institutions will also need to draft a plan on who will provide medical care to these patients (e.g., Critical Care Anesthesiologists, Internists, Surgeons, ED Physicians, or combination).

    Resources:

     

    Updated March 27, 2020

Sterilization

  • Are there any special decontaminating and cleaning procedures for reusable laryngoscopes used for COVID-19 positive patients?

    Answer: Care of laryngoscopes should be according to manufacturer’s instructions for use and the AORN Guidelines for Cleaning and Care of Surgical Instruments.

    • Laryngoscope blades and their handles should be cleaned, decontaminated, dried, and stored in a manner that reduces the risk of exposing patients and personnel to potentially pathogenic microorganisms.[Recommendation]
    • After each use, clean laryngoscope blades and high-level disinfect or sterilize them according to the manufacturer’s written IFU. [Recommendation]
    • Clean and low-level disinfect laryngoscope handles after each use. Laryngoscope handles may be high-level disinfected or sterilized according to the manufacturer’s written IFU. [Recommendation]
    • Package and store laryngoscope blades and handles that have been cleaned and disinfected in a manner that prevents contamination. [Recommendation]
    • Store laryngoscope blades in individual packages. [Recommendation]

    COVID-19 is an enveloped virus and is susceptible to EPA-registered disinfectants that are used in the health care setting.  There are no additional recommendations by CDC for disinfection and sterilization of these items used for COVID-19 patients.

    Resources:

    • AORN Guideline for Cleaning and Care of Surgical Instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

     

    Updated March 23, 2020

  • Are there special considerations for cleaning, decontaminating, and sterilization of surgical instruments that have been used for a patient with suspected or confirmed COVID-19?

    Answer:  Instruments and devices that have been used in procedures for patients with known or suspected COVID-19 should be handled the same as other instruments.  Reprocessing should follow manufacturer’s instructions for use (IFU) and be consistent with recommendations in the AORN Guidelines for Cleaning and Care of Surgical Instruments, Sterilization Packaging Systems, and Sterilization. 

     

    Resources:

    • AORN Guideline for Cleaning and Care of Surgical Instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • AORN Guideline for Sterilization Packaging Systems. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • AORN Guideline for Sterilization. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

     

    Updated March 23, 2020