Surgical Services COVID-19 FAQs

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1. My patient is known COVID-19 positive or person under investigation (PUI). My patient is already intubated.
   • What are the required precautions for transporting the patient from the ICU to the OR and back?
   • Who will be present during intubation?
   • Who will be in the room during extubation?
2. My patient is known COVID-19 positive or PUI. My patient is NOT intubated.
   • What is the flow of the patient from the floor/ICU to the OR? How do I make sure that there will be a negative pressure room available for intubation/extubation in the PACU, prior to my arrival?
   • Who will be present during intubation?
   • Who will be present during extubation?
3. My patient does not have symptoms of COVID-19 and is having urgent/emergent surgery.
   • My patient is already intubated. What is the appropriate precautions for transporting the patient from the ICU to the OR and back?
   • My patient is not intubated. What is the flow of the patient from the floor/ICU to the OR?
4. My patient does not have symptoms of COVID-19. The patient will be intubated for the surgery.
   • Who will intubate the patient in the OR?
   • What is the PPE that is to be worn by the person doing the intubation?
   • What is the role of the circulating nurse during the intubation?
   • What is the PPE that is to be worn by the circulating nurse during intubation and extubation?
5. My patient is planned for a MAC and regional/local anesthesia in the OR. My patient is known COVID-19 positive or PUI.
   • How do OR team members protect themselves from exposure?
6. My patient is planned for a MAC and regional/local anesthesia in the OR. My patient does not have symptoms of COVID-19.
   • What PPE am I supposed to wear after intubation and before extubation?
7. My patient is having laparoscopic/robotic surgery. My patient is known COVID-19 positive or PUI.
   • What PPE am I supposed to wear as the scrub tech, circulating nurse, anesthesiology team member, surgeon during the surgery?
8. My patient is having laparoscopic/robotic surgery. My patient does not have symptoms of COVID-19.
   • What PPE am I supposed to wear as the scrub tech, circulating nurse, anesthesiology team member, surgeon during the surgery?
9. My patient is known COVID-19 positive or PUI.
   • What is the mechanism to be sure that EVS knows this and takes appropriate measures to clean?
10. I am a nurse or PACU Resident in the PACU. My patient does not have symptoms of COVID-19.
    • My patient is coughing in the PACU. What PPE should I be wearing? Should I place a standard surgical mask on the patient?
    • My patient is resting comfortably.  What PPE should I be wearing? Should I place a standard surgical mask on the patient?
11. I am a nurse, tech, surgeon, resident, or anesthesia team member in Pre-Op. My patient does not have symptoms of COVID-19.
    • What PPE am I supposed to wear during my interaction with this patient?
12. I am scheduled to care for a patient who is known COVID-19 positive or PUI and surgery is expected to be done in the Eye Hospital.
    • What do I do?
13. I am in a demographic that puts me at high risk of complications if I contract COVID-19.
    • Can I opt out of the care of patients who are known to be COVID-19 positive or under investigation as a nurse, tech, anesthesiology team member?
14. I have small children at home. I do not want to bring COVID-19 home to them.
    • Can I opt out of caring for patients who are known to be COVID-19 positive or who are under investigation?

1. My patient is known COVID-19 positive or person under investigation (PUI). My patient is already intubated.

What are the required precautions for transporting the patient from the ICU to the OR and back?

• Transporting Staff PPE Attire: Whole team transporting patient is to wear the following PPE:
  appropriately fitting N95 mask or PAPR, isolation gown, gloves, and eyewear from the ICU into the OR.

Who will be present during intubation?

• If intubation occurs in the ICU: Airway Response Team (Assigned RRT RN, Respiratory Tech, and most senior anesthesiologist caring for this patient.

Who will be in the room during extubation?

• If the patient goes directly to the ICU, the ICU Respiratory Therapist will be in attendance after the patient is weaned. If the patient emerges in the PACU, the anesthesiologist of the team and the PACU RN. If the patient emerges in the OR, the anesthesiologist will extubate the patient. The rest of the team will be in the ante room.

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2. My patient is known COVID-19 positive or PUI. My patient is not intubated.

What is the flow of the patient from the floor/ICU to the OR? How do I make sure that there will be a negative pressure room available for intubation/extubation in the PACU, prior to my arrival?

• Following Dr. Truwit’s directive on 3/20/2020, negative pressure rooms are not required for intubating known COVID-19 positive or person under investigation (PUI) patients, therefore we will transport the patient directly from the floor/unit directly to the OR (IPP 24 or 25) and follow the practice below.

Who will be present during intubation?

• If intubation occurs in the Operating Room: Attending Anesthesiologist, CRNA/CAA or Anesthesia Resident will be present.
• Prior to patient entry, the Scrub Tech and OR RN should set up the room. The surgical table/instruments should be prepared, then covered with a drape, anticipating aerosolization of virus during airway management.
• The Scrub Tech should retreat to hallway, prior to entry of patient into the OR.
• The circulating nurse will interview the patient in the OR upon their arrival, and may remain in the OR if there is a clinical need. If there is no clinical need for the circulating nurse to remain in the OR, the circulating nurse should retreat to the hallway, remaining immediately available in the event they are needed.
• If requested by the Anesthesia Team, the Anesthesia Tech should remain outside of the room on standby during airway management, remaining available in the event they are needed to assist with intubation.
• If the patient bed or cart cannot remain in the OR once the patient is transferred to the OR Surgical Bed, the circulating nurse should notify EVS to clean it prior to transfer to the hallway.
• There will be a delay following airway management for the room to undergo sufficient air exchanges that aerosolized material is no longer present (30 minutes), during which time the anesthesiology team members (+/- circulating nurse should the patient require) should be the only people in the room.

Who will be present during extubation?

• If extubation occurs in the Operating Room: Attending Anesthesiologist, CRNA/CAA or Anesthesia Resident will be present for extubation.
• The anesthesiologist will extubate the patient alone in the OR if this is felt to be safe. If determined that the circulating nurse should be present for patient safety, he/she can remain in the OR. The patient will then be recovered for at least 30 minutes while the air exchange occurs. If the patient is to be transferred to the ICU intubated, the patient can be transferred immediately.
• The anesthesiology team will call report to floor nurse prior to transfer to the next unit.
• Stretcher guard rails should be wiped down before transferring patient.
• Patient will wear a surgical face mask for transfer if not intubated
• If requested by the Anesthesia Team, the Anesthesia Tech should remain outside of the room on standby during airway management, remaining available in the event they are needed to assist with extubation.
• Prior to extubation, the scrub tech should remove as much of their instrumentation as possible and follow the standard process for transport to SPD decontamination.

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3. My patient does not have symptoms of COVID-19 and is having urgent/emergent surgery.

My patient is already intubated. What is the appropriate precautions for transporting the patient from the ICU to the OR and back?

• Follow current standard transport protocol

My patient is not intubated. What is the flow of the patient from the floor/ICU to the OR?

• Follow current standard transport protocol. Staff not needed for the intubation/extubation should step outside of the operating room and remain immediately available.

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4. My patient does not have symptoms of COVID-19. The patient will be intubated for the surgery.

Who will intubate the patient in the OR?

• Attending Anesthesiologist and CRNA/CAA/Anesthesia Resident and Anesthesia Tech, if needed

What is the PPE that is to be worn by the person doing the intubation?

• Anesthesia will wear an appropriately fitting N95 masks (covered with surgical mask)/PAPR and eyewear protection, for all intubations, regardless of etiology.

What is the role of the circulating nurse during the intubation?

• If intubation occurs in the OR, the circulating nurse should remain immediately outside of the room, available to support the anesthesia team if needed.

What is the PPE that is to be worn by the circulating nurse during intubation and extubation?

• If they are not assisting with the intubation, they should wear standard surgical PPE.
• If they are asked to assist with the intubation, they should retrieve an N95 mask to assist prior to entering the OR.

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5. My patient is planned for a MAC and regional/local anesthesia in the OR. My patient is known COVID-19 positive or person under investigation (PUI).

How do OR team members protect themselves from exposure?

• The patient should proceed to the OR on oxygen with a surgical mask over their O2. If their requirements are at 6 liters, they need to have anesthesia induced as per the previous policy.

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6. My patient is planned for a MAC and regional/local anesthesia in the OR. My patient does not have symptoms of COVID-19.

What PPE am I supposed to wear after intubation and before extubation?

• The patient should have O2 per need and the anesthesia team should wear appropriate PPE (N 95). The OR team if 6 feet away should wear surgical masks.

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7. My patient is having laparoscopic/robotic surgery. My patient is known COVID-19 positive or PUI.

What PPE am I supposed to wear as the scrub tech, circulating nurse, anesthesiology team member, surgeon during the surgery?

• Follow current APG workflow for now.
• UPDATED ANSWER TABLED PER TEAM: NEED FURTHER INFORMATION AND VERBIAGE FROM TOM DURIS RE: INSUFLATION/FILTER SIZE ISSUE AND CHANGE IN PRACTICE.

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8. My patient is having laparoscopic/robotic surgery.  My patient does not have symptoms of COVID-19. 

What PPE am I supposed to wear as the scrub tech, circulating nurse, anesthesiology team member, surgeon during the surgery?

• Follow current APG workflow for now.
• UPDATED ANSWER TABLED PER TEAM: NEED FURTHER INFORMATION AND VERBIAGE FROM TOM DURIS RE: INSUFLATION/FILTER SIZE ISSUE AND CHANGE IN PRACTICE. ONCE WE HAVE UPDATED INFO AND IF THE FILTER IS SUFFICIENT, WE WOULD NOT TREAT THESE PATIENTS AS PUI

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9. My patient is known COVID-19 positive or PUI. 

What is the mechanism to be sure that EVS knows this and takes appropriate measures to clean?

• Following the “Procedure/Operating Room Rule-Out or Confirmed COVID-19 Isolation Workflow” document, the OR Front Desk is to page the EVS Lead prior to wheels-in
• Isolation signage to be hung on operating room doors
• OR Front Desk to page the EVS Lead one hour prior to wheels-out so that OR EVS can acquire and setup UV Light system
• OR Staff in room to utilize the appropriate Isolation Terminal Clean Rauland Button
• OR EVS to let operating room sit one for hour after wheels-out, then follow Standard Terminal Clean and UV Light process

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10. I am a nurse or PACU Resident in the PACU.  My patient does not have symptoms of COVID-19.

My patient is coughing in the PACU. What PPE should I be wearing? Should I place a standard surgical mask on the patient?

• Staff PPE: It is appropriate for the staff providing direct patient care to wear a standard surgical mask and eyewear protection, following the PPE Conservation Tool-Kit protocol
• Patient PPE: It is appropriate to place a surgical mask on the patient

My patient is resting comfortably. What PPE should I be wearing? Should I place a standard surgical mask on the patient?

• • It is appropriate for staff to follow the PPE Conservation Tool-Kit protocol when not at the patients beside.

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11. I am a nurse, tech, surgeon, resident, or anesthesia team member in Pre-Op.  My patient does not have symptoms of COVID-19. 

What PPE am I supposed to wear during my interaction with this patient?

• It is appropriate for the staff providing direct patient care to wear a standard surgical mask and eyewear protection, following the Mask Conservation Guidelines. Eyewear should be reused and disposed of when soiled or cleaned daily following this protocol: Use sani-wipes to clean eye protection patients.  If eyewear becomes contaminated/soiled, please secure new eyewear.

12. I am scheduled to care for a patient who is known COVID-19 positive or PUI and surgery is expected to be done in the Eye Hospital. 

What do I do?

• Known COVID-19 positive or persons under investigation should not be done in the Eye Institute. They should be sent to the IPP.

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13. I am in a demographic that puts me at high risk of complications if I contract COVID-19. 

Can I opt out of the care of patients who are known to be COVID-19 positive or under investigation as a nurse, tech, anesthesiology team member?

• If you feel you cannot care for a known COVID-19 positive or person under investigation (PUI) patient because of your own health, we ask that you notify your leader and reach out to the FMLA/Leave of Absence office to get formal restriction from your primary care physician. For Froedtert staff, we may deploy you to do non-patient facing tasks.

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14. I have small children at home.  I do not want to bring COVID-19 home to them. 

Can I opt out of caring for patients who are known to be COVID-19 positive or who are under investigation?

• If you feel you cannot care for a known COVID-19 positive or person under investigation (PUI) patient because of extenuating circumstances at home, reach out to your leader.

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One response to “Surgical Services COVID-19 FAQs”

1. COVID-19 Anesthesia Teams Simulation-Based Training: Objectives & Simulation Instructor Notes – MCW Anesthesiology Intranet says:

   March 27, 2020 at 6:44 pm

   […] See the document created by the Department. It covers how patients will transfer to the OR, where they will be intubated, specific techniques etc. […]

   Reply