Principles For Resuming Elective Surgery
aci.health.nsw.gov.auaci.health.nsw.gov.au th.nsw.gov.auPrinciples for resumingelective surgeryAdvice for NSW health servicesThis document outlines the key principles for resuming non-urgent electivesurgical procedures to safely increase access to services, while maintainingservice capability to respond should a surge in pandemic activity occur.In response to COVID-19 preparedness, the NSWMinistry of Health directed all local health districts(LHDs) and private operators on 26 March 2020 tosuspend all non-urgent elective surgery, operating onlyon Category 1 and stratified Category 2 cases.This will allow flexibility for the health system torespond dynamically should a second wave ofCOVID-19 infections occur, while balancing the riskto patients of delaying planned surgery against therisks of undergoing non-urgent elective surgery.This suspension was supported by professionalsocieties and colleges, as well as by clinicians withinNSW LHDs.This document provides advice on surgical servicedelivery during the COVID-19 pandemic. For advice onLHD response to changing risk profiles and appropriateinfection prevention and control measures, please referto the CEC COVID-19 Infection Prevention and ControlResponse and Escalation Framework.Since this time, the slowing of the spread of COVID-19has shifted the focus of health services and clinicalteams to preparing to resume some elective surgery.There are a number of issues that must be addressed atthe state, district and local level when recommencingelective surgery. Readiness and ability to resumeelective surgery will vary across states.It is imperative that resuming elective surgery in anyhealth facility does not impede that facility’s capacity tomanage current COVID-19 pandemic activity or itscapacity to respond to a potential surge in COVID-19levels in the future.Evaluating and addressing each of the principlesbelow will support health facilities provide safe, highquality patient care and ensure that surgery resumesin a gradual manner that can be sustained in thelonger term.Given the rapidly changing conditions of both theCOVID-19 pandemic and the NSW health system,this advice will be regularly updated to reflectcontemporary evidence and current advice fromrelevant health authorities.Key principles1. Awareness of local COVID-19 prevalence,surgical demand and hospital capacity2. Ensuring facility readiness to resumeelective surgery3. Sufficiency of resources and consumables4. Safety and continuity of the workforce5. Prioritisation of elective surgery cases6. Patient preparedness for elective surgeryMore detail is outlined below for each key principle.ACI-0426 [06/20]
Principles for resuming elective surgery: Advice for NSW health services1. Awareness of local COVID-19prevalence, surgical demand andhospital capacityEnsure sufficient staff and equipment are available toprovide safe care to surgical patients across all phasesof their hospital journey.The NSW Ministry of Health is aiming to graduallyresume theatre and endoscopy lists, previously closedin response to the pandemic, in line with localcircumstances and capacity.Ensure sufficient capacity in medical imaging, alliedhealth and hospital corporate services to supportincreased surgical service requirements, ensuring staffsafety or the hospital’s ability to address a potentialsurge in local COVID-19 cases are not compromised.Clinical review of urgency and risk of continued delayfor all waitlisted patients must inform the decision toproceed to surgery.To promote equity of access, theatre lists may beallocated to departments rather than individual surgeons.Regular review of resources, waiting list urgency andcomposition should inform allocation of theatre time.Selection of patients suitable to undergo electivesurgery during the resumption period should be basedon clinical need and guided by the following, asidentified by the Commonwealth National Cabinet.Strategies to address increased volumes of patientswaiting for elective surgery should be developed.These may include: Low risk, high value procedures Patients at low risk of post-operative deterioration extending hours of theatre operation,where safe and feasible to do so Children awaiting procedures for which they haveexceeded the clinically recommended wait time pooling lists for increased efficiency coordinating waitlist management at theLHD level Assisted reproductive procedures Endoscopic procedures concentrating high complexity work in tertiaryhospitals Procedures associated with screening programs designation of COVID-19 and non-COVID-19theatres to minimise transmission risk and reduceturnover time between patients. Critical dental procedures.2. Ensuring facility readiness to resumeelective surgeryWhere operating theatres have been converted tonegative pressure environments, these should remainpreserved for confirmed COVID-19 surgical cases oraerosol generating non-operative procedures such asendoscopy and bronchoscopy.Consider which sites across a hospital or LHD aresuitable and ready to resume elective surgery.Review critical care requirements for elective surgery,including intensive care and close observation unitcapacity.In recent months new ways of working have alsoevolved, particularly where public and private facilitiesenter into agreements to provide care collaboratively.While these arrangements increase health systemcapacity, it is important to ensure the same standardsand quality of care is delivered, regardless of thefacility in which care is provided.Be aware of changes to patient flow in facilities,particularly where the creation of COVID-19 positivezones in wards, theatres and intensive care units, maylimit unit availability and capacity.Consider which patients and procedures are suitable tobe undertaken as ambulatory or day only casesto minimise the impact of elective surgery on inpatientbed capacity across the hospital.NSW Agency for Clinical Innovation2 Clinical Excellence Commission
Principles for resuming elective surgery: Advice for NSW health services3. Sufficiency of resources andconsumablesVulnerable staff undertaking essential work, who aremost at risk of acquiring COVID-19, should undertakerisk assessments and implement mitigation strategies.Where necessary, these staff may be redeployed toalternative duties.Sufficient stock of surgical supplies, implants andequipment must be secured prior to resuming electivesurgery, including confirmation of ongoing supplychains with vendors.Training and educational activities in the operatingtheatre should be thoroughly risk-assessed prior torecommencing.Adequate cleaning and sanitation products, includingenvironmental cleaning products, must be availableand not detract from the ability of the facility toaddress a potential surge in local COVID-19 cases.Hospitals should have social distancing policies inplace for staff, patients and visitors.Personal protective equipment5. Prioritisation of electivesurgery caseFacilities should not resume non-urgent electivesurgery until adequate PPE and other supplies areavailable. Sufficient stored inventory to supportoperating theatre activity should be confirmed by theLHD and continuously monitored against plannedsurgical service activity.In planning to resume elective surgery, amultidisciplinary committee should be establishedwithin the hospital or LHD to develop a prioritisationstrategy based on clinical need and facility capacity.A prioritisation strategy should consider:Reliability of equipment and consumable supply chainsshould also inform plans to resume elective surgery. volumes of postponed patients prioritisation across and within specialtiesMonitor and map the use of PPE and surgicalconsumables to ensure adequate supply, being awarethat usage profiles may change for some proceduresas advice on personal protection evolves. care teams required and available for clinical work a phased approach to re-opening dormantoperating theatresMapping the use of PPE for individual surgicalprocedures may further inform which procedures andcase volumes can safely recommence. plans to increase the time available for surgery coordination of local strategy with those developedin peer and LHD facilities.4. Safety and continuity ofthe workforce6. Patient preparation forelective surgeryElective surgical cases must be consultant surgeon andanaesthetist led.Risk assessmentMultidisciplinary staffing coverage for routine hoursand extended hours, if required, must be confirmedprior to resuming elective surgery.Patients with confirmed COVID-19, or those ina high risk category, or from a high risk setting forCOVID-19, should not undergo elective surgery unlesspostponing the procedure creates a greater risk to life.Staff should be routinely screened for symptoms ofCOVID-19 using the most up-to-date clinical andepidemiological criteria, and if symptomatic, should betested and quarantined.Patients should meet NSW Health release fromisolation criteria prior to surgery.COVID-19 testing must be undertaken in line with NSWHealth testing criteria and prioritisation guidelines,which does not recommend routine COVID-19 testingpre-operatively for elective surgery patients.Contingency plans should be in place for the potentialsituation of newly diagnosed or vulnerable healthcareworkers.NSW Agency for Clinical Innovation3 Clinical Excellence Commission
Principles for resuming elective surgery: Advice for NSW health servicesPatient preparationAssessment of clinical urgency and local capacity tosafely undertake the case should be made by amultidisciplinary team.Wherever possible, usual preoperative preparationactivities should also be maintained, withconsideration for alternative methods for conductingface to face appointments to minimise hospitalattendance.If a decision is made to go ahead with electivesurgery, patients should not be instructed to selfisolate prior to admission.Patients who are significantly immunocompromised arerequired to have two negative swabs prior to being releasedfrom isolation. If these patients subsequently requiresurgery, seek advice regarding readmission to hospital.Previous COVID-19 infection but now recoveredEvidence is currently emerging that patientsundergoing surgery within three months of infectionwith COVID-19 are at increased risk of post-operativecomplications. If a patient has recovered fromCOVID-19, met the criteria for release from isolationand is awaiting elective surgery, they should beinformed of the increased risk of adverse outcomes anddiscuss their individual situation with their surgeon.Previous COVID-19 infection but now recoveredEvidence is currently emerging that patientsundergoing surgery within three months of infectionwith COVID-19 are at increased risk of post-operativecomplications. If a patient has recovered fromCOVID-19, met the criteria for release from isolationand is awaiting elective surgery, they should beinformed of the increased risk of adverse outcomes anddiscuss their individual situation with their surgeon.In these circumstances, surgery may be deferredwhere it is clinically safe to do so. If surgery is toproceed, patients may take additional precautions tolessen the risk of complications before and after theirsurgery, such as:Identification of suspected or probableCOVID-19 cases physical distancing wherever possible voluntary self-isolation before and/or after surgeryAs per the CDNA guidelines for Public Health Units,an individual must meet both clinical andepidemiological risk factors to be considered asuspected or probable case. avoiding unnecessary travel and social activities wearing a mask mask when outside their home andphysical distancing is not possible reporting any respiratory symptoms to theirtreating team and/or doctor.Clinical criteria Does the patient have a fever ( 37.5 C)? Does the patient have an acute respiratory infection(e.g. cough, shortness of breath, sore throat)? Does the patient have a loss of taste or loss of smell?Epidemiological criteriaIn the 14 days prior to illness onset: Has the patient had close contact with a confirmedor probable case? Have they travelled internationally? Were they a passenger or crew member on acruise ship? Are they a healthcare, aged or residential careworker with direct patient contact? Do they live, or have they travelled through ageographically localised area with elevated riskof community transmission?NSW Agency for Clinical Innovation4 Clinical Excellence Commission
Principles for resuming elective surgery: Advice for NSW health servicesAppendix 1: Patient screen questionnaireAFFIX PATIENT STICKERPatients must have positive COVID-19 antibody and a compatibleclinical illness PLUS at least one epidemiological criteria to beconsidered a probable case.Patients must meet at least one criteria from BOTH clinical andepidemiological risk factors to be considered a suspected case.Name MRN DOB Clinical criteriaEpidemiological criteriaFever ( 37.5 C) or history of fever (e.g. night sweats, chills)In the 14 days prior to illness onset:OR acute respiratory infection (e.g. cough, shortness ofbreath, sore throat) close contact with a confirmed or probable case international travelOR loss of smell or loss of taste. passengers or crew who have travelled on a cruise ship healthcare, aged or residential care workers and staffwith direct patient contact people who have lived in or travelled through ageographically localised area with elevated riskof community transmission.Date of surgery / procedure:Surgery / procedure:Has the patient travelled overseas or interstate in the last 2 weeks? YES NOHas the patient had contact with suspected or known COVID-19 positive person in the last 2 weeks? YES NOHas the patient been tested for COVID-19 in the last 2 weeks? YES NOIf the patient has been tested for COVID-19, what was the result?Stop. Escalate as per local process POSITIVE NEGATIVE Proceed to next sectionComments:Does the patient have, or have they had in the past 48 hours, any of the following symptoms? Fever ( 37.5 C)CoughSore / scratchy throat Shortness of breathLoss of smellLoss of taste Runny noseMuscle painJoint pain Nausea / vomitingDiarrhoeaLoss of appetiteComments:If the patient answers ‘yes’ to any of these questions, escalate as per local process to confirm next stepsCompleted by:Signature:Designation:Phone contact:NSW Agency for Clinical Innovation5 Date:Clinical Excellence Commission
Principles for resuming elective surgery: Advice for NSW health servicesDocument informationVersion number2Original publication date9 June 2020Developed bySurgery Community of PracticeConsultationAnaesthetic CoP, NSW Ministry of Health, Clinical Excellence CommissionEndorsed byNigel LyonsReview date30 September 2020Reviewed bySurgery Community of PracticeFor use byDistrict and Network Chief Executives, Directors of Medical Services, Clinical Directors of Surgery, SurgeryOperations Managers, Departments of Anaesthesia and Perioperative Service State of New South Wales (Agency for Clinical Innovation and Clinical Excellence Commission).Creative Commons Attribution-NoDerivatives 4.0 licence. For current information go to: aci.health.nsw.gov.auThe ACI logo is excluded from the Creative Commons licence and may only be used withexpress permission.TRIM: ACI/D20/1086 ACI 0426 [06/20]
2. Ensuring facility readiness to resume elective surgery Consider which sites across a hospital or LHD are suitable and ready to resume elective surgery. Review critical care requirements for elective surgery, including intensiv
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