University of Iowa and Dartmouth College researchers have developed a rapid-adoption plan that hospitals nationwide can use to prevent spread of the novel coronavirus (COVID-19) in their operating rooms.

The paper outlining the plan was published March 27, along with a checklist for hospitals to follow.

Also on March 27, the Journal of the American Medical Association (JAMA) published results of a clinical trial conducted by Loftus, Dexter, and others, which provides some of the scientific evidence supporting the coronavirus recommendations.

Randy Loftus, MD, associate professor of anesthesia at Iowa, who has studied perioperative infection control for 14 years, worked with Franklin Dexter, MD, PhD, FASA, professor of anesthesia at Iowa; Michelle Parra, MD, associate professor of anesthesia at Iowa; and Jeremiah Brown, PhD, MS, professor of epidemiology at Dartmouth, to create the evidence-based action plan that helps protect both patients and healthcare providers.

Randy Loftus, MD     Franklin Dexter, PhD, MD, FASA    Michelle Parra, MD

“The current pandemic has made preoperative infection prevention even more critical,” Loftus says. “Historically, anesthesiology has been at the forefront of patient safety advocacy. Now, we also need to be at the forefront of provider safety advocacy.”

Even as hospitals scale back their surgeries and procedures to only the most essential or urgent cases, the patients they do see in the OR could be at high risk of contributing to community spread of the novel coronavirus.

“This could lead to environmental contamination, especially since we now know that this virus can survive on surfaces like stainless steel and plastic — which are all over every operating room — for up to three days,” Loftus says.

Loftus and his colleagues recommend these 8 steps to reduce the risk:
 

1. Put alcohol-based hand rubs where the anesthesia provider can reach them easily. The team recommends placing them on the IV pole to the left of the anesthesia provider. They also recommend double gloves during induction.
2. Create a designated space for used instruments. The team recommends a wire basket lined with a zip-close bag. Providers place used instruments in the bag and close it. The team also recommends that providers
3. Decolonize patients. The team recommends using pre-procedural chlorhexidine wipes, 2 doses of nasal povidone iodine within one hour of incision, and chlorhexidine mouth rinse
4. Create a closed lumen IV system and use hub disinfection.
5. Track ESKAPE transmission and share the data.
6. Implement relatively long (e.g., 12-hour) shifts for OR teams and have those teams handle all OR cases for the day. Dexter, an authority on OR management and efficiency, says this strategy reduces the use of surgical personal protective equipment. It also lowers the number of people who may be exposed to an infected patient.
7. Do terminal cleaning in each OR after each case. Dexter notes that having a few teams work in many ORs allows for terminal cleaning, including UV-C, at the end of each case.
8. Have patients recover in the OR rather than moving them to a pooled recovery unit. Congregating patients in a large post-anesthesia care unit increases the risk of viral spread, and the shortage of masks makes it impractical to provide one to each recovering patient. Instead, Dexter recommends following the Japanese model for post-anesthesia recovery, which takes place in the operating room with the anesthesia provider in attendance.

“We studied recovery times in a hospital in Japan and compared them with recovery times at University of Iowa Hospitals & Clinics,” Dexter says. “The longest recovery time in Japan was shorter than the shortest recovery time here."

Loftus says the team felt it was critical to get this blueprint out as soon as possible because of the current pandemic.

“Hospitals can and should take these steps now because of the COVID-19 crisis, but these patients represent only the tip of the iceberg,” Loftus says. “Even after this crisis ends, we need to be ready for ongoing infections and resurgence as hospitals return to normal OR operations.”