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Subject : COVID-19.. 03/18/2020 04:36:29 PM

Dr. Basem Abdelmalak, MD, FASA, SAMBA-F

Posts: 28
Location: Cleveland, OH

Hello,
Hope this finds you all and your families safe and well,
No doubt that COVID-19 has changed our lives, and our practices in an unprecedented manner.
As we continue to face COVID -19 related challenges, I thought of starting this forum topic to stimulate discussion around it, for us all to benefit from the collective wisdom of the whole membership. Please feel free to post your challenges and how you are working on them, or ask others to weigh in and share their approaches.

I'll start with the hot topic of the hour, which system are you using to declare the urgency status of different surgeries to decide whether it is OK to delay or to proceed with as we are asked to postpone elective procedures to preserve personnel and resources, and minimize exposure??
Are you using different approaches for your hospital ORs vs. your ASC?

Thank you, and please take great care of yourselves, families, and patients,

Basem Abdelmalak, MD, FASA
SAMBA President

asem Abdelmalak, MD, FASA, SAMBA-F | Professor of Anesthesiology | Director, Anesthesia for Bronchoscopic Surgery | Director, Center for Sedation | Departments of General Anesthesiology and Outcomes Research
Cleveland Clinic | Cleveland, OH e-mail: [email protected]

Past President, Society for Amb

Subject : Re:COVID-19.. 03/18/2020 04:45:00 PM

Lucinda Everett M.D.

Posts: 2
Location:

At Mass General, we have canceled all elective surgery and procedures. Urgent/emergent as well as "elective" but medically necessary such as cancer, are continuing. I am not sure if our ASCs are doing any cases at this point; it changes daily.

Subject : Re:COVID-19.. 03/18/2020 05:13:04 PM

Dr. Gregory Dodson

Posts: 2
Location:

At Cooper Health System in Camden NJ we have one offsite ASC. We are presently open. Our health systems mandate has been to cancel all procedures at our main campus and ASC that are deemed by the surgeon or proceduralist as non-urgent or elective. As we have an affiliation with MD Anderson, we care for a large quantity of cancer patients and thus have a cohort of patients who still require surgical treatment. Our health system has prioritized moving any cases amenable to ASC inclusion criteria to us to conserve resources of staff, PPE, ventilators, etc at our main hospital in Camden. AS Dr. Everett mentioned this is a moving target and changes daily if not hourly as the situation worsens here in NJ.

Subject : Re:COVID-19.. 03/18/2020 05:28:13 PM

Steven Spiro M.D.

Posts: 2
Location:

At Providence St. Joseph Health, we are instructed to cancel all elective cases at the hospitals and surgery centers. No more screening colonoscopies or cataract surgeries. Patients with tumors or bleeding will be done. Other elective cases will be reviewed at each facility by a committee for appropriateness and urgency. Elective cases are being moved to the surgery centers as much as possible. All patients, staff and physicians are screened with a questionnaire (over the phone for patients) and temperature check on arrival. Family members are being asked to wait outside the facility for their loved ones in surgery to keep the waiting room as empty as possible. Elective cases with ASA III and age >65, COPD, uncontrolled asthma, cardiovascular disease or immunosuppression are cancelled. Supplies are being rationed to surgery centers - there are no N95 masks for the ASCs.

Subject : Re:COVID-19.. 03/18/2020 05:30:50 PM

Niraja Rajan MD, SAMBA-F

Posts: 6
Location:

At Penn State Health, we are currently limiting our cases to "necessary" surgery. This applies to our Surgicenter as well. Surgical departments are required to evaluate their schedules and limit cases to those that cannot be delayed for 8 weeks. As everyone else mentioned the situation is evolving and if we move to tier 3 we would cease operations at the surgicenter and only be performing emergency cases at the main hospital.

Subject : Re:COVID-19.. 03/18/2020 06:38:10 PM

Dr. Nilda Salaman M.D.

Posts: 1
Location:

Hello All,
First I must say, we are in this battle to win against a biological opponent. My institution at the George Washington University in the District of Columbia, in collaboration with the Medical Faculty Associates and the School of Medicine is the first in the region to impose restrictions on elective procedures, exposure of staff, residents, medical students, support staff and trainees. The leadership has kept us inform on a daily basis of this evolving situation, what is being done on the front lines locally, and proposed plans for escalation of effort when necessary. The ASC was closed at the beginnning of the week. The staff was reassigned/repurposed to duties at the main institution. We have been given instruction on the PPE doning and doffing. Daily briefings from our department leaders and updates as they change have been provided to us. The department of anesthesiology and critical care medicine has designated teams to care for patients on a rotating basis. We are here and plan to win the battle against a biological opponent. I hope for the safety of us all, our patients, family and friends.

Subject : Re:COVID-19.. 03/18/2020 08:03:43 PM

Dr. Jarrett Heard

Posts: 16
Location:

Hello. Here at The Ohio State University Wexner Medical Center, we too have officially cancelled elective cases. We have broadly defined elective cases as surgical cases that do not fit one of the following fou criteria: Threat to the patient’s life if surgery is not performed; Threat of permanent dysfunction of an extremity or organ system; Risk of metastasis or progression of disease; Risk of rapidly worsening to severe symptoms (time sensitivity). We have closed two of our ASC's and the remaining ASC has gone from running 6 OR's to 3 OR's with the understanding that only time sensitive outpatient cases should proceed. We have reduced overall case volume by abou 40% and we are dedicating 4 OR's to specifically caring for COVID-19 positive patients. All add-on cases will have to be vetted by our Anesthesia Officer of the Day with the attending surgeon. We are also working to develop a team that will assist with codes and airways on the unit for COVID-19 positive patients. We also have restrictions for residents and support staff. Medical students have been pulled off of their rotations.

Subject : Re:COVID-19.. 03/18/2020 08:52:21 PM

Dr. Melinda Seering

Posts: 3
Location:

At the University of Iowa, we are the first in the state to eliminate non-essential cases. I am hopeful, after discussions all week that others will follow suit. As of today we have 38 COVD +cases, but the majority in our area and cared for by our hospital. We went to 50% capacity Monday and tomorrow (Thursday) we will be at 25% of our OR capacity and by Monday all non-essential cases should be eliminated. This means we will do cases that can’t be delayed for 2-6 weeks (cancer, bone marrow, some fractures and vision surgery). Our ASC is attached to our MOR, so we discussed closing, but in an effort to reduce patients and staff in one area, we did keep 2-3 rooms a day (we usually run 12)in the ASC (especially since we are specialized in these cases compared to our MOR). However like others, this is a daily evaluation of PPE supplies, beds etc to see if we need to change the process. We have flexed our remaining staff to hospital wide screening, telemedicine and CSS (for fun our CSS just went off-site this week too). Anesthesia has a daily COVID team and dedicated ORs in the MOR. We have major PPE education and simulations. In addition our ICU has a biologic emergency response team that is active throughout the hospital and works with the COVID periop team.

Last Edited On: 03/18/2020 08:56:48 PM By Dr. Melinda Seering

Subject : Re:COVID-19.. 03/19/2020 09:01:05 AM

Steven Gayer M.D.

Posts: 5
Location:

At the Bascom Palmer Eye Institute we have suspended surgery at our ambulatory facilities in Naples and Palm Beach. Our Miami location has restricted surgery to urgent/emergent ophthalmic cases—all other services’ procedures have been cancelled. The Medical Director of Surgery / Chief of Anesthesia Services (me) and the Chair of the Surgical Services Committee (an ophthalmologist) are the arbiters designating which cases can be posted to the OR. As a consequence of ophthalmology office closures throughout the state, we are seeing an uptick in numbers of urgent/emergent patients in our emergency room which has translated to additional cases in the OR.

Subject : Re:COVID-19.. 03/19/2020 09:14:30 AM

Dr. Janette Covington

Posts: 14
Location:

Steven - Thanks for sharing that. We have done basically the same at our ophthalmologic ASC, and are restricted to potential sight-loss cases only. I understand the PPE recommended for confirmed and suspected cases, but for the presumably non-infected patient, are you treating it as you did pre-covid 19 vis-a-vis PPE? Thanks. I'm just wondering what we need to purchase, as we don't even have protective eye wear (ironically) besides laser goggles. (We did have face masks with shields, but they are dwindling in number).

Subject : Re:COVID-19.. 03/19/2020 09:19:40 AM

Alvaro Andres Macias

Posts: 3
Location:

HI,
Here at Mass Eye and Ear have adopted the same position. Cancelled elective cases. Me the chief of anesthesia and medical director of the operating room in combination with one ENT and one Ophthalmology surgeon are arbitrating emergent and urgent cases.

Subject : Re:COVID-19.. 03/19/2020 11:30:34 AM

Dr. Radha Rajulapati

Posts: 1
Location: Orlando

I am from Orlando working for 2 freelance ASC centers, which are controlled by Surgery partners. I know we are highrisk and vulnerable professionals in view of
intubations and secretions.
We are a group of 8 MD's performing primarily Spine cases (like Back & neck) and Ortho including GI/Pain/plastics.
We are approaching the cases with close monitoring of the current situation and continuously following the CDC guidelines.
We are avoiding cases involving the geriatric population and patients with multiple comorbid conditions such as Severe COPD ,CAD , ESRD, Nursing home/care giver facility patients, and immune compromised patients.

We are screening the patients with the questionnaire about travel and respiratory symptoms /temperatures

Please feel free to give us any ideas or suggestions given that we are not attached to any hospital or major institutions to get any COVID -19 updates, guidelines or precautions to take.
As of now, we currently lack N 95 masks.

Subject : Re:COVID-19.. 03/19/2020 12:11:31 PM

Dr. Paul Cross

Posts: 9
Location:

Dr. Radha Rajulapati, you should reschedule all elective cases immediately. Our system in Upstate Ny cancelled elective cases over the weekend (5 hospitals, 3 asc). We kept one ASC open for mainly ortho trauma that can be done under regional or local or very light MAC. At our hospitals, we are intubating and extubating with the anesthesia providers donning n95, level 3 mask with shield over that (so the n95 can be reused), gown, gloves, shoe covers. All staff and surgeon leaves the room during intubation and extubation and stays out for 4 minutes (one complete turnover from air handlers). On covid positive is Patients under investigation, everyone wears n95s.

Subject : Re:COVID-19.. 03/19/2020 12:43:35 PM

Dr. Gurwinder Gill

Posts: 1
Location:

Hi all. I work in the same institution as Dr. Nilda Salaman where we have infact stopped doing elective cases and closed our ASC. I am part of a team to put together a national legislative piece for an executive order (not just a recommendation) to stop everything but emergency surgery. This will then leave no room for discussion as to what is urgent versus emergent. We are only 2 weeks behind Italy and in the worst case scenario, may be put in a horrible situation of trying to choose between the 40 year old with covid needing a vent and 80 year old with heart failure needing a vent. Please take a look at the url below and spread the word. Reach out to any congressman you know or any connections in the CDC or CMS.

http://tinyurl.com/moreVents

Thanks you!

Subject : Re:COVID-19.. 03/19/2020 03:38:43 PM

Monica Servin

Posts: 1
Location:

Hello everyone, I am an anesthesiologist working for Michigan Medicine. I am the medical director for one of the university's free standing ambulatory surgery sites. We significantly ramped down our outpatient case volume starting this past Monday. All truly elective cases were canceled and will be rescheduled. The only cases we will continue to do include those procedures for cancer, chronic pain (ie: kidney stones), and certain types of orthopedic cases (ie: fractures). We are evaluating those on a case by case.
Of interest to the group, new PPE guidelines came out from our institution that will help conserve resources. For those of you, like me, who may be redeployed to other areas of the hospital, this information may be helpful.

For Standard Care (non-aerosol generating procedures / non ICU patient):
• Standard facemask
• Eye protection
• Gowns
• Gloves
For Aerosol generating procedures (during procedure and for 60 minutes after procedure)
• N95 mask or PAPR
• Eye protection
• Gowns
• Gloves
Place stop sign to indicate aerosol procedures is
occurring.

Aerosol-generating procedures that require
respirators and droplet/contact precautions:
• Tracheal intubation
• Bronchoscopy
• Oropharyngeal or tracheotomy suctioning
• Non-invasive positive pressure ventilation
• Cardiopulmonary resuscitation (CPR)
• Nebulizer treatment
• Bag valve mask (BVM) ventilation
• High-flow supplemental oxygen therapy
• Sputum induction or cough assist treatments

For ICU patients:
All care requires N95 or PAPR, gown, gloves, eye protection.

Subject : Re:COVID-19.. 03/20/2020 01:20:11 AM

Stuart Solomon

Posts: 1
Location:

Hi Everyone,

I am an anesthesiologist and perioperative management fellow at Stanford (and also spend a lot of time at our ASC). I trained at UW in Seattle and am now in the Bay Area, and similar to New York we are likely mere days away from running out of critical care capacity on the west coast. I believe the rest of the country is not far behind us. We have been feverishly working to garner support to have stricter guidelines for canceling non-emergent cases, achieving better standards for PPE, and creating operational plans to mobilize our OR's and even ASC's into critical care units. I know it sounds farfetched, but just as every other decision thus far has been reactive, people will soon be scrambling for ventilators (as they have in China, Iran, Italy and Europe before us). We need a plan right now to greatly expand our capacity.

Do you have insights/thoughts on how we as a nation could feasibly access ASC space and ventilators for covid? This is a totally open source project and we are moving fast. Anyone is welcome to join. Dr. Gill posted above but our basic summary document can be found here:
http://tinyurl.com/moreVents

PS- Our ASC is somehow still open and although volume is down at the hospital, we are continuing to do surgeries as long as "progression of care" is needed within 30 days. Meanwhile, we are being told to ration PPE away from pts that aren't exhibiting symptoms even though the Bay Area has had a "shelter in place" order for the past week due to community spread.

Subject : Re:COVID-19.. 03/22/2020 11:22:09 AM

Dr. Basem Abdelmalak, MD, FASA, SAMBA-F

Posts: 28
Location: Cleveland, OH

Thank you to all of you who responded to this thread, I learned quite a bit about your practices and how you are handling this situation, but more importantly about YOU! I also received many positive comments from members regarding your very useful posts.
If you have not seen this yet, we have launched COVID-19 resources page(https://sambahq.org/covid-19-resources/), and if you scroll all the way down, you will find many important links, hope that you will find it helpful. While you are at it, if you see something that needs updated, or you know of a website and/or a resource that you think might be helpful to others, please share and send it to [email protected], we are all in this together.
We are planning a webinar titled: “Ambulatory Anesthesia in the COVID-19 Era”, date and time to be announced soon. If you have any question(s) that you wish to be answered, please e-mail it to [email protected] . We are also trying to recruit an ID specialist to answer questions about the virus itself and its infectivity.
Stay safe, be well, and God Bless,

Basem Abdelmalak, MD
SAMBA President

Subject : Re:COVID-19.. 03/23/2020 12:02:38 AM

Ellis Lai

Posts: 1
Location:

Hello everyone. I'm an anesthesiologist in Los Angeles who does a lot of GI endoscopy cases. The New England Journal of Medicine published some good guidelines for those of us who are around a lot of GI cases. Hope this helps your practice plan a safer anesthetic during the pandemic.

https://www.jwatch.org/na51139/2020/03/17/endoscopy-during-covid-19-pandemic

Subject : Re:COVID-19.. 03/26/2020 09:39:22 AM

Dr. Erica Escorcia

Posts: 2
Location:

On last night's webinar, there was a suggested JUSTIFICATION FORM that would be used in addition to a booking sheet. Is that available? I don't see the webinar uploaded yet in that section of the SAMBA website.

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