COVID-19

Guidance on the triage of 'non-emergent' surgical operations




Article 1: Update on Guidance to surgeons on triaging surgeries during COVID-19

Article 2: Guidance on the triage of 'non-emergent' surgical operations




Update on Guidance to surgeons on triaging surgeries during COVID-19



27th March 2020


Dear Members,

Following the escalation of COVID-19 cases in Malaysia, healthcare services, including surgery, are under increased strain. This is reflected in the morbidity and mortality affecting the healthcare workers.


It is ESSENTIAL for adoption of a safe or cautious approach towards surgery. The guiding principles are:

1. PROTECTION of health care workers and patients
2. MAINTENANCE of a safe healthcare environments, including operating theatres and surgical wards
3. CONSERVATION of resources - personnel, personal protective equipment (PPE), ventilators etc.

Based on emerging evidence, the College of Surgeons, Academy of Medicine of Malaysia (CSAMM), with its integrated Chapters, STRONGLY ADVISE members to do the following:

1. Assume all patients are potential contacts and take adequate precautions.
2. Postpone all non-urgent clinic appointments.
3. Stop all elective operations and aerosol-generating procedures (AGPs, such as dental and oropharyngeal procedures, endoscopy).
4. Use enhanced PPE if surgery/AGP in COVID-positive patients is unavoidable, minimize involved staff.
5. Avoid laparoscopy if surgery is necessary. If laparoscopy is deemed essential, filtration devices for aerosolized particles must be used.

Other advisory measures, WHERE FEASIBLE, include:

1. COVID-testing for all patients undergoing emergent surgery.
2. A non-operative approach for some emergent conditions e.g. cholecystitis, appendicitis, provided the clinical status allows.
3. CT thorax prior to emergent surgery in high-risk patients
4. Cessation of positive pressure ventilation in OT during the procedure until 20 minutes after patient leaves.
5. Isolation of, and full PPE when nursing, post-operative patients until COVID status known

It is IMPERATIVE that the surgical community takes leadership in flattening the curve in this pandemic, for the safety of ALL. The above measures are advised until further evidence becomes available, or until such time that the Ministry of Health declares a return to normalcy of health services.

 

Prof Dr April Camilla Roslani
President
College of Surgeons
Academy of Medicine of Malaysia

Dato’ Dr Selvalingam Sothilingam
Chair
Urology Chapter

Assoc Prof Dato’ Dr Hari Chandran Thambinayagam
Chair
Neurosurgery Chapter

Dato’ Dr Imi Sairi bin Ab Hadi
Chair
Breast and Endocrine Chapter

Prof Dr Jamal Azmi Mohamad
Chair
Orthopaedic Surgery Chapter

Dr Chew Loon Guan
Chair
Vascular Surgery Chapter

Dr Lim Yang Kwang
Chair
Maxillofacial, Aesthetic, Plastic Surgery Chapter

Prof Dr Raja Amin Raja Mokhtar
Chair
Thoracic & Cardiovascular Surgery Chapter

Dr Siow Sze Li
Chair
Upper GI Chapter

Prof Dr Tan Ing Ping
Chair
Otorhinolaryngologists - Head and Neck Surgeons Chapter

Dato’ Dr Zakaria Zahari
Chair
Paediatric Surgery Chapter

Assoc Prof Datuk Dr Ismail Sagap
Chair
Colorectal Surgery Chapter


References:
1. Surgical smoke and infection control. Alp E et al J Hosp Infect 2006.
2. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Kwak HD et al Occup Environ Med 2016.
3. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Repici A et al Gastrointest Endosc 2020.
4. Perioperative considerations for the 2019 Novel Coronavirus (COVID-19) Zucco L et al Anesthesia Patient Safety Foundation 2020
5. Correlation of chest CT and RT-PCR testing in Coronavirus Disease 2019 (COVID-19) in China: A report of 1014 cases. Ai T et al RSNA 2020






Guidance on the triage of 'non-emergent' surgical operations



In light of the recent escalation of the COVID-19 outbreak in Malaysia, the College of Surgeons, Academy of Medicine of Malaysia (CSAMM) would like to provide the following guidance on the triage of `non-emergent' surgical operations.

The re-deployment of staff and resources towards managing the outbreak has limited delivery of elective surgeries. Nevertheless, CSAMM is of the opinion that deferring all elective surgeries risks progression of disease states that will present further down the line with more complexity and worse outcomes.

In rationalizing the use of limited resources, the following should be considered:

1. Surgical case-mix: 
Surgeries can be categorized according to the urgency of surgery as per the Perioperative Mortality Review (POMR) Guidelines: Prioritization of Cases for Emergency and Elective Surgery (2nd Revision) 2018. As an example, hospitals may choose to concentrate resources on emergencies and category one electives.

The POMR Guidelines can be accessed via the link below

http://www.moh.gov.my/moh/resources/Penerbitan/POMR/GARIS_PANDUAN_POMR_PRIORITISATION_OF_CASES_FOR_EMERGENCY_AND_ELECTIVE_SURGERY_2018.pdf

2. Hospital capacity:
Consideration should be given to the available resources: human resources, facilities, equipment and consumables. Designated COVID-19 hospitals may not be able to support all elective cases, in particular those that require post-operative intensive care or significant use of blood products.

3. Balance of risks:
Surgeons, in consultation with anaesthetic and nursing colleagues, should weigh the risks of proceeding (exposure, lack of resources) against those of deferment (progression of disease, worse patient outcomes). Hospital-wide policies should be fluid, and guided by emerging data.

Further guidance can be obtained from the American College of Surgeons website:
https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage


Prof Dr April Camilla Roslani
President
College of Surgeons

Academy of Medicine of Malaysia