TABLE 1.

General Measures to Prevent Perioperative Nosocomial Spread as Implemented in Singapore⁵

Hospital measures related to surgery and anesthesia: Reduce elective activities to increase capacity and accommodate infection prevention measures Screening of patients, visitors, and staff for symptoms or travel history Setting up efficient communication channels with staff (COVID-19 website, helpline for anxiety and burnout)

OR management: Reserve a specific OR area for COVID-19: Independent, negative pressure ventilation Physically isolated from the main OR Control traffic by locking all but the scrub room door during surgery Assign an anesthetic team exclusively for COVID-19 patients Design and teach new workflows for COVID-19 patients

Anesthesia staff training and management: Formal N95 fitting sessions Formal training sessions on PPE use Segregation of staff between hospitals to minimize the risk of nosocomial spread from one hospital to the other Attendance tracking on all face-to-face meeting to facilitate contact tracing in the event of an outbreak Postponement of all nonurgent preoperative visits Pregnant or immunocompromised staff did not care for COVID-19 patients

Mandatory use of PPE: When caring for low-risk patients (asymptomatic and no history of travel or contact with COVID-19 patient): surgical masks and droplet precautions When caring for high-risk patients: N95 masks, eye protection, gown, and gloves When caring for COVID-19 patients: N95 masks, eye protection, gown, and double gloves When performing aerosol-generating procedures on COVID-19 patients: powered air-purifying respirator

Specific measures when caring for COVID-19 patients Patients should wear a surgical mask during transport Patients are transported using a designated route minimizing the risk of encounter Keep the COVID-19 OR as empty as possible and only bring equipment and drugs as needed Use single-use equipment as much as possible Do not bring paper charts into the COVID-19 OR Cover all monitors, computers, and machines in plastic wrap Perform the patient review, induction, and recovery within the OR to limit contamination to a single room Limit the number of staff in the OR Limit the movement of staff in and out of the OR

OR decontamination after COVID-19 surgery Discard the anesthetic breathing circuit and soda lime canister Clean all surfaces with quaternary ammonium chloride disinfectant wipes Clean OR with sodium hypochlorite 1000 ppm Treat OR with hydrogen peroxide vaporization or ultraviolet C irradiation All staff to shower and change into new scrubs after each COVID-19 case

Perform a series of simulations and walkthroughs of the COVID-19 workflow