Infection prevention and control practices for emergency surgery during the COVID-19 pandemic in a tertiary care hospital in South Korea

Highlights

• •Proper risk assessment for COVID-19 should be implemented.
• •Appropriate infection prevention practices for perioperative management are important.
• •Hospitals should organize dedicated protocols considering its facilities and human resources.

Dear Editor

The World Health Organization declared coronavirus disease (COVID-19) as a pandemic in March 2020. COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has posed a serious health threat worldwide [1]. When implementing infection prevention and control measures in healthcare settings, several important characteristics of COVID-19 should be considered. Recent data suggest the possibility of transmission of SARS-CoV-2 from asymptomatic carriers or pre-symptomatic patients [2,3]. SARS-CoV-2 is primarily transmitted from person to person through respiratory droplets, but it can also be transmitted by an airborne route, particularly under aerosol-generating procedures including endotracheal intubation and extubation [4,5]. Based on these findings, we established infection prevention and control practices for emergency surgery in the hospital. There are recommendations for emergency surgery preparation during times of COVID-19 [6,7]. However, each healthcare institution should optimize these recommendations in consideration of its facilities, human resources, and equipment. Herein, we present our experience of risk assessment and perioperative management for emergency surgery in this study.

The hospital is an 846-bed tertiary care teaching hospital located in Incheon, Republic of Korea. Incheon's population is 2.95 million, and the number of confirmed cases of COVID-19 was 718 (2429 per 100 000) as of August 31, 2020 [8]. In the hospital, there are 17 operating rooms (ORs), two of which are negative-pressure ORs, and there are 5, 9, and 14 negative-pressure isolation rooms in the emergency department (ED), general wards, and intensive care units, respectively. Real-time reverse transcription polymerase chain reaction (rRT-PCR) testing for SARS-CoV-2 is conducted 5 times a day in the hospital with a turnaround time of approximately 4 h. During the COVID-19 pandemic, all patients are screened for clinical signs or symptoms compatible with those of COVID-19 and epidemiological risk factors of COVID-19 in the triage prior to entry into the hospital, as previously reported [9]. Patients with findings suggestive of COVID-19 should be placed in a negative-pressure isolation room in the ED until the results of the rRT-PCR test for SARS-CoV-2 are confirmed as negative. Since April 13, 2020, to identify patients with asymptomatic or pre-symptomatic infection, all patients requiring hospitalization should undergo at least one rRT-PCR test for SARS-CoV-2 and chest radiography before admission. However, patients requiring emergency surgery before confirmed negative SARS-CoV-2 rRT-PCR test results are evaluated for the risk of transmission by infectious disease specialists and the infection control team based on 3 criteria: clinical signs or symptoms, epidemiological risk, and chest radiological findings (Fig. 1 ).

Fig. 1.

Risk assessment flowchart for COVID-19 in emergency surgeries before confirming a negative rRT-PCR test result for SARS-CoV-2. COVID-19, coronavirus disease; rRT-PCR, real-time reverse transcription polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

All patients should wear a medical face mask whenever they are transported within the hospital, regardless of the risk, and non-essential contacts between patients and other individuals should be minimized. When transporting high-risk intubated patients, a negative-pressure isolation stretcher is used. Patients are transported directly to the OR by personnel wearing appropriate personal protective equipment. When transporting intermediate- or high-risk patients to and from the OR, the transport route is controlled, and environmental disinfection of the route is performed thereafter.

In principle, the number of personnel participating in emergency surgeries is minimized, and only necessary equipment should be left in the OR. The anesthesia machine and other equipment in the OR are covered with plastic sheets. When performing emergency surgery in high-risk patients, a negative-pressure OR should be used. If a negative-pressure OR is not available, then a general OR set to neutral pressure with proper ventilation is considered for intermediate-risk patients. For anesthesia, rapid sequence induction and intubation is performed by an experienced anesthesiologist, and video laryngoscopy is used whenever possible.

After the surgery, patients should recover in the OR and be transported directly to the room, bypassing the post-anesthesia care unit. Patients who still have unconfirmed SARS-CoV-2 rRT-PCR test at the end of the surgery are transferred to the cohort ward, a single room, or a negative-pressure isolation room according to their risk. The anesthesia machine and other reusable equipment require meticulous routine cleaning, and disposables should be bagged as contaminated waste. After the patient has left the OR, the room should remain closed along with adequate ventilation, and then subjected to enhanced environmental cleaning and disinfection using hydrogen peroxide vapor. Perioperative infection prevention and control measures according to risk are summarized in Table 1 .

Table 1.

Perioperative infection prevention and control measures for emergency surgery before confirming a negative rRT-PCR test result for SARS-CoV-2.

	Low risk	Intermediate risk	High risk
PPE for patients	Medical face mask (for any level of risk)
PPE for patient transport personnel	KF94 or medical face mask (if KF94 is not available), eye/face protection, disposable long-sleeved plastic gown, gloves (for any level of risk)
Patient transport	–	Transport route control Environmental disinfection	Transport route control Environmental disinfection
Air pressure of OR/room air changes	Neutral/15 ACH (≥30 min)	Negative (preferred)/12 ACH (≥35 min) Neutral (if a negative-pressure room is not available)/15 ACH (≥30 min)	Negative/12 ACH (≥35 min)
PPE for anesthesiologists and circulating nurses	KF94 Eye/face protection Disposable surgical gown Gloves Head cover	N95 respirator Eye/face protection Disposable surgical gown Gloves Head cover Boot covers	N95 respirator Eye/face protection Coveralls Two pairs of gloves
PPE for surgeons and instrument nurses	Medical face mask Disposable surgical gown Gloves Head cover	N95 respirator Eye/face protection Disposable surgical gown Gloves Head cover Boot covers	N95 respirator Eye/face protection Coveralls Two pairs of gloves
Bed allocation after surgery	Cohort ward	Negative-pressure isolation room (preferred) Single room (if a negative-pressure isolation room is not available)	Negative-pressure isolation room

ACH, air changes per hour; OR, operating room; PPE, personal protective equipment; rRT-PCR, real-time reverse transcription polymerase chain reaction; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2.

By the end of August 2020, a total of 17 emergency surgeries before confirming a negative SARS-CoV-2 rRT-PCR test result were performed under general anesthesia at the hospital. Five patients with intermediate or high risk underwent emergency surgery in a negative-pressure OR, but none of the patients was confirmed to have COVID-19 at the hospital. Over 1.8 million new COVID-19 cases and 38 000 new deaths were reported in the week ending August 30, 2020 [1]. During the COVID-19 pandemic, there are still patients who require emergency surgery. To minimize the risk of SARS-CoV-2 transmission during emergency surgery, proper risk assessment for COVID-19 and appropriate infection prevention and control practices should be implemented.

Ethical approval

Not applicable.

Funding

Not applicable.

Author contribution

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Yeon Jeong, Youn Jeong Kim, Ye Rin An, Eunji Kwak, Yeseul Seo, and Joong Hyun Ahn. All authors commented on previous versions of manuscript. All authors read and approved the final manuscript.

Guarantor

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Registration of research studies

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Consent

Not applicable.

Availability of data and material

The data used during the current study are available from the corresponding author on reasonable request.

Conflict of interest statement

All authors report no conflicts of interest relevant to this article.