Preoperative Screening for COVID-19

To the editor:

As surgical leaders at eleven North Carolina health systems, we write to draw your attention to the matter of safe surgical care during the ongoing SARS-CoV-2 pandemic. The ongoing spread of SARS-CoV-2 has required health care systems to balance caring for patients with SARS-CoV-2 with the community need for surgical care. By North Carolina executive order, all pre-operative patients must be screened for symptoms of SARS-CoV-2 prior to surgery, but serological testing of asymptomatic patients is not required (1). Health care institutions must therefore decide how to balance allocation of limited testing resources, protection of peri-operative staff, and provision of needed surgical care.

We sought to understand how North Carolina health systems were approaching this dilemma by describing pre-operative testing strategies and results through a survey of fourteen North Carolina health systems. We received eleven responses: nine health systems were systematically screening asymptomatic patients for SARS-CoV-2 prior to non-time sensitive surgeries and could provide the number of tests done and proportion of positive test results.

We divided the reporting period in two in response to an increase in the background prevalence of SARS-CoV-2 in North Carolina in late May of 2020 to assess whether the proportion of positive pre-operative tests reflected the broader increase. The first reporting period began when each institution instituted its asymptomatic testing policy and ran through late May; this period spanned a median of 16 days with a range of 12-55 days. Nine institutions provided pre-operative testing data in the first reporting period. The second reporting period ran from late May through late June/early July, spanning a median of 41 days (range 36-42 days) and including data from seven institutions.

During the first reporting period, 28,353 tests were reported with positivity rates ranging from 0% to 1.43% (average across all health care systems: 0.65%). During the second reporting period, 53,745 tests were reported, with positive rates ranging from 0.31% to 1.35% (average: 0.61%). Four of seven institutions reported higher positive test rates during the second time period, while three of seven institutions reported lower positive test rates.

Timely performance of non-urgent/non-emergent surgeries must be balanced against markedly worse outcomes among patients with unknown SARS-CoV-2 infections who undergo surgery (2, 3). Building pre-operative testing capacity is one strategy to achieve both. Decisions about preoperative asymptomatic SARS-CoV-2 testing are complex and will continue to be re-assessed over time.

The descriptive results presented here are limited by data availability and the heterogeneity of testing policies between institutions; they are therefore not sufficient to provide support for or against a specific pre-operative testing strategy, but are rather intended to stimulate institutional introspection. Evidence suggests that SARS-CoV-2 will continue to affect healthcare delivery through winter, into spring, and possibly beyond.(4) We suggest that North Carolina health care systems collaborate to investigate further the role of pre-operative testing in the safe provision of surgical care in order to generate more consistent testing policies that are responsive to changes in local SARS-CoV-2 incidence.