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Melanie Cole: This is the UAB Medicine Podcast on COVID-19 dated May, 11th 202. UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category one credit. To collect credit, please visit UABmedicine.org/medcast and complete the episodes post-test.

Introduction: Welcome to UAB Medcast, a continuing education podcast for medical professionals bringing knowledge to your world. Here's Melanie Cole.

Melanie Cole: Welcome to UAB Med Cast. I'm Melanie Cole and today we're discussing making operating rooms safe during COVID-19 joining me is Dr. Herbert Chen. He's the Surgeon in Chief and Chair of the Department of Surgery at UAB Medicine. Dr. Chen, it's a pleasure to have you back again with us, in these unprecedented times and this is a really great topic that we're talking about today because patients and other referring providers have questions exactly about what we're talking about. Please tell us about some of the current recommendations that you have going regarding adult elective surgery and procedures.

Dr. Chen: Yeah. So when COVID-19 hit hospitals, including ours across the country, made the decision to basically limit all non-essential planned or elective operations for a period of time. And that was basically to both recognize that we had to conserve critical resources such as ventilators, personal protective equipment or PPE, as well as limiting exposure of patients and staff to COVID-19. And so over these last few weeks, that's what we've been practicing is just doing the operations that absolutely needed to be done. And then as we figured out how to make surgery safe and to make sure we had the adequate supplies to conduct elective surgery, bring that back on board, which we've just recently resumed. So we've come up with a number of practices which allow now today for elective operations to proceed in a very safe manner.

Host: Well then let's start talking. You mentioned supplies. How are you doing with conservation of supplies? Speak about your PPE initiatives and any N95 reprocessing that's going on. Tell us about that.

Dr. Chen: Usually when we do operations, we do it what we call under universal precautions, meaning that we do it in a very sterile environment to minimize the chance of postoperative infection, but also utilize PPE to protect the patient and also to protect the surgeons, anesthesiologists, and other healthcare providers in the operating room. But with COVID-19 that introduced a new challenge because there was this additional risk of both spreading COVID if the patient potentially had disease through the air. And then obviously the important to protect patients from getting COVID-19 from potentially other patients or other people who could be infected. So to do that, we had to deploy additional PPE that we wouldn't normally utilize for operations such as N95 masks, face shields, very innovative aplastic boxes or protective coverings to maintain the safety of everyone involved.

And so with this, we were utilizing supplies that we perhaps weren't utilizing previously at a very high rate. And because initially when this pandemic hit us and we had limited ability to test patients for COVID-19, we had to assume that everyone that we were taking care of was potentially positive and had to take precautions to utilize what we call full PPE, full gowns, N95, face shields, goggles and things to protect the providers during the operation. And so today, one of the reasons we're able to now start elective surgery is that we've been able to reduce the amount of PPE we need because we have adequate testing of all patients for COVID-19 and therefore can limit utilizing all the protective gear in patients who are positive. And then for patients who are negative, we utilize just universal precautions as we had previously.

Host: Well, thank you for that answer, Dr. Chen. So how are you assessing the risk and minimizing the exposure during intubation? Tell us a little bit about how you and your medical partners are taking precautions to protect yourselves while giving this type of treatment. And especially with COVID patients.

Dr. Chen: This is work primarily done by our anesthesia team to minimize the risk for everyone during the intubation. Because during intubation that is a particular time if a patient did have COVID-19, that they could spread particles through the air from the intubation process, which would then potentially spread the virus to the anesthesiologist and other people in the vicinity. So there are a couple things that we've done to make the intubation more safe, one is change location where it happens. Normally operating rooms are what we call positive pressure rooms, meaning that what you want to do is make the environment completely sterile so you don't allow any air to come into the room that's unfiltered. So by having the room positive pressure that actually pushes air out of the room and doesn't allow any air to come into the room except for what comes through, pushed in through the filtering process.

Now, while that's ideal for to maintain a sterile environment, it is not the best place to do an intubation with someone who potentially has COVID-19. Because during the intubation process, the viral particles can be aerosolized into the air. And if you're in a positive pressure room, that just pushes that air everywhere. So what we've done and what other institutions have also done is to perform now, these intubations in patients with COVID-19 in negative pressure rooms, meaning that the pressure is negative. So nothing escapes the room. So if there is a virus that is gone onto the air, it stays in the room and doesn't spread. So now intubations in those patients happen in a negative pressure room and then the patients are transported the operating for the procedure and at the end of the procedure they are transported back to the negative pressure room for the extubation.

And in addition to where the intubation occurs, there's protective apparatuses built to basically put plastic either boxes or plastic shields around the, between the patient and the anesthesiologist to minimize the ability for things get aerosolized. So those provide a barrier between the anesthesia team and the patient. And then plus wearing N95 masks, also minimize that. So there are many things that have been thoughtfully executed to minimize the risk of aerosolization during intubation.

Host: Tell us how you're determining the dedicated PACU spots, dedicated ORs and dedicated pathways to make sure that everything stays where it needs to stay.

Dr. Chen: Yeah, so the, for the COVID-19 patients, they're intubated in the negative pressure room, which happens to be in our PACU and then there's a pathway that they follow to get to the operating room. And then for patients who are COVID-19 there are dedicated operating rooms which are set aside for only patients with COVID-19 because they're basically cleaned both before and after in a different way than we normally would for a non-COVID. And then the patients then are transported during a certain pathway for their extubation in the negative pressure room, as I mentioned before, where they'll do the recovery as well. We've been very thoughtful in how patients flow who have COVID-19 to again minimize the contact that they will have with other patients as well.

Host: And what about after surgery cleaning the OR is there an isolation protocol regimen for patients as of now? Like how long should the room be vacant or cleaning measures, extra cleaning measures that might be required?

Dr. Chen: For cleaning the ORs. The ORs after a COVID patient has been in the operating room. The ORs are supposed to remain vacant for 30 minutes with the doors completely shut for adequate air turnover to occur and then we our initial cleaning and gowns and gloves and they clean the OR with our hospital approved disinfectants. And then there's terminal cleaning where they clean the OR again and it needs to remain vacant for a good period of time to again allow transition before another patient is brought back in. And of course all the trash and medical waste are disposed of in a very safe manner.

Host: And Dr. Chen before we wrap up, but what about the supply chain for other providers that have this question, what supplies do you have that are adequate and which ones might be in short supply? Speak about ventilators, masks, N95, gowns. All of it.

Dr. Chen: Yeah. I think that depending upon your situation and what your supply chain is, you may be sure of some or many of these key PPE or a key equipment. So for ventilators that was predicted that many areas in the United States would have shortages. And they did for a period of time. We were very fortunate that we never got to the point where we needed to use some of the ventilators that we had in the operating room to ventilate patients who were sick in the ICU with COVID. So for us, we have enough ventilators to do our operations and to also take care of the sick patients with access. With regard to masks, N95, gowns and all that, we keep a very close eye and how many days of inventory we have. And of course your days inventory depends upon the use. But I think more importantly is I think the game changing factor to conserve PPE has been the ability to test patients for COVID-19. Because before when we didn't have the capacity to test everyone having surgery, we would have to use what we call full PPE on every patient and that would use a lot of these materials.

However, now that we test all patients having surgery, both emergent and elective operations, we know, and the vast majority are negative meaning that. So far we've tested well over a thousand individuals having procedures and the positivity rate is 0.85%. So if you just think about it that you were burning through a lot of PPE beforehand, but now since less than 1% of people really you need to deploy PPE, we can identify those individuals to utilize the full PPE during their procedure. But the 99 plus percent that don't have the disease, we can use universal precaution which conserves our PPE. So again, I think testing has really been the game changer for us to be able to now do the operations really safely and that patients should be very comfortable having their elective procedures right now because we've created a very safe environment.

Host: Do you have any final thoughts for other providers regarding referral and things that they can take forward to their patients regarding what you were just discussing? Safety and the procedures that you are doing now at UAB Medicine?

Dr. Chen: Yes, with all surgery, pre-COVID and now during COVID, operations need to happen to treat various ailments that people have and important diseases and that we shouldn't allow COVID to curtail us from delivering the best care possible and I think with these new changes, and again with testing and all these safety procedures that we've deployed, I can confidently say that we can do that right now. That we can provide the same level of safe care for patients who need surgery now then similar to what we did before.

Host: Thank you so much Dr. Chen. What an interesting topic and great information. Thank you again for joining us. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.