Algorithm Created To Protect Surgical Teams From COVID-19

COVID-19 Algorithm

Stanford University’s surgery department has created an algorithm to protect surgical team members during emergency operations amid the COVID-19 outbreak and conserve personal protective equipment (PPE). The guidelines were published in the Journal of the American College of Surgeons website. Per the American College of Surgeons (ACS), Stanford Health Care is a level 1 trauma center that serves San Mateo and Santa Clara counties. The first reported case of COVID-19 in this area was reported in early March.


The algorithm was designed after calculating the urgency of the surgical procedure, the potential for aerosolization and the disbursement of COVID-19 droplets at the site, and evidence of a patient being infected. The algorithm also addresses the shortage of PPE during the COVID-19 outbreak. According to Joseph Forrester, MD, MSc, assistant professor in general surgery and the lead author of the algorithm, the goal was to develop institutional guidelines based on how soon the surgery needs to be performed and the patient’s condition.


They also took into account the potential risk that a surgeon would access an area of the body where the virus could be high, and the risk that a patient could be infected with COVID-19. Dr. Forrester conducted many investigations while performing as a field agent in Liberia during the 2014 Ebola outbreak. During that time, he assisted in the preparedness with the Centers for Disease Control and Prevention as an Epidemic Intelligence Service Officer.

Here are some key highlights of the guidelines:


  • A team of medical professionals came together to develop an institutional algorithm to protect operating room teams during the COVID-19 outbreak and conserve personal protective gear.
  • Hospital and medical school leaders assigned an international platform consisting of endoscopy, interventional suites, and operating room departments to develop a way to use PPE. Medical leaders worked with infectious disease experts to reduce the spread of COVID-19, minimize the risk of exposure, and conserve PPE.
  • A decision tree algorithm describing the institutional guidelines for surgical team members was created. The guidelines are based on several factors, including the urgency of operation, anticipated viral burden during the surgery, the possibility that the virus may be aerosolized, and the likelihood that a patient could have COVID-19 based on testing and symptoms.
  • Results show that despite being a new threat, healthcare workers can ensure their safety from the spread of COVID-19 by following these easy protocols.


Algorithm Details


On March 19, a PPE task force consisting of medical school and hospital leaders from different departments, including interventional radiology, endoscopy, and the operating room, met with infectious disease experts at Stanford to create guidelines that could be put into place within 72 hours. During that time, there were approximately 10 patients infected with COVID-19 at Stanford Health Care. Guidelines included current data (at the time) about COVID-19 in both hospital and non-hospital settings. It also included operating room risk during outbreaks of SARS and Ebola.


Patients were categorized by illness severity and urgent and emergency procedure demands. Emergency cases were put into a low or high-risk category, depending on the expected viral burden during surgery. Procedures were considered high risk if they were categorized as aerosol-generating (AGP), including those that involved endoscopy, the aerodigestive tract, and laparoscopic or open surgery on the bowel with gross contamination.


Above all, the guidelines state that any patient could be a carrier of COVID-19 until an RT-PCR test showed negative. The guidelines require operating room team members to wear an N-95 mask, a gown, gloves, and eye protection when operating on a patient with COVID-19. Team members can only wear standard surgical clothing when a patient tests negative for the virus using an RT-PCR test. A surgeon may consider delaying an urgent or emergency surgery based on a patient’s symptoms, such as fever, sore throat, and cough. If delaying the surgery comprises the patient’s health, then the surgeon may order an in-house RT-PCR COVID-19 test with a 24 hour turnaround time. If the patient cannot wait 24 hours for the test results, then the case is considered urgent, and the patient is assumed to have COVID-19.


Considerations for the use of PPE during and after bag-mask ventilation and endotracheal intubation are made because both of these are high risk for viral transmission. Healthcare workers who are not directly involved are asked to leave the operating room. Anesthesiologists need to be fitted with N-95 face masks and droplet-protective PPE. This is because they are positioned at the patient’s head throughout the surgery. Cleaning staff also needs to wear droplet protection while cleaning operating rooms.


Here are some key highlights:


  • Every surgical patient is assumed to have COVID-19 unless they test negative.
  • Elective surgery patients are not considered as these cases were ruled out.
  • Surgical team members are required to wear a fitted N-95 mask, face shield, gown, and gloves during the procedure.
  • Urgent cases are categorized as high-risk or low-risk, depending on the anticipated viral burden at the surgery site and the likelihood that the procedure would aerosolize the virus.
  • All aerosol-generating procedures, such as lung, tracheal, oropharyngeal, and nasopharyngeal) are considered high-risk, based on previous experience with SARS.
  • Patients are to be screened for symptoms, such as fever, cough, and sore throat. Patients that test positive need to receive approval by hospital leadership, anesthesia, and surgeons to continue with the surgery after being deemed necessary.
  • To conserve masks, hospital workers must wear a face shield over their masks. Cleaning staff must also wear droplet-protection gear when cleaning operating rooms.
  • Mandatory training on proper fitting of PPE for all healthcare workers was mandated. Also, training was mandated for protocol on how to treat patients that have tested positive for COVID-19.


When the guidelines were created, there was a nationwide shortage of N-95 masks. The algorithm requires a face shield to be placed over the mask in order to preserve the hospital’s mask supplies and use them again. Dr. Forrester noted that the federal government has announced that millions of face masks, face shields, gloves, and gowns are being made. He recommends that healthcare centers continue to conserve their emergency equipment and consider following these guidelines to protect workers, even when they receive more supplies.


He stated that you never know what’s going to happen, and it’s better to be prepared by not being wasteful of PPE. He continued by saying that guidelines such as the ones implemented at Stanford show that healthcare workers on the frontline are trying to take care of everyone with a serious surgical condition and make sure that they have what they need to carry out the mission safely.


You can read more about the algorithm here.