April 10th Bulletin

The Centers for Medicare & Medicaid Services (CMS) announced that hospitals, physicians, and other health care providers would be receiving $30 billion in grants directly from CMS. The American College of Surgeons (ACS) has been actively advocating for these grants. In short, it appears that each physician who participated in the Medicare program in 2019 will receive approximately 6.1 percent of their 2019 Medicare revenue. These are payments, not loans, to health care providers, and will not need to be repaid. The specific announcement including the formula of how much each individual will receive, how the payments will be made and other details regarding the program can be found

here.  

Efforts to provide resources and practical suggestions for surgeons to consider as they strive to combat the financial pressures resulting from the COVID-19 pandemic, the Practice Protection Committee met this week by videoconference and has developed an updated resource document found in this issue. Fellows will find information and links to application information for three federal programs that provide financial resources, a list of questions to consider for discussion with their professional tax advisor, a document to assist surgeons who provide telehealth services, and perhaps most importantly, a section on practical suggestions and options to consider using in these unprecedented times.

In addition, this issue of Bulletin: COVID-19 Updates responds to some of the critical challenges facing members of the ACS. Questions continue regarding clinical and ethical decisions. Among the most wrenching are decisions regarding end-of-life and resuscitation maneuvers such as cardiopulmonary resuscitation (CPR). Throughout this epidemic, patients and their families must trust that CPR will be administered fairly and without restraint to all patients who need it. The Alden March Bioethics Institute of Albany Medical College, NY, has developed a framework to guide CPR decision making, which is highlighted in this issue. We also provide guidance on providing ventilator care to patients with acute respiratory distress syndrome. 

We review new therapies for COVID-19 patients in this issue, including the use of convalescent plasma, which has been used successfully in the past to treat patients suffering from Ebola, polio, and mumps, and severe acute respiratory syndrome. More specifically, a consortium of more than 50 hospitals and universities has created the National COVID-19 Convalescent Plasma Project to pool efforts to investigate the use and efficacy of convalescent plasma from COVID-19 patients who recovered from the disease.

Telemedicine is increasingly used to protect the health and safety of both health care professionals and their patients, to share knowledge across borders, and to ensure access to care for individuals in rural and other under-resourced areas. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, enacted March 27, appropriated $200 million to the Federal Communications Commission (FCC) for an emergency program to provide funding so health care providers can purchase services and devices necessary to provide telehealth care. Additionally, the FCC separately allocated $100 million to create a Connected Care Pilot Program, which will provide monies to cover 85 percent of the costs of broadband connectivity. These efforts are summarized in this issue of the newsletter.

The ACS is concerned that African Americans are disproportionately affected by COVID-19 and are dying from the virus at higher rates than whites. This issue includes an analysis of the problem.

The public service announcements asking people to stay home to stop the spread of COVID-19 continue. Today, former Los Angeles Chargers placekicker Rolf Benirschke partnered with ACS to ask people to help their communities by practicing social distancing. 

It has been said that great challenges bring great opportunities. The COVID-19 pandemic has proven to be perhaps the greatest challenge many ACS members have experienced. This newsletter continues to serve as a valuable resource for members who are on the frontlines and points them toward opportunities to create a better future for their patients. Be sure to stay tuned for the next edition, when we start to ramp up hospital capacity in the coming weeks.

The American College of Surgeons (ACS) is aware of reports of racial and ethnic discrimination during the COVID-19 pandemic. Since this outbreak started, Asian members of both our own surgical community and the public at large continue to experience bias. We strongly condemn these actions.

COVID-19 does not discriminate. It affects all people, regardless of gender, race, ethnicity, age, sexual orientation, or geographic location. Discrimination of any kind is antithetical to the mission of any health care professional. We were drawn to this profession to serve all patients.

The ACS supports all health care personnel who provide essential services in our communities at this time and maintains that they should be able to continue to do so without the specter of hatred and violence resulting from xenophobia, racism, and bigotry. We also encourage you to discuss any discriminatory acts you witness at any time to your institution’s leadership and to the ACS.
 

As the COVID-19 pandemic continues, it is more important than ever to share stories about surgical challenges and triumphs. The ACS is interested in learning more about how COVID-19 is impacting your ability to practice and provide quality surgical care as this will help to ensure that the College is well-equipped to continue to advocate on your behalf both in Washington, DC, and across the country.

Please take a moment to share how COVID-19 is impacting you, both personally and professionally. This could include practice impediments; access to, or ability to provide, care; additional administrative burdens; equipment shortages; personal shortcomings (health, finances, etc.), or other concerns.

Thank you for taking the time to share your story. As activity continues to unfold, all Fellows and residents are encouraged to review ACS resources related to COVID-19.

The American College of Surgeons (ACS) recognizes that many health care facilities are facing shortages of personal protective equipment (PPE), including face masks, gowns, and respirators. The ACS believes it is essential that surgeons, nurses, anesthesiologists, and other health care personnel be able to speak freely, without fear of retribution, as they seek to find a solution to accessing PPE. We advise surgeons to speak with their institutional leadership on these matters and to be able to direct any concerns to the ACS, with the goal of protecting themselves and their colleagues.

The Joint Commission has released a statement supporting the use of standard face masks and respirators provided from home when health care facilities cannot provide access to PPE that is commensurate with the risk to which health care personnel are exposed during the COVID-19 pandemic. Where masks or respirators are recommended, the ACS maintains that surgeons should have access to and latitude to wear these masks at their sole discretion. The Centers for Disease Control and Prevention (CDC) also has released a document that offers a series of strategies or options to optimize supplies of disposable N95 filtering facepiece respirators.

The ACS strongly supports the ability of surgeons to use their own masks or PPE, but this option does not obviate the hospital’s responsibility to provide adequate PPE to all their health care workers. In these extraordinary times, the ACS encourages institutions to adapt and be flexible so that health care personnel continue to feel safe; The Joint Commission guidelines are a reasonable starting point.

Increasing information is becoming available regarding protection of health care professionals, including the operation room (OR) team. The American College of Surgeons (ACS) has developed a guide that brings together the latest information, data, and recommendations for personnel in the OR, as well as how to minimize risk of COVID infection afterwards. Of note is a video developed by a physician at Weill-Cornell Medical Center with practical information for frontline healthcare workers. The following topics are covered:

1. Use of personal protective equipment in the OR, including donning/doffing of the PPE
2. Intubation risks
3. Specific operative risk issues
4. After operation: leaving the OR and leaving the facility

The American College of Surgeons has posted updated COVID-19 Guidelines for Triage of Emergency General Surgery Patients.

The goal of the guidelines is to provide timely surgical care to patients presenting with urgent and emergent surgical conditions while optimizing patient care resources (such as hospital and intensive care unit beds, personal protective equipment, ventilators) and preserving the health of caregivers.

Because many of you are experiencing the effects of the novel coronavirus and have questions about how to handle the anticipated onslaught of cases, the American College of Surgeons (ACS) has developed a twice-weekly newsletter from the Bulletin to keep you informed and updated on best practices. The information in the newsletter was conceived and compiled by members of the ACS Board of Regents and Officers and is published under the aegis of our Division of Integrated Communications. We anticipate you will find this newsletter useful in providing optimal care to your patients.

Our goal is to keep you informed on how to address this ever-evolving pandemic using the best available information. The Regents and staff look forward to receiving your feedback.  Subscribe to the newsletter

Given the many ethical issues that have arisen in the response to and the management of COVID-19 patients, the American College of Surgeons (ACS) Committee on Ethics has prepared some guiding principles to help our Fellows and their institutions in their decision-making process. These guidelines provide a framework for discussion and do not supersede or supplant thoughtful recommendations coming from institutional bioethics committees. Rather, they should be viewed as an adjunct where such committees exist, and as a resource where they do not. In this initial installment, we examine ethical issues caused by the triaging challenges, moral distress, and financial burden created by this global pandemic.

https://www.facs.org/covid-19/newsletter/032420/ethics

An important point for surgeons is the use of PPEs in the operating room. Because there seems to be a variable understanding of the recommendations, we have provided some basic recommendations. The CDC has the following information and recommendations for PPE use for COVID-19 patients, or persons under investigation (PUI).

While in the operating room (OR), N95 respirators are recommended, particularly when operating on confirmed or suspected COVID-19 patients; however, the American College of Surgeons recognizes that many health care facilities have limited access to N95s at this time. Recent recommendations have been developed by the ASA and others for projected shortages of N95 masks. These include: implementing leadership controls to minimize who needs respiratory protection, use of alternatives to N95 masks, practices allowing extended use and or limited reuse of N95 masks, prioritization of N95 masks for health care personnel at highest risk of COVID-19 and consider use of masks approved by the National Institute of Occupational Safety and Health typically used in manufacturing and construction. For individuals at highest risk of exposure at institutions that are unable to provide N95 masks to all members of the OR team, we recommend that all surgeons and other personnel who are not wearing N95s evacuate the OR during intubation, extubation, and other procedures that may generate aerosolized small particles. The Centers for Disease Control and Prevention and the American Society of Anesthesiologists have recommendations to help prioritize.

Ensuring a proper fit of the N95 mask is paramount, so FIT TESTING is needed. The CDC also has delineated some key factors for using the N95 mask effectively, as well as checking for an appropriate mask “seal”.

Finally, shortages of masks increasingly are being reported, so strategies for optimizing facemasks/PPEs from the CDC are provided in this link.

Proper Donning and Doffing of PPE to Treat COVID-19 Patients

A similar donning and doffing technique can be used as the Centers for Disease Control and Prevention (CDC) recommended for physicians on the front lines during the Ebola crisis. Informational materials are available that demonstrate the procedures described in CDC guidance for putting on and removing PPE.

PPE for Office Visits

The same recommendations made for hospital care should be applied to outpatient office visits. The safety of patients and health care professionals is best served by allowing patients to stay home whenever possible to avoid bringing together large numbers of people. Although much of the focus has been on surgery and procedure areas, outpatient office areas experience a much higher volume of traffic with more providers in a smaller area without routine PPE during patient interactions. In addition to trying to discourage social interaction in these settings, additional preservation of PPE is a priority, which is undermined by continuing to see patients without urgent problems in outpatient offices. Thus, whenever possible outpatient evaluation should be by permissible remote connectivity. Patients who the provider deems in need of urgent personal evaluation may still be offered in-person office visits.

The ACS has collected guidelines from various specialties, facilities, and thought leaders to help inform the decision making occurring at the local level.

The guidelines include

• Cancer Surgery
• Breast Cancer Surgery
• Colorectal Cancer Surgery
• Thoracic Cancer Surgery
• Emergency General Surgery
• Gynecology
• Metabolic-Bariatric Surgery
• Neurosurgery
• Ophthalmology
• Orthopaedic Procedures
• Otolaryngology
• Pediatric Surgery
• Urology
• Vascular Surgery

Some overarching principles for all cases include the following:

1. Be aware that while some of the following triaging guidelines include a “Level 1” (e.g., lowest level of COVID-19 acuity) in the recommendations, one must be aware that the rates of COVID-19 are predicted to skyrocket in the next few weeks, and the overarching recommendation is to prepare for markedly increased rates when triaging elective cases at present.
   
   
2. Patients should receive appropriate and timely surgical care, including operative management, based on sound surgical judgment and availability of resources.
   
   
3. Consider nonoperative management whenever it is clinically appropriate for the patient.
   
   
4. Consider waiting on results of COVID-19 testing in patients who may be infected.
   
   
5. Avoid emergency surgical procedures at night when possible due to limited team staffing.
   
   
6. Aerosol generating procedures (AGPs) increase risk to the health care worker but may not be avoidable. For patients who are or may be infected, AGPs should only be performed while wearing full PPE including an N95 mask or powered, air-purifying respirator (PAPR) that has been designed for the OR. Examples of known and possible AGPs include:
   1. Intubation, extubation, bag masking, bronchoscopy, chest tubes
   2. Electrocautery of blood, gastrointestinal tissue, any body fluids
   3. Laparoscopy/endoscopy
7. There are insufficient data to recommend for/against an open versus laparoscopy approach; however, the surgical team should choose an approach that minimizes OR time and maximizes safety for both patients and healthcare staff. Refer to to Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines for these patients.