American Society of Plastic Surgeons
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  1. COVID19 Member Resources

Important Update to Considerations for the Continuation or Resumption of Elective Surgery and Visits
ASPS Statement – Updated December 2020

Executive Summary

COVID/COVID-19 has required plastic surgeons to adapt to the ongoing pandemic, and to stay tuned to current local trends.

In particular:

Awareness

  • Know what's happening in your own area in terms of COVID prevalence, hospital numbers, and local and state policies affecting your practice.
  • Stay current with major CDC/FDA updates.
  • Familiarize yourself with CDC recommendations for return to work after COVID exposure (see document).

Enhanced cleaning measures

  • Hand hygiene, more than ever.
  • Implement enhanced cleaning protocols for your office and facility, especially high touch-areas.

Patient Flow

  • Implement social distancing measures in your office.
  • Consider how to minimize unnecessary exposures - e.g., telemedicine, restricting visitors, online pre-registration and completion of documents, eliminate waiting area, etc.
  • Consider Point-of-Service testing
    • PCR testing
    • Antigen testing
      • Home Antigen testing

Greater awareness of PPE needs and PPE use

  • Learn what PPE is required for a given procedure and ensure its availability for yourself and your staff. Make sure everyone knows how to use it correctly, including in the clinic and the med-spa. See details in document.

Pre-op testing & scheduling

  • Be extra thoughtful with patient co-morbidities & resource use when scheduling surgery.
  • Pre-op PCR testing is recommended, since COVID and anesthesia together seem to greatly increase morbidity and mortality. Patients should self-quarantine during time period between test and surgery. See document for discussion.
  • If a patient has a Positive PCR COVID test, an elective operation should be postponed.
    • As yet, there is little specific guidance about when it is safe to re-schedule a patient following their recovery from an acute episode of COVID-19.
  • For purely cosmetic surgery in a previously positive patient:
    • Refer to local Department of Health and/or Institutional standards
    • Patients who have had COVID and are antibody positive may test PCR positive for up to 90 days, which may not confer active infection. ASPS recommends postponing surgery until the patient is asymptomatic and is approved for surgery by infectious disease and/or primary care physician.
  • Vaccinated Patient
    • ASPS recommends that COVID-19 vaccinated patients should be PCR tested preoperatively, until data regarding transmissibility after vaccine is made available.

New consents

  • Use a consent that has appropriate COVID-19 language, explaining risks and limitations.

Communication:

  • Share with your patients the efforts you are making to ensure their safety.
  • Make sure they understand that surgery may be cancelled or postponed for safety reasons related to COVID exposure, or staffing/resource changes at your facility.
  • Have a fair financial policy regarding cancellations, which is communicated.

NOTE: As restrictions change in various regions of the country, members have requested an update to prior statements regarding elective procedures, breast reconstruction, and office visits. The previous working group was re-convened which included plastic surgeons who are in practices across the country, in urban and non-urban settings, at different career states, and in academic, employed, and private practice settings.

Local/Regional Factors: ASPS recognizes that the management of operative procedures and clinical visits depends on local/regional factors. Hospital, local, county, state, and regional regulatory bodies will determine the actual practice in each hospital or facility. We recommend that our members consult with these organizations and institutions to better determine the appropriate course for their situation, while considering the issues discussed below.

Ongoing Assessment: In addition, the dynamic nature of the COVID-19 crisis will necessitate an ongoing assessment of new trends, new data, new testing, and new treatments. Thus, the considerations below will be reviewed regularly and updated as necessary.

Considerations: The following considerations are based on available information, CDC guidelines and other regulations. Future CDC updates and guidelines, and state/regional/county/local regulations should supersede the information listed below.

SURGE SITUATION AND STATISTICS

Realizing that reported numbers are dependent on the availability of testing in the community, understand:

  • Statistics in your community
    • Prevalence and incidence of COVID in your community
    • Local numbers of new COVID cases should be consistently decreasing.
    • Local numbers of new COVID deaths and ICU patients should be consistently decreasing.
  • Local hospital/medical system - Are these entities in a crisis (surge) situation?
    • Even if you plan outpatient procedures in off-site locations, the capacity of these entities may be important in the event of an emergency or complication. In addition, critical resources may need to be diverted to local hospitals if a crisis situation exists.
      • Are Ventilators and ICU beds available?
      • Are acute care (hospital) beds available?
    • Testing Availability - What is the testing situation in your areas?
      • Is testing easily accessible in your area?
      • What kind of tests are available and what is the role of each kind of test?
        • RNA/PCR and isothermal nucleic acid amplification tests (see Testing section under Safety heading below)
        • Serology tests for SARS-CoV-2 antibodies (IgM / IgG) (see "Testing" section under Safety heading below)
        • Antigen testing, followed by PCR testing
        • What are the sensitivity and specificity of the tests being used in your area?
      • What is the turnaround time for testing?
    • Regulations - Know your National, State, and Local regulations - do they allow elective surgeries at this time?

SPACE

  • Social distancing measures: Implement patient flow plans that allow for social distancing protocols in your perioperative area and in the office.
    • Waiting room spacing/staggered scheduling
    • Consider the total number of people in the office at any one time
    • Consider having patients and family wait in their cars or off site
    • Consider the availability of wipes and other hygiene/cleaning products
    • Discontinue self-service hospitality stations (coffee, water, etc.) and magazines/pamphlets that may act as means of virus transmission
  • Cleaning: Reassess cleaning protocols in your office and facility.
    • Have a plan for terminal cleaning of perioperative/ operating room (OR) areas and enhanced maintenance cleaning of clinics, especially in high-touch areas. Show patients that this is being performed.
    • Have multiple hand sanitizing dispensers available throughout the office
  • Transfers: Know your availability of transfer options for your office-based O.R. or Ambulatory Surgery Center
    • This may vary day by day and thus may necessitate regular reassessment

SUPPLIES

  • Is there adequate overall PPE in your community?e., elective surgery will not pull PPE from critical care areas
  • What is the availability of appropriate PPE for your office and/or facility?
    • The current CDC guidelines recommend N95s, eye protection, gowns, and gloves be used in aerosolization-generating procedures. Procedures "above the clavicle" are particularly noteworthy for increased risk and may require additional PPE for surgeon and staff.
    • Universal masking is currently recommended by the CDC in hospitals as well as general masking in public.
    • Continue to check CDC guidelines as these recommendations may change.
  • Are there adequate anesthesia supplies for facilities with operating rooms.
    • Glidescopes
    • Sedatives
    • Oxygen
    • Inhaled anesthetics
    • Protecting your anesthesia machine
    • Are there appropriate cleaning supplies?
    • Evaluate the reliability, consistency, and adequacy of your office and OR Supply chain
      • In many areas, PPE such as surgical masks, N95's, gowns, gloves, cleaning supplies are sporadic, on back order, or not available
      • Appropriate PPE must be available to open safely!
      • Contact your insurance carrier(s) to discuss if and how your front-line staff, those who treat patients with potential COVID-19, are protected.

STAFF (ADEQUACY AND SAFETY)

  • Is your staffing adequate to cover your anticipated needs?
    • Reconsider surgical procedures when staff are being re-deployed
    • Ensure adequate patient/staff ratios
    • Consider staff well-being (both physically and mental wellness) and/or fatigue level
  • Do you have the supplies to address the safety of your staff? (see supplies above)
  • Consider screening of employees, as well as patients.
    • Consider temperature checks and symptom questionnaires on site - follow CDC, state, or local guidelines.
    • Determine your mask policy for staff and patients
    • Consider contacting patients prior to their visit to your site to assess for symptoms and opportunities to minimize risk and to notify them of your office policies regarding screening, masking, etc.
    • Consider an attestation document prior to procedure
  • Evaluate a plan to minimize face-to-face exposure time for outpatient clinical settings. For example:
    • Consider telehealth/virtual encounters, in preparation or as a substitute for in-person encounters
    • Encourage patients to use online patient portals, electronic communication, mail, or fax to complete registration and other paperwork prior to arriving if available
    • Consider having patients wait in the car until their appointment time
    • Minimize the number of family members allowed with the patient
    • Avoid unnecessary staff in the office and in the operating/procedure room
      • Use telehealth roles for staff as appropriate.
      • Minimize non-essential staff, observers, students, industry representatives
    • Ensure staff is educated regarding:
      • Appropriate donning/doffing (where appropriate)
      • Proper hand hygiene
      • Other COVID training/education updates
      • Cleaning protocols: cleaning products that include
        • 70-90% isopropyl alcohol or
        • 60-70% ethanol
        • UV light works well theoretically, but it is not used in many virology labs because dust impedes the effect. However, UV-C light devices are available for smaller objects and in some cases for rooms.

NOTE: The EPA website provides resources and a list of disinfectants for COVID-19 at https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2

  • Social distancing and other safety measures for your clinical areas (see above)
  • Recognizing signs and symptoms of COVID-19
  • COVID-19 disease process and risks
  • Consider discouraging food sharing and open food containers in staff areas
  • Ways to minimize their exposure outside of the work setting
  • Are anesthesia services and personnel available? (if applicable)
  • Have a plan for dealing with potential exposures in the office/OR. If a patient turns out to be COVID+ after they have been to your office/O.R. or if one of your staff members is positive.

SAFETY (PATIENT)

In the office/clinic

  • If patients or staff are known COVID+, defer to CDC guidelines or state/regional/county/local regulations or laws that may supersede the recommendations below) (https://www.cdc.gov/coronavirus/2019-ncov/hcp/return-to-work.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhealthcare-facilities%2Fhcp-return-work.html)
    • COVID+ Healthcare Personnel (HCP) with mild to moderate illness (i.e. pulse ox > 94%, respiratory rate <30, PaO2/FiO2 >300 or lung infiltrates <50%) who are not severely immunocompromised can discontinue isolation and return to work without retesting (per current CDC guidance):
      • After 10 days have passed since symptoms first appeared AND
      • At least 24 hours have passed since last fever without the use of fever-reducing medications AND
      • Symptoms (e.g. cough, shortness of breath) have improved.
    • COVID+ Healthcare Personnel (HCP) with severe or critical illness or immunocompromised can discontinue isolation and return to work without retesting (per current CDC guidance)
      • After 20 days have passed since symptoms first appeared AND
      • At least 24 hours have passed since last fever without the use of fever-reducing medications AND
      • Symptoms (e.g., cough, shortness of breath) have improved.
    • COVID + Healthcare Personnel (HCP) who were asymptomatic throughout their infection and not severely immunocompromised may return to work when 10 days have passed since the date of their first positive viral diagnostic test.
    • COVID + Healthcare Personnel (HCP) who were asymptomatic throughout their infection and severely immunocompromised may return to work when 20 days have passed since the date of their first positive viral diagnostic test.
  • When staff return to work, they should:
    • Wear a facemask for source control at all times
    • Be restricted from contact with severely immunocompromised patients (cancer, transplant, etc.) until 14 days after illness onset
  • Patients who travel should:
    • Conform to local quarantine guidelines before and after surgery
    • Undergo testing in jurisdiction where care is to be provided
  • PPE (based on current information at the time of this document and may change; follow current guidelines of the CDC, state, county, and local regulations/guidelines)

NOTE: See CDC website for infection prevention and control recommendations for healthcare professionals during COVID-19 pandemic at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html.

  • To address asymptomatic and pre-symptomatic transmission, implement source control for everyone entering a healthcare facility, regardless of symptoms.
    • Surgical masks are to be used in all clinical areas by staff
    • Patients may wear either cloth masks or surgical masks
    • For non-clinical areas, patients and staff may wear cloth masks
    • Eye protection worn at all times
    • Have a plan to address staff and/or patients who are non-compliant with facemask or other protective equipment policy
    • N-95 masks or other FDA/NiOSH approved equivalent and eye protection, gowns and gloves, should be used for procedures that may lead to aerosolization of viral particles. N95 masks with exhaust valves may not provide source control and also should not be used in the O.R. Examples of aerosolization-generating procedures per the CDC include:
      • Open suctioning of airways
      • Sputum induction
      • CPR
      • Intubation/Extubation
      • Non-invasive ventilation (eg BiPAP, CPAP)
      • Bronchoscopy
      • Manual ventilation
      • Potentially nebulizer administration
      • High Flow O2 delivery
      • Surgery/procedures involving instrumentation in the head and neck region
    • Clinic Procedures - injectable, peels, microneedling, aesthetic facial device services
      • Universal masking (N95 or other FDA/NiOSH approved) and eye protection/face shield (patient masked as feasible)
      • Gowns and gloves are dependent on the degree of anticipated contact
    • If considering Reprocessing/Reusing/Extended use of PPE, follow guidelines per NIH, CDC, and other regulatory bodies available at https://www.nih.gov/news-events/news-releases/nih-study-validates-decontamination-methods-re-use-n95-respirators

Pre-op

  • Patients undergoing operations, procedures, and engaging in face-to-face clinical visits should be asymptomatic and afebrile.
    • Consider onsite screening of staff and patients
  • Pre-symptomatic patients. Given reports of increased morbidity and mortality of patients who undergo an operation during the pre-symptomatic/incubation period of COVID, efforts should be made to minimize the chance of operating on these patients.
  • Testing considerations.(See Testing information at the end of this document)

Note that this information is based on information available at the time of this document; as testing improves and evolves, recommendations for testing may change.

  • Covid-19 - RNA/PCR and isothermal nucleic acid amplification tests
    • ASPS recommends that members use their clinical judgment and employ measures to avoid operating on a patient who is asymptomatic in the incubation period to minimize postoperative risks and intraoperative exposure for both the patient and the surgical team. In an effort to mitigate risk:
      • Preoperative PCR testing for acute infection of elective surgical patients is recommended. Pre-op PCR testing should be performed as close to the surgery date as feasible, but in time to get results. This statement is mitigated with the understanding that unavailability of and access to testing may be a barrier. ASPS has arranged for its members to have preferred access to testing via Quest. Patients may also be referred to local outpatient testing options including primary care doctors, clinics, and local/regional testing sites.
      • Encourage preoperative patients to self-quarantine for 5-7 days prior to the operation to try to minimize the chance of being in the incubation/pre-symptomatic phase during the operation
      • Consider calling patients for symptom screening 2 weeks prior to the anticipated procedure
      • Currently, the gold standard is the Nasal/nasopharyngeal PCR test, but this may change as other modalities of tests are approved and made available
    • If a patient has a Positive PCR COVID test, an elective operation should be postponed, and the patient referred for further work-up. (See "In the office/Clinic" section)
      • There is no current guidance as to when patients are safe to have surgery after a known COVID positive test. Surgeons will need to use their best judgment depending on the nature of the procedure, the severity of the COVID course, and the general medical status of the patient.
    • The assessment and increased risks specific to COVID19 must be discussed with patients prior to any operation or procedure.
    • After testing all patients preoperatively, the likelihood of operating on a presymptomatic COVID patient is = (local prevalence rate) x (false negative test rate)
    • Consider engaging with relevant anesthesia providers, nurses and OR staff regarding testing rationale, to ensure that there is team agreement and confidence.
  • Delay in testing - Be aware of testing reagent shortages and other testing delays, inform patients of possible disruption and delay, and have a plan to address delays including potential alternative sources of testing.
    • Serology tests for SARS-CoV-2 antibodies (IgM / IgG)
      • Given the current limited understanding of COVID antibodies and the quality of available tests, the utility of serology (IgG/IgM) testing for preoperative testing of patients to assess immunity is questionable. These tests do not determine whether someone has an active COVID-19 infection.
      • Testing staff - at this time the utility of testing of staff with the currently available serology tests is unknown (see discussion about Serology tests below)
      • The role of serological testing will evolve over the coming months and guidelines regarding use of these tests will be adjusted accordingly.
      • Serology testing is currently being used for population prevalence studies as well as for screening for eligibility for convalescent plasma donation.
    • Informed Consent - Consider either additional COVID language in existing consents (or a separate consent) to address potential for exposure to COVID-19, limitations of testing and other mitigating measures, as well as the risk of undetected infection at the time of procedure leading to potential increased morbidity and mortality.

In the OR

  • Ensure adequate and appropriate PPE - Operations above the clavicle should be considered more exposure-prone. CDC continues to update these guidelines and thus those should supersede those listed below
    • Surgeon - PPE (see PPE section above)
    • OR Staff - PPE (same PPE for both scrub tech and surgeon.)
    • Anesthesia - PPE, including N95, face shield and gown
  • Minimize exposure in room during intubation/extubation
    • Know aerosolization time based on air-exchange rate in the operating room
    • Consider having the surgical team leave/ minimize staff in the room during intubation and aerosolization time above.
  • Anesthesia mitigation measures - Consider anesthesia tents and Glidescopes
  • Minimize unnecessary equipment and supplies in the room
    • Consider limiting supplies in the room specifically to those required for each case.

Post-op

  • Consider telehealth when appropriate and available for pre-op/post-op discussions, and post-op wound checks.
  • Consider 7-day post-op social isolation period to reduce incidence of a new exposure and infection as feasible, excluding needed post op visits

SCHEDULING CONSIDERATIONS

In the event that the scheduling of operations needs to be phased in, the following factors can be considered, with the recognition that prioritization will be made at a hospital and surgeon level dependent on local/regional factors.

  • Risk to the patient:
    • The urgency of the case would take most precedence: Emergent >Urgent - will a delay in surgery have a detrimental effect on the patient > Elective non-urgent
      • It is recognized that the urgency / elective status of a procedure may depend on specific patient circumstances that will necessitate the clinical judgment of the surgeon.
    • Comorbidities: Take caution with patient co-morbidities and risk for COVID-19 morbidity / mortality (until adequate testing is available):
      • age >65, DM, HTN, Cardiac, COPD / asthma, Obesity
      • ASA status
    • Likelihood of complications/risk of the procedure
    • Likelihood of needed postoperative long-term care such as a nursing home or inpatient rehab
    • Prolonged time in the OR - multiple procedures or long complicated cases
  • Resource needs
    • Beds & staffing
      • Current hospital status: within a hospital, current inpatients may be prioritized over non-hospitalized patients if the operation is needed for the patient to be discharged or to avoid readmission
      • If an elective case and patient is not currently in the hospital, assess the likelihood/risk of needing an ICU bed/ventilator or a hospital bed post operatively. In this scenario, if resources are an issue, elective outpatient operations might be prioritized over elective same day admits that may need a hospital bed.
    • Blood - likelihood of needing a blood transfusion, assess local blood availability
  • Anesthesia - Does the patient need intubation, sedation, and/or local/regional anesthesia

SERVICE

  • Communicate with your patients the efforts employed for their safety re: COVID 19. For example:
    • Cleaning
    • Social distancing measures
    • Testing where applicable
    • PPE where applicable
    • Telehealth options
  • Communicate with patients that, for their safety, surgery may be cancelled based on factors such as:
    • development of symptoms,
    • suspicion of exposure
    • positive screening test.
    • community need for resources.
  • Communicate that a second surge is expected, and we will evaluate the safety of surgery, procedures, and office visits on an ongoing basis
  • Develop a financial policy regarding cancellations and communicate this clearly preoperatively.
  • Communicate more frequently with your patients, even just to "check in"

SUPPLEMENTAL TESTING INFORMATION

  • Covid-19 - RNA/PCR and isothermal nucleic acid amplification tests
    • RNA/PCR and isothermal nucleic acid amplification tests demonstrate the presence of viral particles, which are present in both symptomatic and asymptomatic individuals who are infected with the virus, and throughout the period of time when an individual sheds virus.
    • This test is done with a nasal/ nasopharyngeal swab or saliva sample.
    • Many tests have reported sensitivities to be as low as 60-70% and thus may miss COVID positive patients 30-40% of the time. In the absence of national data, ask your hospital/lab for internal validation data on in-house tests.
    • It is unclear if the high false negative rates are due to timing of test or due to swab techniques or specimen handling.
  • Serology tests for SARS-CoV-2 antibodies (IgM / IgG) - not recommended for pre-op screening.
    • This test is usually done with a finger prick
    • There are qualitative and quantitative tests for IgM and IgG.
      • Qualitative tests only report out whether antibodies are detected or not. Currently there are only a few that are marketed under the FDA Emergency Use Authorization provision, but none are verified by the FDA
      • Quantitative tests can report the level/titers of the antibodies - currently none of these are approved in the US but have been employed in other countries
    • Quality of tests:
      • Most tests were allowed on the market by FDA under emergency protocols, without the usual level of evaluation. Thus, the quality and reliability of these tests are unknown, and some have been withdrawn from the market.
      • Some may have cross-reactivity with other non-COVID coronaviruses or have low detection rates.
    • Utility of test
      • The antibody tests for IgG and IgM show that the person has antibodies but
        • it is still unknown whether these antibodies are protective or whether you can still get COVID-19 again.
        • It is still unknown if all previous COVID + patients will have antibodies and how long they persist.
        • Current tests do not establish immunity or exclude active infection.
      • Thus, given the serology testing with our current limited understanding of COVID antibodies, the utility of serology testing for preoperative testing of patients is questionable.
        • If accurate, validated tests were readily available and if the presence of the detected antibodies were understood to confer a protective immunity, then serology testing (IgG/IgM) may have a role as
          • an adjunct with PCR testing of patients. Serology testing does not rule out active infection and thus should not be used alone to rule out active COVID infection in preoperative patients
          • A means to test staff for past infection/immunity. However, depending on the evidence for how long the antibody is expected to remain (indefinitely/time limited), consideration would be needed as to the timing and regularity of testing
        • The tests may have utility to determine the prevalence of COVID exposure in the population.
        • The tests may also have utility in determining who is eligible to donate their plasma in a COVID Convalescent Plasma program where the plasma of a patient who has recovered from COVID is transfused in a patient with an acute COVID infection.
        • A quantitative test may also have the additional utility of identifying plasma that has a higher concentration of antibodies for convalescent plasma transfusion. Plasma with higher titers may require fewer units for efficacy and preferentially used.

For more information, please see our ASPS COVID-19 Member Resource page and check with your local, county, state, and regional resources for local guidance.

Approved by the ASPS Executive Committee on August 13, 2020.
Originally document approved on April 21, 2020.

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