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Created by F Belmonte| Created 5.4.2020 | Revised [Date] | Approved by M Gavigan

Contributors Dr. Frank Belmonte – CMO ACH Dr. Mark Butterly – Vice Chair ACH-OL Dr. Mike Cappello – Vice Chair ACH-PR Dr. Jonathan Sherman Dr. Mark Faasee Dr. Bethany Slater Dr. Luca Vricella Dr. Vince Biank Dr. Jessica Kandel Dr. Thang Ngo Dr. John Ruge Dr. Deena Leonard Dr. Andrea Kramer Dr. David Walner Dr. Frank Vicari Dr. Shimoni Dharia Dr. Frank Zimmerman

COVID-19 Information Center:

https://www.advocatehealth.com/covid-19-info/

ACH COVID-19 Surgical Advisory Council Essential Pediatric Surgery & Procedure Criteria Guidelines for Pediatric Surgeons & Operational Leaders April 2020

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Created by F Belmonte| Created 5.4.2020 | Revised [Date] | Approved by M Gavigan

Table of Contents Surgical Task Force Overview Page Purpose & Guiding Principles 3

Essential Procedure Guidelines 4

Pediatric Cardiovascular

Pediatric Cardiac Electrophysiology

Pediatric Cardiac Cath Lab

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Pediatric Gastroenterology 9

Pediatric General Surgery 10

Interventional Radiology - Pediatric 11

Pediatric Neurosurgery 12

Pediatric Ophthalmology 13

Pediatric Orthopedics 14

Pediatric Otolaryngology 15

Pediatric Plastic Surgery 16

Pediatric Pulmonary Medicine 17

Pediatric Urology 18

COVID-19 Procedure Planning Template

ACH Surgical and Procedural Review Committee

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Created by F Belmonte| Created 5.4.2020 | Revised [Date] | Approved by M Gavigan

Purpose

• Define surgical indications for essential surgery/procedure

• Provide guidelines for phased return to normal operations to effectively prioritize and

manage case backlog

• Extend support to operational leaders and surgeons to ensure adherence to the

guidelines

Guiding Principles • Guidelines are evidence-based and in accordance with COVID-related

recommendations made by governmental and recognized medical societies

• Guidelines assist organizational planning and decision-making The

surgeon/proceduralist has a key role in prioritizationbased on the patients history and

condition.

• Contributors are advocates for both surgeons and operational leaders to ensure

restrictions/guidelines will secure surgical care for those patients who would potentially

face permanent damage or harm by delay

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Essential Procedure Planning Guide Surgeons should determine patient’s status based on definitions below

If status is deemed essential, surgeon and operational leader(s) should assess the patient’s needs against available resources

The procedure planning guide can support decision-making to determine the best date, time, and location for the surgery/procedure

Surgery/Procedural Definitions

Emergent

• Life or limb threatening condition or injury requiring surgery; life or tissue loss is

imminent or expected quickly without surgery. It is presumed that these procedures

will proceed regardless of COVID-19 status

Essential

• Non-life or limb threatening condition in which delaying surgery could result in harm;

delaying surgical treatment is likely to have a negative impact on patient outcome

Elective • Surgery or procedure that can safely be delayed for days, weeks or months, without

resulting in permanent harm

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Created by F Belmonte| Created 5.4.2020 | Revised [Date] | Approved by M Gavigan

Essential Procedure Planning Guide

Goals for Surgeons/Proceduralists & Operational Leaders • Prevent harm to the patient by a delay in care • Optimize our resources – human, equipment, supplies, etc. • Reduce potential COVID exposure to physicians, team members and patient

Guiding Principles • Be flexible on date/time • Operational leaders determine capacity based upon available resources • Physician ultimately determines necessity for essential surgery/procedure

within AHCMG supported guidelines • Patients understand given current conditions, cases may be canceled or

rescheduled on short notice • Patients understand they will remain on isolation (home quarantine) until

surgery date to minimize risk of COVID-19 exposure

Patient Considerations • Chronic respiratory disease • Congenital Anomaly • Immunocompromise • Renal disease • Liver disease • Chronic Neuromuscular disorders • Hematologic disorders • h/o of ASA status of 4 or higher assigned

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Pediatric Cardiovascular Essential Case Indications

• Premature infant PDA • Ductal dependent and complex neonates and fetuses as per standard protocol

(First- stage palliation vs. bi-ventricular repair requiring complete repair as per standard of care within the first two weeks

• of life) • Inter-stage complex single ventricle infants and toddlers with cyanosis or having

reached or exceeded appropriate timing of subsequent intervention • Unacceptable cyanosis (all age groups and diagnostic categories) • Lesions with PHTN at risk for developing chronic PHTN (unrestrictive Left to Right

shunts) or CHF • Lesions with Right, Left or biventricular failure with CHF not responsive to medical

therapy • Symptomatic CHD not responsive to medical therapy or associated with sudden

death or other major complication • Endocarditis with indication for surgical intervention • Lesions associated with sudden death:

Aortic dilation Myopathies associated with sudden death Coronary artery anomalies Severe obstructive lesions

• Shunt / prosthetic thrombosis • Other anomalies and clinical scenarios in which deferring therapy poses a

significantly greater risk than proceeding in the current environment • ECMO & VAD for refractory circulatory and/or respiratory failure

Abbreviations: CHD = Congenital heart disease; CHF = Congestive heart failure; ECMO = Extra-corporeal membrane oxygenation; PHTN = pulmonary hypertension; VAD = Ventricular Assist Device

Citations Levy E, Blumenthal J, Chiotos K, Dearani JA. Covid-19 FAQ’s in pediatric cardiac surgery. World Journal for Pediatric and Congenital Heart Surgery 2020 [In press] Stephens EH, Dearani JA, Guleserian KJ, Overman DM, Twedell JS, Backer CL, Romano JC, Bacha E. COVID-19: crisis management in congenital heart surgery. Ann Thorac Surg 2020 [In press]

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Pediatric Cardiac Electrophysiology Essential Procedures

• Pacemaker/ICD generator change for battery depletion • Pacemaker/ICD implant for urgent/emergent conditions

o (symptomatic bradycardia, heart block, risk for life-threatening arrhythmia) • Cardioversion for urgent/emergent conditions

o (symptomatic arrhythmias, risk for thrombus) • EP studies for urgent/emergent conditions

o (peri-op patients, sports/job clearance, medication clearance) • Ablation for urgent/emergent conditions

o (WPW with Afib, medically refractory arrhythmias, peri-op arrhythmias)

Additional Cases as Expansion Occurs

• Pacemaker/ICD implant for indicated conditions o (AV block with stable junctional escape, SND, conditions at risk for SCD)

• Ablation for mildly symptomatic conditions o (Documented SVT, VT or PVCs +/- medications)

• Ablation for asymptomatic WPW o (Procedures that are needed prior to school year or sports participation)

Citations

Guidance for Cardiac Electrophysiology During the Coronavirus (COVID-19) Pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology, American Heart Association

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Pediatric Cardiac Cath Lab Essential Procedures

• Rashkind (balloon atrial septostomy) • Any desaturated patient (shunt or sano, pda-dependent lesions or narrow rvot)

requiring stenting of pda, rvot, stent or pulmonary atresia with intact septum requiring radiofrequency perforation

• Critical and moderate aortic and pulmonary valve stenosis • Any single ventricle caths (except pre-fontan unless cyanosis and critical timing) • Any right ventricular outflow tract obstruction causing ventricular failure • Coarctation of the aorta • Patent ductus arteriosus closure in prematures • Trans catheter pulmonary valve placement • VSD device closure • Caths for preoperative evaluation

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Pediatric Gastroenterology Essential Case Indications

• Potential life threatening gastrointestinal bleeding – including newly diagnosed IBD patients with a life threatening bleed.

• Small bowel endoscopy for ongoing transfusion dependent bleeding • Re-evaluation of life threatening bleed as indicated. • Foreign bodies classified as emergent (esophageal button battery/multiple magnet

ingestion) • Bowel obstruction amenable to endoscopic therapy • Evaluation of caustic injury • Tissue sampling required to diagnose a life threatening disease • Volvulus decompression • Endoscopic vacuum therapy for perforation/leaks • Acute biliary obstruction decompression secondary to stone, lesion or cholangitis • Endoscopic ultrasound for infected pancreatic necrosis or walled off necrosis • Liver biopsy +/- PTC for neonatal cholestasis, suspicious for biliary atresia • Liver biopsy+/- PTC for acute liver failure or impending acute liver failure • Follow up endoscopic band ligationof high risk varices that have recently bled. • Small bowel endoscopy/capsule for suspected small bowel malignancy • Foreign body classified by NASPGHAN as urgent (esophageal coin) • Moderate to severe dysphagia/odynophagia • Dilation of stricture • ERCP or PTC for bile leak • Removal or exchange of temporary stent • EUS for symptomatic pancreatic fluid collection • Urgent initial nutrition support or urgent replacement of PEG/NJ • Polypectomy for complex high risk lesion • IBD – new diagnosis, guide treatment decision • Severe and progressive failure to thrive unresponsive to medical management • Severe C.Diff colitis refractory to medical therapy for fecal transplant • Severe chronic diarrhea unresponsive to medical management • Anorectal manometry or suction rectal biopsy for suspected Hirschsprung’s • Liver biopsy for hepatitis of uncertain cause

Citations

https://www.asge.org/home/advanced-education-training/covid-19-asge-updates-for-members/gastroenterology-professional-society-guidance-on-endoscopic-procedures-during-the-covid-19-pandemic Journal of Pediatric Gastroenterology and Nutrition, Publish Ahead of Print DOI : 10.1097/MPG.0000000000002750 April 2020

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Pediatric General Surgery Essential Case Indications

• Most congenital neonatal anomalies (ex TEF, atresias, anorectal malformations, etc) • Closed loop bowel obstructions • Volvulus/malrotation • Pyloric stenosis • Appendicitis (some can be managed nonoperatively) • Diverting ileostomy for patients with IBD who fail medical therapy • Operative trauma • Incarcerated inguinal hernia • ECMO • Perforated viscus • Ovarian torsion • Bleeding Meckel’s diverticulum with significant hemoglobin drop • Portoenterostomy • Esophageal dilation for stricture • Tunneled lines for chemotherapy/ nutrition (in cases in which a PICC is not

appropriate) • Tumor resections • Pullthrough procedures without diverting ostomies (ex Hirschsprung disease) • Empyema if requires surgical decortication • Cholecystectomy in patients with symptomatic biliary colic

Time-Sensitive Elective cases

• Inguinal hernias in kids < 1 year of age (higher risk of incarceration) • Gastrostomy tube if difficulty with other enteral access • Lobectomy

Citations

https://www.facs.org/covid-19/clinical-guidance/elective-case/emergency-surgery

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Pediatric Interventional Radiology Essential Case Indications

• Any child with joint effusion and clinical picture of septic joint. Need to aspirate. • Conventional arteriogram to identify the bleeding site particularly the GI tract. • Embolization to stop active bleeding site such as bronchial artery bleeding in Cystic

Fibrosis patient. • Any condition that requires IV access (chest port, vascular line, PICC) to treat patient

immediately such as active osteomyelitis / oncology patients. • Biopsy of newly diagnosed mass on imaging which includes malignancy on the

differentials.

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Created by F Belmonte| Created 5.4.2020 | Revised [Date] | Approved by M Gavigan

Pediatric Neurosurgery Essential Case Indications

• Any condition that involves brain or spinal cord compression secondary to fracture, hemorrhage, edema, abscess, instability, or space occupying mass, or compression of the peripheral nerves in which delay would risk irreversible or permanent damage should continue to be treated as a neurosurgical emergency (i.e. subdural hematoma, spinal epidural abscess etc.)

Tumor Guidelines

• Brain tumor with neurologic deficits or other symptoms feared to be progressive. • Spine For patients with progressive deformity, neurologic deficits, and significant

epidural disease, surgery or emergent/essential radiotherapy (i.e. spinal lymphoma) should be offered where appropriate

Spine

• Neurologic compression secondary to fracture, instability, or space occupying mass dorsal spine, tethering of the spinal cord or peripheral nerve in which delay would risk irreversible or permanent damage

• For patients with progressive deformity scoliosis where respiratory or cardiac impairment is documented.

Pediatric congenital

• Myelomeningocele closure needs to be performed within 24 hours of birth along with any other variation of open CNS congenital defect

Hydrocephalus

• Symptomatic hydrocephalus either shunted (shunt malfunction) or not shunted requires emergency surgery

Craniosynostosis

• Those cases where delay of surgery by one month would lead to unfavorable outcome or the need for more complex surgery with additional risk should be considered semi-urgent

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Pediatric Ophthalmology Essential Case Indications • Ruptured globe/globe laceration • Retinal detachment/tear • Vitreous hemorrhage, choroidal effusion/hemorrhage • Endophthalmitis • Intraocular/intraorbital foreign body • Eyelid laceration repair • Canalicular repair • Foreign body removal (corneal/conjunctiva/eyelid if can’t remove in office) • Uncontrolled glaucoma or intraocular pressure • Intractable pain Orbital abscess drainage • Cataract in amblyopic period • Exam under anesthesia (EUA) for ocular or orbital malignancy • EUA on other retinal conditions that may evolve and threaten vision (Coat’s, prior

ROP w/ possible progression to retinal detachment, etc) • Orbital fracture with muscle entrapment • Torn or lost extra ocular muscle • ROP laser/avastin • Some presentations of large chalazion • Tear duct probing/irrigation/tubes with dacryocystitis

Citations https://www.aao.org/headline/list-of-urgent-emergent-ophthalmic-procedures

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Pediatric Orthopedics Essential Case Indications • All new trauma-fracture, dislocations • Acute disruption of tendons-quad, patella, achilles • Infections-all joint/bursa • Hip pinning for Slipped capital femoral epiphysis • Tumor/presumptive tumor • Life/limb threatening pathology • Compartment syndrome • Dysvascular limb • Spine trauma • Polytraumatized child

Time Sensitive Electives

• Scoliosis-case dependent • Guided growth procedures-epiphysiodesis/hemiepiphysiodesis • Developmental hip dysplasia-closed, open reductions, reconstruction

Citations

Top 10 Pediatric Orthopaedic Surgical Emergencies: A case based approach for the surgeon on call. Instr course Lecture 2011;60:373-95.

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Pediatric Otolaryngology Essential Case Indications

• Aero- digestive tract foreign bodies • Disc Battery in any ENT location • Laryngoscopy/ Bronchoscopy due to Severe airway obstruction • Abscess drainage if impending airway obstruction or not responding to antibiotic

therapy • Tracheostomy for severe airway obstruction or prolonged ventilator dependence if not

safe to maintain via ETT • Mastoidectomy or Ear tubes due to Coalescent Mastoiditis/ Complications of Acute

Otitis Media • Complications of Sinusitis • Post-tonsillectomy hemorrhage • Ear tubes if pending mastoiditis or very resistant antibiotic therapy and inconsolable

child. • Tonsillectomy or Adenoidectomy if severe upper airway obstruction/OSA and unsafe to

wait > 1 month • Laryngoscopy and bronchoscopy or Supraglottoplasty or airway surgery in a child with

significant upper airway obstruction and unsafe to wait > 1 month • Closed Reduction Nasal Fracture if severe deformity and family understands risk • Head and Neck Mass Resection/ Biopsy with airway obstruction or concerns about

malignancy • Esophagoscopy with/ without removal foreign body

Citations

Otolaryngologists and the COVID-19 Pandemic – The American Academy of Otolaryngology -Head and Neck Surgery

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Pediatric Plastic Surgery Essential Case Indications

Emergency Cases Emergency cases are those that must be done in an operating room under general anesthesia in an immediate sense and cannot be managed in the ED or in an office setting. Fortunately, these are not common for pediatric plastic surgery. Many of these involve problems that if isolated might be handled in an urgent setting but are going to the operating room as part of a larger patient issue involving another service, most commonly pediatric general surgery, neurosurgery or orthopedic surgery or possibly ENT.

Urgent Cases There is another subset of “urgent” cases which are best done in the operating room under anesthesia but do not require immediate care. The majority of pediatric trauma related to pediatric plastic surgery requiring a general anesthetic fall into this category. A common example would be a

• complex facial laceration or dog bite • pediatric hand injury involving tendons or nerves.

Time Sensitive Elective Cases These are cases where postponement would change the treatment options for the patient.

• Certain synostosis where the postponement of the case would change the surgical options available to the child.

• Mandibular distraction for airway management • Certain cleft cases where the postponement of the case would change the surgical

options available to the child.

Citations https://www.plasticsurgery.org/for-medical-professionals/covid19-member-resources

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Pediatric Pulmonary Medicine Essential Case Indications

• Oncology patients that need BAL • Acute pneumonia of unknown etiology • Noisy breathing with increased work of breathing – diagnosing malacia that can results

in repeated admissions – aspiration/cleft may be included in this category. • Chronic cough – having failed all outpatient treatment that is concerning for more

acute issues (rather than psychogenic, etc) • Cardiac patient with suspicion of plastic bronchitis. • Primary Immunodeficiency Workup. • Acute worsening in CF patients • Pulmonary hemorrhage

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Pediatric Urology Essential Case Indications

• Testicular torsion • GU trauma • Urinary stones: symptomatic, obstructing, and/or infected • Priapism • Paraphimosis • GU abscesses/soft tissue infection • Urinary retention/clot retention • Orchiectomy for testicular cancer • Penile surgery for symptomatic patients (e.g., circumcision for patients with severe

phimosis and balanitis) • Inguinal hernia repair • Orchiopexy in peripubertal/pubertal boys • Urinary stones present > 4 weeks or symptomatic/obstructing • Cystoscopy for stent removal or hematuria

Citations https://www.facs.org/covid-19/clinical-guidance/elective-case/urology

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Goals for Surgeons, Proceduralists & Operational Leaders - Prevent harm to the patient by a delay in care - Optimize our resources – human, equipment, supplies, etc. - Reduce potential COVID exposure to physicians, team members and patient

Guiding Principles - Be flexible on date/time - Operational leaders determine capability based on available resources - Physician determines necessity for essential surgery/procedure within ACH

supported guidelines

Planning Physician:_____________________ Procedure:___________________________

Patient:_______________________ DOB:____________ MRN:_____________

Considerations

Proposed Facility

Bed Requirement (Med Surg/PICU)

Anesthesia (e.g. general, regional, spinal)

Special PPE

Ventilator Post-Op

Blood Requirements

Additional Clinicians (e.g. 2nd surgeon, APC etc.)

OR Team requirements

Expected stay (e.g. <24 hours)

Comorbidity needs

AAH COVID-19 Procedure Planning

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Surgical and Procedural Review Committee • The resumption of medical-surgical procedures will be led at each site by a site-based

team. This team is charged with prioritizing surgical activities based upon patient and

team member safety, availability of testing, PPE and other resources and consistent

with guidelines provided by local, state and federal authorities. This committee will be

co-chaired by the Hospital CMO and Vice

• Recommended committee members include CMO and Vice Chair (co-chairs), Pediatric

Surgeons, Vice President Operations, Director of Clinical Operations, and the

anesthesia, critical care (NICU and PICU) and hospitalist leads

• Guiding principles:

o Patient and team member safety

o Preservation of PPE

o Wise use of testing resources (ACL Central Testing vs. Cepheid)

o Coordination with Operations and Support Services

o Utilization of existing site-based leadership structures & meetings is highly

encouraged with members being recommended

o Coordination with site leadership to scale operations up or down based upon

local COVID-19 prevalence

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ACH Oak Lawn Surgical and Procedural Review Committee

Dr. Frank Belmonte – CMO ACH Dr. Mark Butterly – Vice Chair – ACH-OL Dr. Jonathan Sherman – Pediatric Otolaryngology Dr. Mark Faasse – Pediatric Urology Dr. Luca Vricella – Chief of Pediatric Cardiovascular Surgery Dr. Conrad Mgbodile – Director of Pediatric Anesthesia ACH-OL Barb Perino – COO ACH Jean Smith – Director of Clinical Operations ACH-OL Dr. Luis Torero – Unit Director PICU ACH-OL Dr. Brett Galley – Unit Director NICU ACH-OL Dr. Rinku Patel – Hospitalist Director ACH-OL Dr. Rajeev Nagpal – Pediatric GI Dr. Shimoni Dharia – Pediatric Pulmonology Dr. Thang Ngo – Pediatric Radiology Dr. Frank Zimmerman – Pediatric Cardiology Dr. Alex Javois – Pediatric Cardiac Cath Dr. Manish Raiji – Pediatric General Surgery ACH Park Ridge Surgical and Procedural Review Committee Dr. Frank Belmonte – CMO ACH Dr. Mike Cappello – Vice Chair – ACH-PR Dr. Bethany Slater – Pediatric General Surgery Dr. David Walner – Pediatric Otolaryngology Dr. Aisha Siddiqui – Director of Pediatric Anesthesia ACH-PR Barb Perino – COO ACH Kim Vander Ploeg – Director of Clinical Operations ACH-PR Dr. Maureen Quaid – Unit Director PICU ACH-PR Dr. Jeff George – Unit Director NICU ACH-PR Dr. Svetlana Kravtchenko – Hospitalist Director ACH-PR Dr. Vince Biank – Pediatric GI Dr. Thang Ngo – Pediatric Radiology Dr. Lauren Camarda – Pediatric Pulmonology Dr. Frank Zimmerman – Pediatric Cardiology