COVID-19 testing for adult patients before surgery / treatment/ attendance at LTHT

Standard Operating ProcedureVersion 4 - 2.06.2020

All patient testing for COVID utilises the PCR swab test. Whilst patients may be offered an antibody test if we are already taking a blood sample, this does not form part of our COVID risk reduction measures.

1. Acute Non elective patientsAcute non-elective patients should be swabbed for COVID on decision to admit (alongside all usual pre-admission checks) and a decision made to proceed with/ without swab result based on patient condition/ level of urgency to proceed. As part of the routine workup for emergency general surgery, abdominal CT will also be combined with Chest CT for adult patients.

2. Elective patientsThis protocol applies to both clinically urgent elective patients and those who have been identified by CSUs in their waiting list backlog as a priority for the capacity released from areas temporarily repurposed for COVID-19 patients.

Please note that the Chest CT previously indicated for elective surgical patients has now been removed for all following updated guidance from the Joint Royal Colleges (updated advice issued 13/05/2020 and 21/05 for Cardiac surgery). There are no new indications for additional CXR as part of the COVID screening process.

Normal pre-assessment checks should still be completed by existing surgical teams, including referral to Pre-assessment teams at the point of decision to treat, cessation/ commencement of relevant medications, bed information and confirmation from wards/ICU/HDU of availability. Patients should also be consented specifically for COVID risks.

There is a separate procedure for Paediatric patients and accompanying carers.

3. Recommended Testing RegimesCOVID testing for elective patients is currently advised as follows:

3.1Cardiac, Cancer and Urgent IP General Surgery Patients (and their household members) should be advised to isolate at

home for 14 days, and be able to confirm they are COVID-symptom free for 7 days pre-operatively.

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Swab to be taken at 48 hours (2 days) or within 72 hours (3 days) of TCI date for significant treatment/ surgery (from Monday 8th June).

3.2Day case procedures General Anaesthetic daycases

o Patients (and their household members) should be advised to isolate at home for 14 days, be able to confirm they are COVID-symptom free for 7 days pre-operatively. A single swab to be taken within 72 hours (3 days) of intended procedure.

Local Anaesthetic daycases using Aerosol Generating Procedures (see Appendix 1 for list of AGPs)

o Patients (and their household members) should be advised to isolate at home for 14 days, be able to confirm they are COVID-symptom free for 7 days pre-operatively. A single swab to be taken within 72 hours (3 days) of intended procedure.

Local Anaesthetic daycases There are no pre-treatment swabbing / COVID testing requirements, although all patients should be screened before any attendance.

Endoscopy procedureso Patients (and their household members) should confirm they are

COVID-symptom free for 7 days pre-attendance with one swab taken within 72 hours (3 days) of procedure.

Cardiology daycaseso For General Anaesthetic cases patients (and their household

members) should be advised to isolate at home for 14 days, be able to confirm they are COVID-symptom free for 7 days pre-operatively with a swab taken at 48 hours (2 days) and within 3 days of TCI date.

o For Local Anaesthetic cases all patients should be screened to confirm they are COVID-symptom free and one swab taken within 72 hours (3 days) of intended intervention.

MaternityThe majority of cases will be acute deliveries where the patient should be swabbed on arrival.For elective caesarean cases, the patient should be advised to home isolate for 7 days prior to their procedure, with a single swab taken within 72 hours (3 days) of intended admission.

DentistryWe are currently working through dentistry issues in relation to AGPs and any pre-treatment isolation and swabbing requirements.

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3.3Common patient flow areasFor any areas where patients from different categories as above would share a common, admission /recovery/ discharge area or theatre environment, consideration should first be given as to how these groups could be separated.If that is not possible then all patients should be isolated and swabbed using the same protocol.

3.4Cases that do not meet the defined criteriaWhere patients do not fulfil the criteria regarding isolation or pre- procedure swabbing they cannot be admitted via our supercold pathways / areas.If the clinical team deem that the patients treatment must go ahead and cannot be delayed to achieve the required pre-treatment isolation/ swabbing, then any admission/ surgery must be via the suspected COVID areas.

For some Learning Disability patients there may be individual circumstances where the pre treatment regime cannot be followed. These patients will need to be admitted and treated via suspected COVID areas/ theatres after specific arrangements tailored to that individual are agreed between the surgeon, anaesthetist and the Learning Disabilities team.

Exceptional cases may require a discussion with the Deputy Chief Medical Officer (with as much notice prior to planned surgical date as possible).

3.5Time crucial / semi-elective surgery

These patients should be swabbed at the time the assessment is made that they need surgery. Teams should wait for the result before any decision to proceed with the planned surgery.

3.4 Outpatients/ OP DiagnosticsThere are no OP swabbing / COVID testing requirements, although all patients should be screened before any face to face appointment.

4. Process

4.1 For patients who require pre-assessment and COVID swab testingAll patients should be routed via the centralised pre-assessment service with the following exceptions:

Chapel Allerton (own pre-assessment and swabbing service) Endoscopy (using AQP swabbing service) Independent Sector (pre-assessing and swabbing LTHT patients referred)

All patients should be booked for pre-assessment using the electronic surgical booking form and be pre admitted on PAS and TMS as soon as possible to allow the Pre-assessment team to coordinate appropriate pre-treatment COVID-19 testing.

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Patient swab testing will be undertaken by the pre-assessment team, utilising the COVID isolation PODs at SJUH and LGI. PODs are located at the roundabout at SJUH (former union coffee shop) and outside LGI A&E department. Whilst patients should be advised to maintain isolation for 14 days prior to surgery/ significant treatment, hospital attendance for pre-operative tests is required. Visits for swabbing, pre-operative assessment and any additional tests will be combined where possible and will be coordinated by the pre-assessment team.

For those patients who do not drive, or do not have a household member of staff that can drive them, arrangements will be made on a case by case basis either through their home hospital team, pre-admission or a home delivery service.

If not provided at the decision to treat appointment, pre-operative packs of MRSA washes and any other necessary preparatory medicines (e.g. bowel prep) should be delivered to patient’s homes, maintaining social distancing guidelines. This will be arranged by the Pre-assessment team as well as any Group and Save requirements.

This is a 7 day service and both appointments and results checking will be available on weekends. Patients should be contacted and the advice leaflet for patients (sample in appendix 3) should be issued by surgical teams at least 14 days before the planned treatment date to advise patients of the need for isolation and COVID testing pre any significant treatment/ operation.

4.2 For CSUs that just require a swabbing service (ie normally undertake their own pre-assessment )All patients should be routed via the centralised pre-assessment service, who will either:

undertake patient COVID swabbing for the CSUs coordinate access to the LDI drive through swabbing team capacity

There will be a small number of CSUs that wish to undertake their own pre-treatment swabbing due to other pre-assessment/ pre-treatment requirements. This must take place in a peripheral location / as a drive through option in order that patient isolation is maintained as much as possible prior to treatment. Further advice on how to achieve this is available via the IPC or Tactical testing teams.

4.3 All patientsIt is hoped that the majority of patients/ household members will be able to transport themselves for swabbing / treatment. Where this is not possible there are a range of options (for both LTHT and LTHT Independent Sector patients):

Use of LDI local home swabbing service

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Liaison by LTHT teams with patients local hospital referring team to access local testing

Posting/ courier of kits to patients home Limited pre-admission/ use of local accommodation ahead of admission date.

The central pre-assessment team can advise /coordinate this where required.

If not provided at the decision to treat appointment, pre-operative packs of MRSA washes and any other necessary preparatory medicines (e.g. bowel prep) should be delivered to patient’s homes, maintaining social distancing guidelines. This will be arranged by the Pre-assessment team.

5. ResultsCOVID swab samples will be processed and returned within 18-24 hours of the swab being received. Surgical admission teams should check for results day 1 pre-operatively. If results are not available within expected turnaround times, please contact:

Swab samples – Mon-Fri 9am to 5pm = 0113 392 8750 (select option 2). Weekends & Bank holidays 9am to 5pm = 07901 108477

Patients should be notified of their results by surgical teams. If the results are negative, admission / administrative staff can do this For positive results, a clinically trained member of staff must contact patients

to discuss next steps following discussion with the MDT about an appropriate alternative treatment plan. Patients should also be informed that they may subsequently be contact by the NHS or LTHT Test and Trace team

If results come back as “indeterminate”, please contact the appropriate team via the above methods for further clinical advice on next steps.

If the decision is made to delay treatment as patient is COVID +ve, they should normally restart the 14 day isolation period and repeat all pre- treatment COVID tests (but not pre-assessment process). If the delay is due to bed capacity then an alternative date should be offered as soon as possible with the patient continuing to isolate and a further swab if required (if previous swab more than 72 hours before admission).If the decision is made to proceed with treatment, advice should be sought from the infectious diseases team about the most appropriate environment and necessary precautions to do so in.

6. SchedulingThe existing theatre list sign off process remains in place, with an understanding that there is likely to be a higher likelihood of changes to patients listed. Teams should therefore plan as follows:

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21 days before days before scheduled date – have a full list of patients identified, and have options for substitution re any pre-treatment issues. Letter, any pre-assessment information and patient leaflet should be issued.

14 days before scheduled date patient should be contacted to ensure they (and any household members) are self-isolating

7 days before scheduled date – confirm priority order of patients listed and identify any specific requirements on PAS and TMS for theatre teams to plan

3 days before scheduled date – contact theatre teams directly with any substantial changes made to patient list regarding 1st swab results to ensure requirements can be accommodated

1 day before scheduled date – confirm patient list on TMS by 3pm post 2nd swab result

If the patient has not isolated for the required period or had the relevant number of pre-treatment swabs, treatment should not proceed without a discussion with the Deputy Chief Medical Director.

7. Sign OffThis process has been approved for use by:Group: LTHT COVID Testing Tactical groupDate: 2/06/2020Review: This will be an iterative process as further national guidelines are available and further LTHT treatment capacity is released as recovery plans progress.

Author(s):Sarah Dempsey, Programme ManagerAngie Craig, Associate Director OperationsOn behalf of LTHT COVID Testing group and Cancer Board

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Appendix 1 – Aerosol Generating Procedures (AGPs)

The following procedures are currently considered to be potentially infectious AGPs for COVID-19:

Intubation, extubation and related procedures, for example, manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)

Tracheotomy or tracheostomy procedures (insertion or open suctioning or removal)

Bronchoscopy and upper ENT airway procedures that involve suctioning

Upper gastro-intestinal endoscopy where there is open suctioning of the upper respiratory tract

Surgery and post mortem procedures involving high-speed devices

Some dental procedures (for example, high-speed drilling)

Non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)

High Frequency Oscillatory Ventilation (HFOV)

Induction of sputum

High flow nasal oxygen (HFNO)

Currently Spirometry and CPEX testing are not considered to be part of the national AGP categories.

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Appendix 2 - Process Flow Diagram

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Appendix 3 Patient information Leaflet (available via LTHT website)

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There are some additional risks to both patients and healthcare workers during this period. We have made new arrangements to greatly reduce these risks – please read this information carefully and feel free to ask questions.

We have arranged to treat patients in hospital as normally as possible - we are using different wards and theatres in dedicated ‘clean zones’. This means that we are keeping people away from other people as much as possible. Please be aware that staff may be wearing a lot of protective clothing ‘PPE’ which can look a little intimidating. (See picture).

In recommending treatment, we have carefully weighed up the risks and benefits to you, taking into account any additional risks. These risks are real – doctors, nurses and patients have unfortunately died of pneumonia caused by coronavirus. These measures are to help reduce the risks and should be highly effective if you comply with them.

The risks of coronavirus infection will also be mentioned on your consent form.

There are four new measures we have put in place to ensure your safety: We are asking you to strictly adhere to a quarantine period; which will be advised when we contact you to arrange your operation. Do not leave home and do not mix with anyone who does not already

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• You will receive regular phone calls from our specialist nursing team. We understand your situation is very stressful and we will support and reassure you whilst at home.

• We will arrange a coronavirus swab test before your admission for surgery. This is to confirm that you are not suffering from the virus.

• In the unlikely event that we detect coronavirus or lung changes, it is likely that your surgery will be put back by 2-3 weeks. We will continue to discuss your treatment options with you.

After your treatment, the team looking after you may decide that you are suitable for early discharge from hospital, with appropriate support. This is to help reduce your length of stay in hospital and the risk of catching any Coronavirus associated infection.

This may mean, depending on the treatment you have had, that a major part of your recovery will be at home supported by the community team and/or in our outpatient clinics. Please be assured we will carefully consider your case to make sure that the quality of

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