New process evaluates patients for elective surgeries following COVID-19

Acknowledging that COVID-19 may be here to stay, Oregon Health & Science University has laid out a series of steps to prepare patients for elective surgery following their illness.

The evaluation, outlined in a commentary published in the journal Perioperative Medicine, is believed to be the first published protocol laying out a COVID-era path forward in American medicine.

"We think this is groundbreaking," said senior author Avital O'Glasser, M.D., associate professor of medicine (hospital medicine) in the OHSU School of Medicine. "We are hoping other clinics and surgical centers can use this to keep their patients safe."

The work started around Memorial Day, when OHSU clinicians began to see an increasing number of patients who had survived COVID-19 but now were in need of myriad types of elective surgeries. These patients needed hip replacements, fracture repairs, colonoscopies and other procedures that normally flow through OHSU Hospital.

"At the time, the main focus was on patient de-isolation protocols and determining appropriate PPE for providers," said co-author Katie Schenning, M.D., M.P.H., associate professor of anesthesiology and perioperative medicine in the OHSU School of Medicine. "How to safely manage surgical patients who had recovered from COVID was a big black box."

Surgeons had concerns about blood clots, cardiac scarring and other early reports of the compromised condition of COVID survivors. They wanted to be sure surgery would be safe for these patients.

"This is not the flu," O'Glasser said. "It's not a garden-variety upper respiratory infection. It's a serious, potentially fatal illness that affects any and all organs in the body. That's why we want to slow down and make sure it's safe enough for a patient to undergo surgery."

Researchers combed through data published worldwide about health outcomes of patients who underwent surgery following illness. By mid-August, OHSU had adopted a set of guidelines based on the research.

Among the key recommendations:

• Minimum recovery time: The protocol calls for waiting a minimum of four weeks from the initial COVID-positive test for patients who had an asymptomatic infection and six to eight weeks for those who were more severely ill, "acknowledging that there is currently little data on the timeframe of recovery."
• Evaluation: Patient history and physical assessment to determine any potential complications of surgery and to determine whether a patient has returned to their "pre-COVID" baseline health.
• Objective testing: The protocol includes guidance for specific tests such as blood work based a patient's age, severity of symptoms, whether it's a major or minor procedure, and whether it includes putting a patient under general anesthesia.

The protocol does not account for patients who have not recovered from the illness, known as COVID long-haulers.

"As millions of people in the U.S. have recovered from COVID and are presenting for elective and non-urgent surgeries, we feel it is appropriate to set a standard for preoperative evaluation given the high risk of complications and high degree of clinical uncertainty," the authors write.