When the number of confirmed cases of coronavirus disease 2019 (COVID-19) began rising across the U.S. in March, regulators and administrators called for hospitals, surgeons, and other providers to take several measures to combat the disease and its spread, including delaying or postponing elective surgical and procedural cases. As the immediate threats waned, public health authorities called on the public and the health care community to respond in other ways.
Immediate response to the crisis
The Centers for Disease Control and Prevention (CDC) recommendations to health care organizations included delaying both inpatient and outpatient nonemergent surgical and procedural cases, as well as prioritizing urgent and emergency visits and procedures to keep staff and patients safe, preserve personal protective equipment (PPE) resources and other supplies, and ensure that hospitals could keep up with the anticipated demands in capacity.1
My take on the ACS recommendations is that we all must rise to the local challenges this pandemic poses and preserve the “three S’s” (space, staff, and stuff) to serve the anticipated needs of our patients.
The U.S. Surgeon General also recommended canceling all nonemergent operations. Then, on March 13, the American College of Surgeons (ACS) released recommendations for hospitals and surgeons on delaying or postponing nonemergent procedures, followed by “COVID-19: Guidance for triage of non-emergent surgical procedures” on March 17, 2020.2-3
As the number of COVID-19 cases began to level off, hospitals and surgeons sought to provide opportunities to patients who needed nonemergency operations. In response, the ACS issued “Local resumption of elective surgery guidance” April 17.4
My take on the ACS recommendations is that we all must rise to the local challenges this pandemic poses and preserve the “three S’s” (space, staff, and stuff) to serve the anticipated needs of our patients. I also believe that the principle of having the medical need for a given procedure determined by the surgeon is paramount to protect the patients at large and surgeon-patient trust. And although the logistical feasibility is determined by administrative personnel, the principle that the surgeon determines the need puts the health care professional at the center of the decision-making process. This is good for medicine and for patients.
At a time when surgical procedures were postponed and nonemergent visits to the clinic also were being rescheduled, many surgeons turned their attention to the service they could provide in the intensive care unit (ICU), demonstrating their leadership and commitment to patient care.
Staying safe in a post-pandemic world
As surgical professionals returned to the operating room and clinic, concerns about the risk of transmitting COVID-19 virus continued to surface. To help alleviate these concerns, hospitals and ambulatory surgery centers (ASCs) around the country began requiring that everyone who entered the facility—including staff, patients, and visitors—wear a mask. As surgeons resume nonemergent procedures, this policy will be critical in curbing the spread of COVID-19 to patients and staff.
People wearing cloth face coverings or face masks over their mouths and noses to contain their respiratory secretions helps to reduce the dispersion of droplets from an infected individual.
The CDC added this advice to their late-April infection prevention and control recommendations related to COVID-19, and The Joint Commission supports this policy. The CDC guidance—“Interim infection prevention and control recommendations for patients with suspected or confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings”—states that health care facilities should “implement source control for everyone entering a healthcare facility (e.g., health care personnel, patients, visitors), regardless of symptoms.” This process is critical to address asymptomatic and presymptomatic transmission of COVID-19.5
People wearing cloth face coverings or face masks over their mouths and noses to contain their respiratory secretions helps to reduce the dispersion of droplets from an infected individual.1 Face coverings will decrease the possibility that anyone with unrecognized COVID-19 infection will expose others to the disease.1 However, for source control to be effective, everyone in the hospital or ASC must wear a mask while inside to prevent droplet and—to a lesser extent—aerosol spread of COVID-19 and other respiratory viruses.2
The Joint Commission has issued a statement that universal masking within health care settings is a vital tool to protect staff and patients from being infected by asymptomatic and presymptomatic individuals and should be implemented anywhere coronavirus is occurring. Even one case of community spread means that the facilities and staff are at risk because asymptomatic and presymptomatic patients may come in for care and inadvertently infect staff.
The Joint Commission’s statement also summarizes key steps for implementing the CDC’s recommendation, as follows.5
If there are actual or anticipated shortages of face masks, they should be prioritized for health care personnel and for patients with symptoms of COVID-19.
For patients and visitors
- All patients and visitors should be instructed to wear a cloth mask when entering any health care building.
- If they arrive without a cloth mask, one should be provided.
- If there is a sufficient supply of medical-grade face masks, one may be provided instead of a cloth mask.
- Patients may remove the cloth face covering while in their own rooms, but they should put the face covering back on when leaving their room or when others who are not wearing a mask enter the room.
- If available, hospitals and ASCs should consider switching patients who have tested positive for COVID-19 or who have respiratory symptoms—such as a cough or sneeze—to a medical-grade face mask.
Per the CDC recommendations, face masks and cloth face coverings should not be placed on the following:
- Infants and toddlers younger than age two
- Anyone who has trouble breathing
- Anyone who is unconscious, incapacitated, or otherwise unable to remove the mask without assistance
For health care personnel
- Facility staff should wear at least a cloth mask when leaving their home
- When providing direct patient care to any patient, health care personnel should don a medical-grade, official PPE face mask or respirator, depending on the care provided. According to the CDC, “Cloth face coverings are not considered PPE because their capability to protect health care personnel…is unknown.”
- Health care personnel who provide support services but do not provide direct patient care should also wear a face mask. However, to conserve supplies, the face mask may be cloth. Outbreaks of COVID-19 have occurred among health care personnel who provide support services.
- Masks may be removed when social distancing of at least six feet is possible (such as after entering a private office). To ensure staff can remove their masks for meals and breaks, scheduling and location for meals and breaks should ensure that at least a six-foot distance can be maintained between staff.
- It is important for hospitals and ASCs to emphasize that hand hygiene is essential to maintaining employee safety, even if staff are wearing masks. If the face mask is touched, adjusted, or removed, hand hygiene should be performed.
The CDC guidance recommends that “as part of source control efforts, [health care personnel] should wear a facemask at all times while they are in the health care facility.”4 If there are actual or anticipated shortages of face masks, they should be prioritized for health care personnel and for patients with symptoms of COVID-19. Health care personnel may wear cloth face coverings when not engaged in direct patient care.5
Resources and the full statement on universal masking can be found on The Joint Commission’s website
“To avoid risking self-contamination, [health care personnel] should consider continuing to wear their respirator or facemask (extended use) instead of intermittently switching back to their cloth face covering,” the guidance recommends. “Of note, N95s with an exhaust valve might not provide source control. [Health care personnel] should remove their respirator or facemask and put on their cloth face covering when leaving the facility at the end of their shift. They should also be instructed that if they must touch or adjust their facemask or cloth face covering, they should perform hand hygiene immediately before and after.”5
The Joint Commission encourages health care facilities to remind patients and visitors that they should be wearing a face mask when they arrive for care. Hospitals and ASCs also can provide links to CDC resources, such as how patients can make their own masks with commonly available materials.6
To assist with rapid implementation of the CDC recommendations, The Joint Commission developed the following resources:6
- Signage that can be posted at entrances in black and white and in color
- An infographic on the do’s and don’ts for wearing face masks during the COVID-19 pandemic that can be used to educate staff and patients
These resources—as well as the full statement on universal masking—can be found on The Joint Commission’s website.
The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the ACS.
- Centers for Disease Control and Prevention. Resources for clinics and healthcare facilities. March 16, 2020. Available at: www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/index.html. Accessed May 31, 2020.
- American College of Surgeons. COVID-19: Recommendations for management of elective surgical procedures. March 13, 2020. Available at: facs.org/about-acs/covid-19/information-for-surgeons/elective-surgery. Accessed May 31, 2020.
- American College of Surgeons. COVID-19: Guidance for triage of non-emergent surgical procedures. March 17, 2020. Available at: facs.org/about-acs/covid-19/information-for-surgeons/triage. Accessed May 31, 2020.
- American College of Surgeons. Local resumption of elective surgery guidance. April 17, 2020. Available at: facs.org/covid-19/clinical-guidance/resuming-elective-surgery. Accessed May 31, 2020.
- Centers for Disease Control and Prevention. Interim infection prevention and control recommendations for patients with suspected or confirmed Coronavirus Disease 2019 (COVID-19) in healthcare settings. Available at: www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Accessed May 31, 2020.
- The Joint Commission. Statement on Universal Masking of Staff, Patients, and Visitors in Health Care Settings. Available at: www.jointcommission.org/-/media/tjc/documents/covid19/universal-masking-statement-04232020.pdf. Accessed May 31, 2020.