Screening for elective and emergency surgery patients

This guideline is out of date and will be retired from the website in two months (on 12 May 2023). For up-to-date clinical guidelines, please see COVID-19 - National Clinical Evidence Taskforce. If you have any concerns, please contact clinicalguidance@safercare.vic.gov.au.

This page provides guidance on screening for coronavirus (COVID-19) in elective and emergency surgery patients during the coronavirus (COVID-19) pandemic. Screening includes application of a surgical screening checklist and testing where indicated (for example Coronavirus (COVID-19) surgical screening checklist).

This information is intended for healthcare workers involved in managing patients scheduled for elective and emergency surgery.

For the purpose of this guidance the definition of elective surgery includes all planned operative and invasive procedures performed under a general anaesthetic.

Scope

This guidance is relevant to a period when the following conditions apply:

• There is community transmission of coronavirus (COVID-19).
• High levels of immunity are not evident in the population.
• Infection prevention and control efforts are influenced by:
  • health service capacity, demand and ability to physically distance in different areas of the organisation
  • availability of individual single rooms (with or without negative pressure) with bathrooms for known or suspected coronavirus (COVID-19) cases
  • requirements for use of personal protective equipment (PPE)
  • specific risks of a planned procedure in terms of its being aerosol generating or not.

Assumptions made in this guidance

• Persons who have contracted coronavirus (COVID-19) infection have a high likelihood of testing negative within the first 4-5 days. Testing all patients for elective surgery using currently available reverse transcription polymerase chain reaction (RT-PCR) will not completely prevent any elective surgery occurring in coronavirus (COVID-19) positive patients. 
• Some patients will present with atypical, or subclinical, disease and so will not be immediately identifiable as a suspected case at the point of entry into the healthcare system.
• The pre-test probability of a patient having coronavirus (COVID-19) increases with:
  • clinically compatible syndrome; and/ or
  • relevant epidemiological risk.
• Patients whose signs of coronavirus (COVID-19) include severe acute respiratory illness may have a higher viral load and therefore be more likely to transmit disease.
• Patients still asymptomatic but who are about to become symptomatic can be shedding a high viral load.
• The mortality and morbidity rates for patients with coronavirus (COVID-19) undergoing both elective and emergency surgery are higher than otherwise expected, even when such surgery is relatively minor. Therefore, it is usually safer to postpone elective surgery for someone who is symptomatic or who tests positive for coronavirus (COVID-19), even if they subsequently prove to be negative or a false positive, than to proceed and find out they are a true positive. 
• Despite the potential for false negatives and false positives, when the prevalence of coronavirus (COVID-19) infections is high, supplementing screening questions with routine pre-operative testing will reduce the risk of unknowingly operating on a coronavirus (COVID-19) infected patient.
• There is a variable delay in the turnaround of coronavirus (COVID-19) tests across different health services for which the logistics must be worked out at a local level.

What are the aims of screening surgical patients?

Screening of surgical patients aims to support:

• Prevention of patients with coronavirus (COVID-19) undergoing surgery, except in circumstances where the risks of not having surgery outweigh the risk of proceeding with surgery, while coronavirus (COVID-19) positive
• Minimisation of the risk of transmission to patients without coronavirus (COVID-19) and to healthcare workers by preventing coronavirus (COVID-19) positive elective surgery patients entering the hospital system for elective surgery
• Identification of potentially coronavirus (COVID-19) infected emergency patients to ensure appropriate precautions are taken until coronavirus (COVID-19) status known.

Who should be screened using the coronavirus (COVID-19) surgical screening checklist for coronavirus (COVID-19)?

All Victorian patients should continue to be screened using the Coronavirus (COVID-19) surgical screening checklist even in times of low coronavirus (COVID-19) prevalence.

Who should be tested for coronavirus (COVID-19)?

All patients who live in, work in, or have visited areas with high coronavirus (COVID-19) prevalence, identified case location or outbreak, or have had contact with a confirmed or suspected case of coronavirus (COVID-19) in the last 14 days, or have screened positive to any of the clinical risk factors of coronavirus (COVID-19) identified in the Coronavirus (COVID-19) surgical screening checklist (or a similar screening tool). 

What must Victorian hospitals do to screen elective surgery patients for coronavirus (COVID-19)?

• Ensure all patients receive open, timely and appropriate information about coronavirus (COVID-19) and elective surgery that is communicated to them in a way they can understand to make informed decisions and more effectively participate in the screening process. To do this, hospitals should:
  • provide patients with COVID-19 and elective surgery – what you need to know factsheet ahead of discussion with their consulting clinician
  • include discussion about the coronavirus (COVID-19) risks and risk-reduction actions in the informed consent for elective surgery processes
  • consider the special needs of patients from culturally and linguistically diverse (CALD) backgrounds and differing health literacy levels.
• Use the Coronavirus (COVID-19) surgical screening checklist (or a similar screening tool) before the patient's day of surgery to screen for epidemiological and clinical risk factors of coronavirus (COVID-19). The screening checklist needs to be completed by a healthcare worker. 
• Base decisions on whether patients should be tested for coronavirus (COVID-19) before presenting to hospital on responses to epidemiological and clinical risk factors of coronavirus (COVID-19). 
• Advise patients who are tested that they should isolate in the days after testing and before surgery unless there are exceptional circumstances. Discuss the reasons for isolation with the patient and record in the patient’s clinical notes a best plan for isolation or protection. Exceptional circumstances include seeking urgent medical care, end of life care and carer duties where no alternative arrangement can be organised.
• Repeat use of the Coronavirus (COVID-19) surgical screening checklist (or a similar screening tool) on the day of surgery and take the patient’s temperature. 
• If the patient screens positive for epidemiological or clinical risk factors prior to, or on the day of, surgery the case should be discussed with the surgeon and anaesthetist who will determine whether the patient should be sent home to isolate, or re-tested and/or what the likely impact of any delay in proceeding with anaesthesia and surgery are likely to have.
• Discuss postponement and follow up plan with treating perioperative team.

Screen, test and don’t delay!

What must Victorian hospitals do for screening of emergency surgery patients living or working in areas of high prevalence, identified case location or outbreak?

• Ensure all patients receive open, timely, and appropriate information about coronavirus (COVID-19) and its implications for surgery, communicated to them in a way they can understand to make informed decisions about their care
• Use the Coronavirus (COVID-19) surgical screening checklist (or a similar screening tool) to screen all emergency patients for epidemiological and clinical risk factors on arrival at the hospital. The screening checklist needs to be completed by a healthcare worker.
• Patients who screen positive to epidemiological and/or clinical risk factors on the screening checklist should be tested for coronavirus (COVID-19). 
• Emergency surgery should not be delayed waiting for a test result where there is additional risk to the patient's clinical condition. Any decision to delay surgery needs to be made by the perioperative team in consultation with the patient or their decision-maker, and according to the patient’s clinical condition and likely impact on their outcome if treatment is postponed.
• When emergency surgery cannot be delayed for a test result:
  • if a patient screens negative to all other epidemiological and/or clinical risk factors on the Coronavirus (COVID-19) surgical screening checklist, the patient’s care should proceed as if the patient is coronavirus (COVID-19) negative*. This includes the use of droplet/contact precautions if surgery is required to proceed. The patient should not be moved to a ward or a part of the hospital designated for patients suspected of being coronavirus (COVID-19) positive. 
    *in situations of high community prevalence, it may be reasonable to manage the patient as ‘suspected COVID-19’ until test results are known.
  • if a patient screens positive to other epidemiological and/or clinical risk factors on the Coronavirus (COVID-19) surgical screening checklist, but their surgery cannot be safely delayed waiting for a test result, the procedure should take place with the appropriate urgency. The patient’s care should proceed as if the patient is coronavirus (COVID-19) positive, using full aerosol and contact precautions and a designated coronavirus (COVID-19) operating room (where possible) and an appropriate location following surgery.
• If a patient cannot be screened and an adequate history is unable to be obtained (such as if unconscious) they should be tested for coronavirus (COVID-19) and care should proceed as if the patient is coronavirus (COVID-19) positive when there is high community prevalence.
• Vulnerable healthcare workers should not normally be responsible for providing care to a patient who screens positive to epidemiological and clinical risk factors on the checklist and whose coronavirus (COVID-19) status is unknown.
• Make sure all healthcare workers involved in managing patients scheduled for emergency surgery are aware there are false negative coronavirus (COVID-19) test results, particularly in the first five days for patients who are asymptomatic for coronavirus (COVID-19) symptoms, and that emergency conditions can co-exist with coronavirus (COVID-19) infection. 
• The development of pulmonary, thrombotic, or other suspicious symptoms of coronavirus (COVID-19) infection in the perioperative period after admission should prompt further testing.

This guidance aligns with the Charter of Human Rights and Responsibilities Act 2006.

Where to find more information

• Coronavirus (COVID-19) Victoria (Victorian Government)
• Coronavirus (COVID-19) pandemic (Australian Government)
• WHO coronavirus outbreak
• WHO coronavirus resources