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SIS Guidance on Interventional Pain Procedures During the COVID-19 Global Emergency

When planning for interventional pain procedures during the COVID-19 emergency, consider the Centers for Disease Control and Prevention (CDC) statement regarding goals for the U.S. healthcare system in response to COVID-19:

  1. Reduce morbidity and mortality
  2. Minimize disease transmission
  3. Protect healthcare personnel
  4. Preserve healthcare system functioning

In order to achieve these goals, several steps should be taken:

  • STEP 1: PRIORITIZE ALTERNATIVES TO IN-PERSON VISITS
    • Implement telehealth and telephone visits when possible.
    • Penalties will not be imposed on physicians using telehealth in the event of noncompliance with the regulatory requirements under HIPAA. Click here for more information about the specific requirements and see telehealth resources on the SIS COVID-19 webpage.
  • STEP 2: RESCHEDULE ELECTIVE AND NON-URGENT PROCEDURES
    Whenever possible, reschedule non-urgent interventional pain procedures with the goal of reducing interpersonal exposure and potential for disease transmission to patients, staff, and the community.
    • Governmental regulations may apply now or in the future that restrict or prohibit performing interventional pain procedures. Those regulations supersede guidance provided by SIS.
    • While the recommendations of individual hospitals, facilities, and practices may differ, many major hospitals and academic medical centers are cancelling all elective interventional pain procedures in order to limit COVID-19 exposure and to preserve healthcare resources.
    • Corticosteroid injections may contribute to immunosuppression [SIS Glucocorticoid Impact FactFinder, Popescu 2019] and increased risk of viral infection [Sytsma 2018].
    • Information from the COVID-19 outbreak in China demonstrates a significantly higher mortality rate in hospitalized adults using corticosteroids [Zhou 2020].
  • STEP 3: PRIORITIZE PROCEDURES USING A COMPLETE RISK/BENEFIT ANALYSIS
    The final decision regarding the necessity and urgency of performing interventional pain procedure should be made by the treating physician after taking into account all the risks posed to the patient by presence of COVID-19 in the local community, in addition to risks to medical personnel and the public.
    • As with other systemic infections, when considering a procedure for a patient with known COVID-19 infection, suspected COVID-19 infection, recent return from a high-risk area, or a patient who has had close contact with an infected individual, non-urgent interventional pain procedures should be postponed until the patient is no longer contagious or it is confirmed they do not have COVID-19. (See CDC materials relative to identifying at-risk patients and guidance on potential exposure.)
    • For very select urgent interventions (e.g. intrathecal pump refill) in at-risk patients, N95 masks should be worn. These masks should be preferably fit-tested and can be reused per CDC guidance. Alternatively, powered air purifying respirators (PAPR) can be considered on a case-by-case basis. Surgical gowns, gloves, and adequate eye protection should be used. Procedure areas should be disinfected after each procedure.
    • A patient’s risk for contracting and surviving COVID-19 infection must be considered, including age and smoking status, as well as co-morbidities such as diabetes, hypertension, cardiopulmonary disease, and immunosuppression.
    • If the alternative to delaying (rescheduling) an interventional pain procedure clearly exposes the patient to increased risk via the alternative treatment option, proceeding with the procedure may be appropriate in select cases with good chances of a favorable outcome from the interventional pain procedure. In those cases, if possible, the procedure should be performed at the same visit as the evaluation in order to reduce exposure (unless the evaluation is performed via telehealth).
    • Consider alternatives and, given the current pandemic, reassess the risk/benefit ratios for the planned interventional pain procedure compared with other available treatments (e.g. home/virtual therapy options, medications, surgical telehealth consultation, etc.) as appropriate.
    • Consider the consumption of healthcare resources, including both PPE and staffing needs, when interventional pain procedures are performed.
    • Consider the prevalence of COVID-19 in your geographic area.
  • STEP 4: PREPARE YOUR PRACTICE
    Prepare your facility and personnel to safely manage patients during the COVID-19 emergency.
    • FACILITY
      • Consider shifting inpatient procedures to outpatient settings, when feasible.
      • Prepare your facility to safely triage and manage patients: patients should be contacted by telephone before coming to your facility to make sure that potential COVID-19 infection symptoms or exposure are identified and addressed appropriately.
      • Ask that family/friends do not accompany the patient into the clinic unless necessary for medical reasons. Consider encouraging patients to remain in their vehicles in lieu of waiting areas. Staff can contact patients via cell phone when it is time to enter the facility.
      • If possible, leave entrance doors open, to avoid contact with door handles.
      • In receptions areas, install glass or plastic physical barriers (if possible) to limit contact between staff and potentially infectious patients.
      • Make sure that the waiting room, clinic, and procedure areas are appropriately cleaned and disinfected with increased frequency, consistent with the known high-transmission rate of COVID-19.
      • Implement visual alerts (signs, posters) at building entrances and in strategic locations to provide instructions on hand hygiene, respiratory hygiene, cough etiquette, and reporting.
      • Ensure that adequate supplies are available (tissues, waste receptacles, alcohol-based hand sanitizer).
      • Create measures to spatially separate patients in waiting rooms, clinic areas, and procedural settings (at least 6 feet apart); and remove reading materials and other shared items.
      • Consider implementing a system to restrict access to a single entrance and screen all patients and medical personnel who enter the clinical building for risk of undiagnosed COVID-19 infection or exposure. Screening measures include assessment for fever (objectively by temperature check), for symptoms of new or worsening cough, for new or worsening shortness of breath, and for contact with an individual diagnosed with COVID-19 infection.
    • PERSONNEL
      • Advise employees to check for any signs of illness before reporting to work each day and to notify their supervisor if they become ill.
      • Train all patient care personnel on the proper sequencing of donning (putting on) and doffing (removing) PPE—including respirators, surgical masks, gloves, isolation gowns, and eye protection—to prevent transmission of infection.
      • Communicate with your staff about managing stress and address concerns they will have about their own health, the health of their family and income security during this period.
  • STEP 5: REDUCE USE OF PERSONAL PROTECTIVE EQUIPMENT (PPE)
    • Procedures involving the nose, mouth, or throat present higher risk for disease transmission and require more stringent PPE. This is not the case for most pain interventions including cervical spine procedures.
    • When performing common pain procedures for patients without symptoms of infection or exposure to COVID-19, use standard protective equipment (standard mask, gloves, eye protection). N95 masks and masks with face shields are not necessary.
    • PPE can be conserved by wearing the same face mask without removal during sequential patient encounters. In addition, sequential scheduling of all procedure patients will reduce staff needs and exposures, and reduce overall PPE use.
  • STEP 6: MANAGE POTENTIAL EXPOSURE
    If you suspect that you, your patients, your medical personnel, or your facility may have been exposed to COVID-19, refer to CDC’s guidance on potential exposure.

(Reviewed and updated April 2, 2020)

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