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     Facility Preparation

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     Resuming Elective Procedures
    
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Regulations regarding elective procedures will change by locality in the coming weeks and months, and will be dependent upon the prevalence of COVID-19 and availability of healthcare resources in a given region. Please remain vigilant and be prepared to prioritize procedures accordingly.


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 below.
  • STEP 2: CONSIDER WHETHER TO RESUME OR CONTINUE TO RESCHEDULE ELECTIVE PROCEDURES
    Regulations regarding elective procedures will change by locality in the coming weeks and months, and will be dependent upon the prevalence of COVID-19 and availability of healthcare resources in a given region. The Center for Medicare and Medicaid Services (CMS) has issued Recommendations on Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I to provide guidance for regions with low risk of incidence preparing to resume procedures. Physicians should consider whether rescheduling interventional pain procedures will further the goal of reducing interpersonal exposure and potential for disease transmission to patients, staff, and their 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.
  • 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 or suspected COVID-19 infection or exposure, interventional pain procedures should be postponed until the patient is no longer contagious and has recovered.
    • Procedures should be delayed until the patient is afebrile for 72 hours without the use of fever-reducing medications, respiratory symptoms have resolved, and either 10 days have passed since symptom onset or it is confirmed by 2 negative SARS-CoV-2 tests, collected at least 24 hours apart, that they do not have COVID-19. 
    • For patients with laboratory-confirmed COVID-19 without any symptoms, procedures should be delayed until 10 days have passed since the date of their first positive COVID-19 test or until it is confirmed by 2 negative SARS-CoV-2 tests, collected at least 24 hours apart, that they do not have COVID-19.
    • 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, obesity, and immunosuppression.
    • Consider the risks posed by ceasing anticoagulation for certain procedures since coronavirus 2 (SARS-CoV-2) may predispose patients to thrombotic disease, both in the venous and arterial circulations.
    • When adequate pre-visit COVID-19 testing capability is established, patients should be screened by laboratory testing before planned procedures.
    • Consider requiring pre-visit COVID-19 testing for high risk (aerosol generating) procedures.
    • 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.
    • While obtaining informed consent from a patient who is a candidate for a corticosteroid injection, discuss that while there is a current lack of information about whether the risk of contracting COVID-19 is increased following a corticosteroid injection, it is theoretically possible.
    • 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 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.
      • Consider working with other providers in your facility to schedule clinics to avoid overlap, limit the number of patients moving through your facility, and minimize the opportunity for cross-infectivity between clinical staff members.
      • When scheduling and confirming appointments, patients should be advised that in order to reduce the risk of exposure and transmission, they are expected to wear surgical or cloth face masks while at the facility. Masks should be made available immediately upon entering the facility. If surgical masks are in shortage, they should be reserved for healthcare staff and patients should wear cloth masks.
      • 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. Individuals who are deemed medically necessary to accompany patients are also expected to wear surgical or cloth face masks when in 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 (surgical masks, 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.
      • Avoid use of sedation that may necessitate airway support.
      • Procedure areas should be disinfected after each procedure.
    • Personnel
  • STEP 5: USE RECOMMENDED PERSONAL PROTECTIVE EQUIPMENT (PPE)
    • Physicians should be adequately protected with the use of surgical masks, gloves, and if available, face shields or goggles. Cloth masks are not considered PPE.
    • The use of N95 masks with face shields should be considered on a case-by-base basis depending on local availability and necessity (e.g. coughing or sneezing patient), but is recommended for encounters requiring close contact per Multisociety Guidance. The N95 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 in individuals who have not been fit-tested, have facial hair, or fail N95 fit-testing (see Multisociety Guidance).
    • Gowns are recommended, but should be prioritized for aerosol-generating procedures when splashes and sprays are anticipated.
    • Keep in mind that the risk of viral transmission is highest during removal of protective gear.
    • 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.
    • Ensure healthcare personnel returning to work after confirmed or suspected COVID-19 infections meet appropriate return-to-work criteria.

(Guidance Reviewed and Updated July 24, 2020)

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Additional Resources and Information

(Resources Reviewed July 24, 2020)

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