OB COVID-19 UMMC Surgical Emergency Workflow Simulations

Last updated: April 17, 2020

Scenario 1. OB Emergency room to Wiser OR

• COVID-19 PUI presents with OB emergency.
• Patient screens positive for COVID 19: Surgical mask placed on patient’s face.
  • If it is not possible to obtain screening questionnaire due to emergent nature of the situation/language barrier and clinical suspicion is high (fever, chills, cough, shortness of breath, hypoxia), place the surgical mask on the patient and presume as a COVID-19 PUI.
• Patient will be placed in isolation room in OB ER.
  • One nurse and OB provider will evaluate the patient wearing the appropriate PPE donned before entering the room (gloves, gown, surgical mask, face shield, 2nd pair of gloves).
• Based on evaluation, if emergent delivery is necessary, additional OB ER nurse will call charge nurse on L&D to notify of STAT COVID PUI cesarean delivery.
• L&D charge nurse will page STAT pager: 000911*19
  • This new designation will only be used to alert all personnel that there is an emergency cesarean delivery involving a COVID PUI.
• In the emergency room, the nurse and OB provider that evaluated the patient will pack up the patient for transport and push patient out of room to new team (OB nurse and Ob provider) waiting outside of room for transfer.
  • The transport OB ER nurse will have donned PPE (gloves, gown, surgical mask, face shield, 2nd pair of gloves) and will remain with their hands on the bed and provide patient care only for the entirety of the transport; they will minimize contact with hospital infrastructure – walls, elevator, doors, etc.
  • The one OB provider will act as the pathway director and clear the patient transport pathway, open doors, call elevators, etc.
  • Pathway director is NOT to wear gloves or touch patient bed.
  • The Ob nurse and OB provider in emergency room that originally evaluated the patient will doff PPE.
• The L&D team that received the 000911*19 STAT page will present directly to the OR to receive the appropriate PPE for their role in the case from the COVID PPE BOX:
  • An emergency cesarean delivery COVID PPE box has been created with the PPE for the following personnel. This will be maintained at all times and charge nurse will know its location.
  • 2 anesthesia providers (don shoe covers, gloves, gown, N95 mask (if available), face shield, 2nd pair of gloves) before entering the OR.
  • 1 scrub tech (don shoe covers, N95 mask (if available) and face shield before entering OR; surgical gown, sterile gloves will be placed inside of the OR before patient arrives.)
  • 2 nurses (Primary Ob nurse and L&D charge nurse will don shoe covers, gloves, gown, N95 mask (if available), face shield, 2nd pair gloves before entering the OR):
    • Top pair of gloves will be used to prepare the patient. Dirty gloves will be removed.
    • Hand hygiene performed.
    • The under pair will be used to tie the surgeons gowns when they enter the OR.
  • 2 OB surgeons (don shoe covers, N95 mask (if available) and face shield prior to surgical scrub).
    • Scrub tech will put surgical gown and gloves on first surgeon when they enter the OR.
    • First surgeon will then assist dressing second surgeon directly on entering the OR, if tech needs to prepare OR table.
• All unnecessary personnel will leave the OR prior to the start of induction of anesthesia. Personnel will doff the dirty PPE except mask prior to leaving OR. Mask will be doffed outside of OR.

• Only those personnel wearing N95 (if available), 2 pair of gloves, gowns, and eye shields will be present for intubation in an emergency cesarean delivery.
  • Anesthesia will communicate when induction is about to begin.
• Limit the number of additional people entering and exiting the room during the case.
• Consider having a hemorrhage kit of appropriate medications to minimize traffic in OR.
• Patient’s stretcher will remain in the OR. Handles and side rails will be cleaned with purple top wipes (contact time 2mins) or bleach wipes (contact time 4mins).
• Anyone that enters the OR after intubation must don PPE (gown, surgical mask, face shield, gloves) prior to entering the OR.
• After completion of the case, decision will be made by anesthesia regarding the appropriate location for extubation, if extubation is possible.
  • If patient requires critical care services, the patient will be transported intubated to the critical care tower to a negative pressure room. The transport team will assist in moving the patient using the institutional transport guidelines.
  • If the patient does not require critical care services, both of the anesthesia providers will transfer patient to negative pressure LDR that contains anesthesia machine. One at a time, the anesthesia providers will remove gowns and gloves prior to exiting OR, perform HH, don new gowns and gloves outside the OR for transportation, ok to leave the same mask and faceshield on. OB team will assist in bag mask ventilation while anesthesia providers are changing gown and gloves. OB team will pass patient to anesthesia providers outside of the OR. L&D will be notified prior to the transfer and L&D nurse will be the pathway director.
  • New sheet will be placed on patient prior to transfer.
  • Patient will be extubated in L&D negative pressure room.
  • After extubation is complete, PACU nurse will enter LDR after donning gown, surgical mask, face shield, and gloves.
  • PACU nurse will remain in the LDR in full PPE for post-op care.
  • The anesthesia providers will doff prior to exiting the LDR (all except mask). Mask doffed after leaving the LDR room.
    • Change scrubs after case.
• After completion of the surgery, all other personnel will doff in the OR (except for mask). Most cesarean deliveries have heavily soiled gowns and gloves, therefore, we will make the following adaptations to the doffing process to avoid contamination.
  • Doff the gloves and gown first together (CDC example 2).
  • Hand hygiene.
  • Remove face shield.
  • Hand hygiene.
  • Leave the OR.
  • Hand hygiene
  • Doff mask outside of OR.
  • Hand hygiene.
  • Proceed to the negative pressure pre-anesthesia room 3 after scrubbing hands for changing of scrubs.
• The patient will remain in LDR for ~4 hours after PACU time completed for routine OB care. As long as there are no ongoing OB issues (i.e bleeding, etc) patient will be then transferred to designated COVID-19 floor.

Scenario 2. LDR to Wiser OR

• OB emergency and/or maternal deterioration develops that requires emergent cesarean delivery on a known COVID PUI/Covid + patient on L&D. Given that the patient is already a COVID PUI, she would be wearing a surgical mask already.
  • Primary nurse and OB provider will evaluate the patient wearing the appropriate PPE (gloves, gown, surgical mask, face shield, gloves).
• If emergency cesarean delivery indicated, L&D charge nurse will page STAT pager: 000911*19
  
  • This new designation will only be used to alert all personnel that there is an emergency cesarean delivery involved a COVID PUI.
• Primary nurse and Ob provider will pack up the patient and hand off patient to a nurse who has donned new PPE to transfer patient to OR and prep patient for surgery. Nurse and charge nurse will push bed to OR. Additional L&D nurse will be pathway director.
• Primary nurse and ob provider will doff the dirty PPE prior to leaving the room (except for mask). Mask doffed outside of room.
• Charge nurse will bring COVID PPE emergency box to OR for providers to have necessary PPE for the case.
• Anesthesia providers, two OB surgeons, and scrub tech will be ready in the OR with PPE (gloves, gown, N95 (if available), face shield, 2nd pair of gloves).
  
  • All will enter the OR in the same way as scenario one.
• L&D nurse and charge nurse will prepare patient for surgery.
• Patient’s bed will remain in the OR. Hand rails and handles will be cleaned with purple top wipes (contact time 2mins) or bleach wipes (contact time 4mins).
• Given the emergent nature of the cesarean delivery, all who will remain in OR for the case must have an N95 mask (if available).
• After completion of the case, if epidural anesthesia was placed, epidural catheter will be removed in the OR and patient will be returned to LDR for post anesthesia care recovery.
• New sheet will be placed on patient prior to transfer.
  
  • Anesthesia providers will transfer patient to LDR. PPE only required if patient care needed for transfer. If PPE required, one at a time, the anesthesia providers will remove gowns and gloves prior to exiting OR, perform HH, don new gowns and gloves outside the OR for transportation, ok to leave the same mask and faceshield on. OB team will assist in bag mask ventilation while anesthesia providers are changing gown and gloves. OB team will pass patient to anesthesia providers outside of the OR. Nurse will be pathway director.
  • PACU nurse will don PPE (gloves, gown, surgical mask, eye shield, gloves) prior to entering LDR and will remain in the LDR with propack in full PPE for post-op care. PACU nurse to doff in LDR upon completion of PACU recovery (except mask). Mask will be doffed outside of LDR.
  • The patient will remain in LDR for ~4 hours after PACU time completed for routine OB care. As long as there are no ongoing OB issues (i.e bleeding, etc) patient will be then transferred to designated COVID-19 floor.
• If GETA was needed, decision will be made by anesthesia regarding the appropriate location for extubation and transfer, if extubation is possible.
  
  • New sheet will be placed on patient prior to transfer.
  • If patient requires critical care services, the patient will be transported intubated to the critical care tower to a negative pressure room. The transport team will assist in moving the patient using the institutional transport guidelines.
  • If the patient does not require critical care services, both of the anesthesia providers will transfer patient to negative pressure LDR that contains anesthesia machine/ventilator. One at a time, the anesthesia providers will remove gowns and gloves prior to exiting OR, perform HH, don new gowns and gloves outside the OR for transportation, ok to leave the same mask and faceshield on. OB team will assist in bag mask ventilation while anesthesia providers are changing gown and gloves. OB team will pass patient to anesthesia providers outside of the OR. L&D will be notified prior to the transfer and L&D nurse will be the pathway director.
  • Patient will be extubated in L&D negative pressure room.
  • After extubation is complete, PACU nurse will enter LDR after donning gloves, gown, surgical mask, face shield, gloves.
  • PACU nurse will remain in the LDR in full PPE for post-op care.
  • The anesthesia providers will doff prior to exiting the LDR (all except mask). Mask doffed after leaving the LDR room.
    
    • Change scrubs after case.
  • See Scenario 1 for doffing procedure for surgeons, scrub tech, nurses and anesthesia following completion of case from the OR.
  • The patient will remain in LDR for ~4 hours after PACU time completed for routine OB care. As long as there are no ongoing OB issues (i.e. bleeding, etc) patient will be then transferred to designated COVID-19 floor.

Scenario 3: Adult ED to Main OR

• A parturient with presumed COVID 19 presents to AED in:
  • Extremis (i.e hypoxemic respiratory failure, hemorrhage, trauma) OR
  • Impending fetal demise (i.e. prolonged fetal bradycardia)
• OB would be notified by the adult ED.
• OB providers would notify charge nurse on L&D of need for Level 0 case in MAIN OR who would notify NICU.
  
  • NICU and L&D would provide delivery and NICU supplies for case.
• Main OR will be notified of the Level 0.
• If intubation is required to stabilize the mother, it will occur in the AED prior to transfer. OB/ER team will then transfer to Main OR and proceed with delivery. As this is an emergent situation and patient will likely need medical assistance during transportation, I would recommend transfer team to have full PPE on as a precautionary measure (gowns, gloves, mask and faceshield).
  
  • Transfer team will have mask and gloves.
  • If care needed in the transfer process, then PPE would be required.
  • OB team would be pathway director.
• If intubation is not required, OB team will transfer to Main OR and intubation and delivery will occur simultaneously (limiting the number of individuals in the OR for intubation). Patient should have a surgical mask on during transportation.
  
  • Transfer team will have surgical masks and gloves.
  • If care needed in the transfer process, then PPE would be required.
  • OB team would be pathway director.
• If patient intubated in ED, OR teams (OB/NICU) can wear surgical masks, gowns, gloves, shoe covers for cesarean delivery.
• At the end of the cesarean delivery (as in scenario 1 and 2), decision for extubation would be made by anesthesia. Patient would be transferred to the appropriate location for extubation (if possible) of to the critical care tower.

Scenario 4: 2 North to Main OR

• Every effort will be made to identify a COVID 19 parturient with impending respiratory compromise as early as possible.
  
  • Example: A parturient with COVID 19 at 35 weeks gestational age that has gone from needing 2L NC to 4L NC with O2 sat of 90%.
• If conservative measures are not maintaining 02 sat of 95%, especially at a gestational age of greater than 34 weeks, and patient is not in extremis, attending OB and/or MFM will make decision regarding moving patient to WISER L&D for delivery in OR2.
• If gestational age is less than 34 weeks, we will attempt stabilization of mother and delivery may not be indicated.
  • If rapid deterioration occurs, a rapid response/code would be called on the floor. If intubation is required to stabilize the mother, it will occur on 2N prior to transfer.
• OB/GYN would be notified of rapid response. OB providers would notify charge nurse on L&D of need for Level 0 case in MAIN OR who would notify NICU.
  
  • NICU and L&D would provide delivery and NICU supplies for case.
• Main OR will be notified of the Level 0.
• Transport to the Main OR would occur with OB/Covid response teams.
• If intubation is not required, OB/Covid response teams will transfer to Main OR and intubation and delivery will occur simultaneously (limiting the number of individuals in the OR for intubation). Patient should have a surgical mask on during transportation.
  
  • Transfer team will have surgical mask and gloves.
  • If care needed in the transfer process, then PPE would be required.
  • OB team would be pathway director.

Scenario 5: ICU to Main OR

• Every effort will be made to communicate with the ICU regarding high risk parturients with COVID 19 greater than 24 weeks gestational age.
• If ICU measures are not maintaining 02 sat of 95%, PaO2 of 70, MAP of 70mmHg, attending OB and MFM will make decision regarding moving patient to Main OR for delivery.
• OB providers would notify charge nurse on L&D of need for Level 0 case in MAIN OR who would notify NICU.
  
  • NICU and L&D would provide delivery and NICU supplies for case.
• Main OR will be notified of the Level 0.
• Transport to the Main OR would occur with OB/ICU teams.
  
  • If the patient to unstable to move, see below.

Scenario 6: Cesarean delivery at the bedside in ICU/ED

• Every effort will be made to communicate with the ICU regarding high risk parturients with COVID 19 greater than 24 weeks gestational age.
• If patient with significant deterioration in ICU despite aggressive measures; furthermore, patient is too sick to move, attending OB and MFM will be notified.
• OB providers would notify charge nurse on L&D of need for bedside ICU/ED delivery.
  
  • NICU and L&D would provide delivery and NICU supplies for case.
• Main OR will be notified of the bedside ICU surgery.

Hand hygiene

• It is extremely important to perform vigorous hand hygiene following each step of the doffing procedure.
• The donning and doffing procedures take time.
• Consider having someone watch you don and doff to make sure you are not contaminating yourself.
• Consider changing your scrubs at the end of the surgery.

PPE

• The UMMC Guidance for Limited Reuse of N95 Respirators policy for OB personnel will be employed for:
  
  • COVID +/COVID PUI undergoing second stage of labor, vaginal delivery or cesarean delivery. Please note, same N95 mask should not be used between COVID PUIs, non-COVID and COVID positives. In any circumstance when N95 intended to be used in non-COVID patient is used for a COVID suspect/confirmed patient, discard N95 in collection bin immediately after use.
  • All emergent cesarean deliveries where sufficient screening has not occurred and patient Covid 19 status is unknown.
  • Please see the University Guidance for limited resources of N95 Respirators for Obstetric Procedures policy for full details.

Neonatology

• The NICU COVID-19 team will be present in both scenarios in the OR in PPE (gloves, gown, N95 mask, face shield, and gloves), ready for newborn resuscitation prior to the start of the case.
• Neonatology will bring their own PPE and don before entering the OR.
• Efforts will be made to reduce the number to 3 personnel at a minimum for resuscitation, if possible.
• Transport isolette and all other necessary supplies will be brought into OR/ICU for transfer of the newborn to the COVID newborn area.