The ACS wants to hear how COVID-19 is impacting you, both professionally and personally. Share your story or experience to help ensure the College can continue to advocate on your behalf. And spread the word via social media. To amplify access to our information, the College has registered #ACSCOVID19 with Symplur Healthcare Hashtags. Use #ACSCOVID19 in all social media messages and to link those messages to ACS communications.

This week, the American College of Surgeons issued guidelines on triage of patients undergoing elective cancer surgery during the COVID-19 pandemic.

During the current COVID-19 pandemic, hospital leadership and individual providers are facing increasingly difficult decisions about how to conserve critical resources, such as hospital and intensive care unit (ICU) beds, respirators, and transfusion capacity, as well as protective gear (PPE) that is vital for protecting patients and staff from unnecessary exposure and intrahospital transmission. While nothing will replace sound medical judgement and local adjudication, it has generally been advised that hospitals discontinue elective surgery, and guidance on the triage of nonemergent surgical procedures during the pandemic is available. Guidance on the triage of elective surgery is based on an Elective Surgery Acuity Scale provided by Sameer Siddiqui, MD, FACS, of St. Louis University.

Triage guidelines contained herewith add another level of specificity on triage of elective cancer surgery patients during the COVID-19 pandemic. This information is intended to help institutions and providers who are facing a rising burden of hospitalized COVID-19 patients and a higher prevalence of community infection. Not all cancer conditions can be outlined; this document will focus on how to manage the more common cancer types during the pandemic. 

Read complete article

In addition to the Bulletin: ACS COVID-19 newsletter we are sending to members, we are also rapidly sharing information related to your practice as we have it. To that end, the ACS Washington team has identified information regarding the Coronavirus Aid, Relief, and Economic Security (CARES) Act, signed into law on Friday, that provides some pathways for physicians to obtain financial assistance for their practices. We know many of you want to apply for this assistance if you are experiencing financial strains on your practice related to COVID-19. 
 
First, the Centers for Medicare and Medicare Services (CMS) has recently expanded the Accelerated and Advanced Payment Program. Surgeons and others may request advanced Medicare payments to address cash flow issues based on historical payments. More information about this program can be found here and here.
 
In addition, relief for small businesses, including those run by physicians, was included in the $2 trillion CARES Act legislation. The provisions include the appropriation of $562 million for Economic Injury Disaster Loans to ensure that the Small Business Administration (SBA) has adequate resources to assist businesses in need.
 
The SBA’s Economic Injury Disaster Loan program provides small businesses with working capital loans of up to $2 million that can provide vital economic support designed to help overcome the temporary loss of revenue. In response to the COVID-19 pandemic, small business owners in all fifty states, Washington, DC, and U.S. territories are eligible to apply.
 
The CARES Act clarified that eligibility would be for those businesses of 500 employees or less at each business location.
 
Fellows may learn more about Economic Injury Disaster Loans and find the appropriate applications here.
 
ACS continues to support all our surgeons who are serving their communities in the COVID-19 crisis and curtailing their normal clinical practices. ACS continues to remind the White House, Congress, the Department of Health and Human Services and CMS to support our surgeons so that when we recover from COVID-19, our surgical practices will recover, too. 
 
Christian Shalgian
Director, Division of Advocacy and Health Policy (DAHP) 

Patrick V. Bailey, MD, FACS
Medical Director,  Advocacy, DAHP

Frank Opelka, MD, FACS
Medical Director, Quality and Health Policy, DAHP

David B. Hoyt, MD, FACS
Executive Director, ACS

The American College of Surgeons website is constantly being updated with useful resources to help us deal with personal and professional challenges in this trying time. Visit facs.org/COVID-19.
 
Members are receiving the twice-weekly Bulletin: ACS COVID-19 Updates newsletter from the Executive Leadership of the College. 
 
RAS-ACS is organizing weekly "hangouts" to allow a forum for students, trainees, and young surgeons to share stories, best practices from our institutions, and to have an opportunity to just connect with each other and have a support network, as we deal with these new challenges. Information about how to connect will be posted in our newsletter, Twitter and Facebook pages. 
 
Given the disruption to education and training, we are also organizing weekly educational sessions for students and residents. The schedule can be found online and make sure to check @RASACS on Twitter for content updates. 

It is important to be prepared for the potential need to operate on a Coronavirus Disease 2019 (COVID-19) person under investigation (PUI) or a COVID-19 patient. Preparation of a specific operating room (OR) and detailed education of the entire OR team who will be providing care for these patients during their procedure is imperative, without using stock protective equipment. The specific roles and responsibilities of all OR team members must be clear, with a common goal of minimizing the spread of infection to health care workers.

• Develop a dedicated COVID-19 OR to control the spread of the disease
  • Centers for Disease Control and Prevention (CDC) Guidelines for droplet/aerosol room environments with # air exchanges. 
• Empty OR of all nonessential materials
• Consider a negative pressure anteroom with separate access if possible
• Anteroom is used for donning/doffing of personal protective equipment (PPE) and separate OR carts for the COVID-19 OR
• Separate OR airway cart; specific airway guidelines for COVID-19 PUI/confirmed patients
• Separate OR equipment cart
• Separate OR medication cart
• Runner outside OR for drugs, devices, equipment
• If intubation required for OR procedure, recommend intubation in negative pressure room prior to OR; avoid intubation in OR
• Use dedicated transport ventilator if being transported on mechanical ventilation (ambulatory bag with viral filter, if ventilator unavailable)
• Additional heat and moisture exchange (HME) filter and viral filter on expiratory limb of anesthesia machine circuit
• Consider additional viral filter on expiratory limb of anesthesia machine circuit
  • Anesthesia Patient Safety Foundation (APSF) recommendation, Perioperative Considerations for the 2019 Novel Coronavirus (COVID-19)
  • APSF recommendation, FAQ on Anesthesia Machine Use, Protection, and Decontamination during the COVID-19 Pandemic
• Minimize airway circuit disconnection, endotracheal tube (ETT) must be clamped if any circuit disconnection planned
• Special PPE for OR (N95 or OR powered air-purifying respirator (PAPR), goggles or face shield, gown, boot covers)
• Provide appropriate PPE education (CDC guidance copied below) and post in anteroom in OR
• Must use N95 or OR PAPR for all aerosol-generating procedures
• Extubation should occur in a negative pressure intensive care unit (ICU)/ward room if possible
• Recover patient in the negative pressure ICU/ward room or in the dedicated COVID-19 OR if negative pressure room not available
• Consider dedicated OR teams to manage COVID-19 patients in the OR with detailed education
• Consider performing procedures in negative pressure rooms with anesthesia team support if possible

Following are links to infographics from other sources that offer additional salient details:

• Canadian Journal of Anesthesia – Management of COVID-19 Cases in OR
• Canadian Journal of Anesthesia Twitter – What we do when a COVID-10 patient needs and operation: Operating room preparation and guidance from a frontline Singapore Hospital
• Anesthesia Patient Safety Foundation – Recommendations for Airway Management in a Patient with Suspected Coronavirus (2019-nCoV) Infection
• CDC – Sequence for Putting On and Removing PPE 

Short answer: Place high-quality viral filters between the breathing circuit and the patient’s airway and between the expiratory limb and the machine. The use of these filters is essential to prevent contamination of the machine. (See previous article for details on which filtration devices to use). Note: Even with filters, breathing circuits should be discarded after every patient.

The anesthesia machine needs to be protected from contamination by a potentially infected patient for two reasons. First, if pathogens can enter the internal parts of the machine, they could be passed on to a subsequent patient. Second, respiratory gases sampled for gas analysis can pass pathogens on to other patients or health care professionals after leaving the gas analyzer if improperly managed.

The good news is that the same precautions can be applied to all patients. The strategy is the same regardless of the patient’s risk of infection. A high-quality filter placed between the breathing circuit and the patient’s airway will protect the machine from contamination and also filter gas sampled for analysis. Heat and moisture exchange filters (HMEFs) are a good choice because they preserve airway humidity and are designed so that sampled gas is filtered before it enters the gas analyzer. It is possible to use a filter at the airway that is not also an HMEF. If a filter only is used, lower fresh gas flows (1-2 L/min or less) are desirable during maintenance of anesthesia to preserve humidity in the circuit.

It is also recommended to add an effective viral filter between the expiratory limb of the circle system and the machine. Not only is this second filter a reasonable backup to protect the machine from any particles that pass the primary filter, but it significantly amplifies the effectiveness of the first filter. Given the fact that the primary filter can become less effective if soiled, the backup filter is a good recommendation. Another filter between the machine and the inspiratory limb is added sometimes but is not necessary to protect the machine from the patient nor to protect the patient if the machine is kept clean. The main reason to add an inspiratory limb filter is to eliminate the chance of error by placing a single filtered limb on the inspiratory rather than expiratory port.

More Resources

Book mark https://www.facs.org/about-acs/covid-19 and check back for updates.

About the Coronavirus Disease 2019 (COVID-19)

Updated March 17, 2020

COVID-19 Update: Guidance for Triage of Non-Emergent Surgical Procedures

ACS has issued guidance for triage of non-emergent surgical procedures during the COVID-19 pandemic.

 Read the entire document online

Posted March 17, 2020

COVID-19 Update: Elective Surgery

ACS has issued recommendations on the management of elective surgical procedures during the COVID-19 pandemic.

 Read the entire document online

Posted March 13, 2020

Participants in this coding workshop will not only learn how to correctly report surgical procedures and medical services, but will also have access to the tools necessary to succeed, including coding workbooks to keep for future reference that include exercises, checklists, resource guides, templates, and examples. Physicians receive up to 6.5 AMA PRA Category 1 Credits for each day of participation. In addition, each day of the workshop meets AAPC guidelines for 6.5 continuing education units. 

Register Today

Thursday Course: Office Procedures and E/M Coding 
At the end of this session, participants will be able to:

• NEW! Recognize the E/M office visit changes for 2021
• Demonstrate accurate coding of E/M office and hospital visits in 2020
• Identify appropriate use of modifiers with E/M services
• Describe the components of the global surgical package, including critical care rules
• Demonstrate coding for screening versus diagnostic colonoscopy
• Apply teaching physician rules and coding for services
• Describe accurate coding of telemedicine, eVisits, consults, and non-face-to-face services
• Implement practice management strategies for collecting from patients with high-deductible health plans. 

Friday Course: 2020 Successful Surgical Coding 
At the end of this session, participants will be able to:

• Distinguish different categories of codes and how payment differs
• Describe what is included in a global surgical package and what can be reported separately 
• Distinguish what surgical modifier to report 
• Describe documentation requirements for unlisted codes 
• Demonstrate correct coding and documentation for radiology services
• Describe coding for different surgical approaches 
• Identify when to report mesh and reinforcement implants
• Demonstrate correct coding for a variety of general surgery procedures

The American College of Surgeons (ACS) is offering two positions for Associate Fellow surgeons in a two-year, fully funded fellowship with the ACS Geriatric Surgery Verification (GSV) program. The application process opened on January 15, 2020 for positions starting July 1, 2020.  Applicants must be Associate Fellows of the American College of Surgeons, and must have graduated from an accredited allopathic or osteopathic medical school in the United States or Canada; have completed residency and/or fellowship training in the United States or Canada; and have been in practice for less than 6 years.

 

The goal of the fellowship is to foster the development of surgical experts in the implementation of such a population-based quality program, as well as, to support the actual implementation of the ACS GSV at the Fellows’ own institution (or an institution within their Chapter’s catchment area). Scholars will be provided mentorship, education, support, and first-hand experience by the College, and will learn the skills necessary to address issues of patient safety and health care quality in this geriatric population. Ideally, at the completion of the two years, the scholar would have the tools and support to apply for grant funding in geriatric surgical care delivery and/or outcomes. 

 

The application deadline is April 1, 2020. For more information, go to: https://www.facs.org/quality-programs/about/clinical-scholars-program/geriatric-surgery

This six-day intensive course, offered by the American College of Surgeons (ACS) Division of Education, is designed to provide surgeons with the knowledge and skills to enhance their abilities as teachers and administrators of surgical education programs.  The course emphasizes the needs of adult learners and the techniques necessary to develop an effective learning environment for medical students, surgical residents, and colleagues.  This course is intended for full-time faculty members who are interested in acquiring or honing skills in curriculum development, teaching, performance and program evaluation, program administration, and faculty who have direct teaching responsibilities for medical students or residents.

 

Applications are available at https://www.facs.org/education/division-of-education/courses/surgeons-as-educators and will be accepted until March 6^th, 2020.