COVID-19, pediatric surgery, perioperative nurse, screening protocol



  1. Dibbs, Rami P. BA
  2. Ferry, Andrew M. BS
  3. Mehl, Steven C. MD
  4. Dunn, James J. PhD
  5. Enochs, Joyce A. RN
  6. Ferguson, Susannah M. PA-C
  7. Archer, Nakeisha M. RN
  8. Ward, Amanda A. RN
  9. Winebar, Janet M. RN
  10. On behalf of the Perioperative COVID Workgroup


Abstract: The provisions of healthcare have significantly changed globally as a result of the impact of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Consequently, SARS-CoV-2 has required hospitals to create institution-specific preoperative screening protocols to minimize nosocomial transmission. Nursing leadership at our institution has served an important role in the evolving screening process. Over 260,000 people have been infected with SARS-CoV-2 within Harris County, significantly impacting healthcare systems within the greater Houston area. Institutional surgical screening protocols have thus been designed to improve patient and provider safety while delivering optimal care in accordance with our institution's guidelines and the Centers for Disease Control and Prevention recommendations. Implementation of screening protocols has helped limit transmission of SARS-CoV-2 infection while maintaining high standards of patient care. Through this experience, perioperative nursing personnel have effectively helped design and implement surgical screening protocols while also safely and properly screening patients. In addition, nurses have shown flexibility in response to the evolving nature of the coronavirus disease 2019 pandemic.


Article Content

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has created significant strain on healthcare facilities worldwide (Ehrlich et al., 2020). When the World Health Organization declared the coronavirus disease 2019 (COVID-19) a pandemic on March 11, 2020, perioperative nursing leadership, in conjunction with other hospital leaders, designed preoperative screening protocols to decrease additional stress to an already-drawn healthcare system (Barney et al., 2020; Parikh et al., 2020; Stylianos et al., 2020). Nurses and other healthcare professionals have had to continuously adapt their management of screening surgical patients in accordance with the ongoing development and evolution of the COVID-19 pandemic. This process was especially important for perioperative nurses because of the likelihood of interaction with patients potentially infected with SARS-CoV-2 (Fernandez et al., 2020; Nayna Schwerdtle et al., 2020).


Because the hospital was located in one of the top five counties in the United States for confirmed cases of SARS-CoV-2, nurses were heavily involved both in the surgical screening of patients and in the implementation of surgical screening protocols (Johns Hopkins Coronavirus Resource Center, n.d.). These institutional screening protocols have undergone a series of modifications over time reflecting the dynamic nature of the COVID-19 pandemic. Soon after the first case was confirmed in Texas, Governor Gregg Abbot ordered that all elective surgical procedures be canceled. The consequences of this order were immediately evident with the hospital reporting a significant reduction in surgical cases from approximately 800 to under 200 surgical procedures performed weekly (Figure 1). An exponential increase in individuals infected with SARS-CoV-2 occurred during the following months of April through July. The current rise in daily numbers of SARS-CoV-2 infections indicates that continued efforts are necessary to control virus exposures through our surgical screening processes (Harris County Public Health and Houston Health Department, 2021). This study describes the process of developing a perioperative intake protocol that can be of use in the setting of transmissible diseases such as COVID-19.

Figure 1 - Click to enlarge in new windowFIGURE 1. Surgical volume at our institution by week. Note the shift in surgical volume after the issuing (dashed line) and initial extenuation (solid line) of the Texas Governor Gregg Abbot's executive order.


As perioperative leadership prepared to provide surgical care for patients with COVID-19, it became evident that most surgeries performed would be for an incidental reason unrelated to their COVID-positive diagnosis. Perioperative team members were concerned of exposure to both symptomatic and asymptomatic patients who could potentially be positive. In an effort to protect the perioperative team, to allay fears, and to control the use of limited personal protective equipment (PPE), a screening protocol for all patients scheduled to undergo surgical procedures was implemented.


This approach was identified by the Perioperative Leadership Team, which consists of surgeon, anesthesia, and nursing leadership. In the early phases of the pandemic, PPE was only indicated for use when managing COVID-positive patients. Perioperative leadership reviewed all cases in the beginning and ascertained that staff were stockpiling PPE for reuse during future patient encounters because of fear of potential PPE shortages. By conserving PPE supply, training perioperative staff to protocol updates, and screening all patients except for those undergoing true emergency procedures, providers were able to safely care for all patients. Our screening protocol was heavily influenced by the availability of testing materials, the myriad of restrictions placed on healthcare facilities by the state, and the confidence of staff in their personal safety. Consequently, the ever-evolving nature of technology and governmental regulations resulted in many changes to preoperative screening practices over time.


In the early days of the SARS-CoV-2 pandemic, patients were tested using real-time reverse transcription polymerase chain reaction and transcription-mediated amplification testing. Although efficacious for the detection of SARS-CoV-2, these testing modalities required up to 8 hours to process patient samples. Once rapid, on-demand SARS-CoV-2 testing was possible, this resulted in a significant shift in our preoperative screening protocol and the ability to screen a significantly higher number of urgent surgical patients.



Surgical procedures can be separated into elective and urgent or emergent cases. Simplistically, elective cases are defined as procedures scheduled in advance of 24 hours before surgery. Urgent or emergent surgical procedures are cases that must be performed within 24 hours of presentation because of the nature of the patient's medical condition. Screening algorithms employed by our institution were designed to address disparities between these two case groups. Access to rapid test supplies was limited and led to the development of screening algorithms designed to protect the supply for patients unable to wait for a result.


Urgent and Emergent Surgery Process

To aid safe care and appropriate use of valuable operating room (OR) resources, our institution developed a classification system for all urgent and emergent procedures. The classification system consists of five categories identified by the letters "A" through "E," which classifies patients based on the severity of their condition (Table 1). Patients classified as "A" through "D" (life-threatening to semiurgent) underwent rapid testing with patients classified as "E" (nonurgent) receiving nonrapid testing. Despite the 70% reduction in processing time when compared with conventional testing methods, rapid tests could not produce a result quickly enough for patients classified as "A" and "B" (life-threatening and emergent). Therefore, the screening protocol evolved and initially we were unable to require a test result before entering the OR for the designated "A" and "B" patients. In an effort to protect staff from possible exposure, patients needing life-threatening or emergent surgery were treated as positive for SARS-CoV-2 until a negative test result was received. Patients classified as "C" through "E" were required to have a rapid on-demand SARS-CoV-2 screening result before undergoing their procedure.

Table 1 - Click to enlarge in new windowTable 1 Classification of Nonelective Cases at Texas Children's Hospital

Elective Surgery Process

Perioperative leadership focused on providing quality patient care while also protecting staff and patients from infection; therefore, preoperative patients undergoing elective procedures were screened for SARS-CoV-2 before surgery. Early on in the pandemic, a thoughtful approach was enacted regarding where preoperative screening would occur for elective surgical procedures. To minimize patient and practitioner exposure to the virus, our institution partnered with its affiliated outpatient pediatric healthcare facilities to provide curbside testing at three locations.


The process of scheduling testing, placing orders for screening tests, and reconciliating results before surgery was carefully designed to establish an efficient and safe provision of care. Perioperative nurses were heavily involved in improvements for each of these responsibilities. At the beginning of the pandemic, postanesthesia care unit nurses would review the screening schedule for elective cases and confirm all orders were placed for patients presenting before surgery. Initially, these nurses would ensure all screening tests were complete the day before the patient underwent surgical intervention. This practice, however, did not limit the significant delays and cancellations of elective surgical procedures because of the timing constraints of patient screening. Consequently, some patients were unable to be cleared for surgery, creating unintended disruption and delays in service. To improve this process, nurses began screening patients at least 48-72 hours before arrival for surgery.


Nurses, often after-hours, were the point of contact to receive any positive result and share that information with the surgeon, who then relayed that information to patient and family. If the surgeon decided the procedure should be postponed, either nursing or a physician assistant would cancel the procedure and follow surgical guidelines described below for rescheduling patients.


Patients who tested positive for SARS-CoV-2 and had their procedure canceled required clearance before undergoing their surgery at a later date. The patient clearance process, designed in accordance to recommendations issued by the Centers for Disease Control and Prevention (CDC), was largely determined by the presence of symptoms, or lack thereof, during screening (Table 2). Initially, all patients, regardless of symptomatology, were required to test negative for the virus on two separate occasions within a 24-hour period. Because of updated CDC guidance, the number of tests required for clearance was decreased to one and then later to a testing-free model based on patients' symptomatology and screening history. This model mandates that all patients who test positive are required to quarantine for a minimum of 21 days until all members of the patient's household exhibit no symptoms indicative of COVID-19. This 21-day self-isolation period is reset should a family member exhibit symptoms suggestive of active SARS-CoV-2 infection.

Table 2 - Click to enlarge in new windowTable 2 Requirements to be Cleared for Elective Surgery Upon Testing Positive

Continuous adjustments to screening guidelines at our institution have culminated in the current protocol established for protecting both patients and providers. Patients ideally should be screened 72 hours before their elective surgical procedure. If results are still pending after the surgical case is confirmed, the procedure should be moved to the last case on the scheduled day to allow for a seamless transition between operations and to permit time for the test to result.


Particular criteria must be met to reschedule patients who are symptomatic with SARS-CoV-2 infection. The patient must lack a fever for 72 hours without use of antipyretics, exhibit improvement in respiratory symptoms (e.g., cough, shortness of breath), pass at least 10 days since they last showed symptoms, and test negative for the SARS-CoV-2 RNA molecular assay. Patients who test positive for SARS-CoV-2 but are asymptomatic must also follow particular guidelines to undergo surgery at a later date. Specifically, isolation measures should be in place for at least 10 days after the date of their first positive SARS-CoV-2 test in conjunction with a negative follow-up screening test.


Although uncommon, there are instances when the surgeon deems that the procedure should be performed despite a positive SARS-CoV-2 test result because of the critical nature of the patient's condition. To approve these patients for surgery, the OR scheduling team should first be notified of the surgeon's decision and be provided with the date and location of surgery as well as an explanation for why the procedure should be performed. The OR scheduling team should then seek approval from perioperative leadership. If approved, the case is moved to the last time slot available on the scheduled day.



Perioperative nurses have played a significant role in the implementation of the various surgical screening protocols adopted since the beginning of the pandemic. To adapt the screening protocols to the rapidly evolving nature of the COVID-19 pandemic, partnerships were formed between pathology, infection control, and perioperative leadership.


Nursing leadership created an automated report to identify patients who either were not scheduled for screening or did not present to the testing site for their scheduled appointment, along with the results of testing. This report significantly reduced the expended resources spent on manually checking and arranging all patients for appropriate screening. Reviewing SARS-CoV-2 results was also principally handled by perioperative nursing staff. Before the automated report was created, nurses would review each patient's medical record daily to confirm a screening result.


Perioperative nurses also played a primary role in both screening surgical patients and educating other nursing personnel on proper administration technique with the nasopharyngeal swab. An otolaryngologist originally trained a single nurse who then served as the leader for instructing an initial nursing cohort to manage collecting the nasopharyngeal specimens used for COVID-19 testing. This group of nurses later served as educators to teach other nursing personnel. Upon showing proficiency, nurses were able to perform independent nasopharyngeal swabs.



The current screening protocols utilized are a product of the constantly evolving atmosphere surrounding the COVID-19 pandemic related to both internal and external forces. The internal forces included changes in our institutional standards or preferences such as inpatient units' comfort in accepting a patient without a COVID-19 result, whereas examples of external forces were the frequent changes in CDC recommendations and Governor's orders. Protocols for screening changed over time. In the 10 months since preoperative screening began, 21,750 tests were run with 3.6% positive results, illustrating the importance of our screening protocols in preventing nosocomial infection and transmission (Table 3).

Table 3 - Click to enlarge in new windowTable 3 COVID-Positive Preoperative Patients by Location

Many challenges have arisen during this time, including testing over holidays, during severe weather conditions such as extreme heat or hurricanes, and technology downtimes. Providers and staff at our institution were able to overcome and learn from these hardships. The big takeaways from this project have been building on current relationships, strengthening communication, and remembering to look within and outside our institution for unusual solutions. Several times, simply reaching out to an internal partner resulted in team members ready to assist, demonstrating strong leadership and unity during this pandemic. Examples of the actions of internal partners include surgical hospitalist team assuming responsibility for day of test resulting accountability and local primary practices assisting to perform swab testing during technology downtimes.



The screening protocols have undergone numerous modifications to reflect both changes to CDC guidelines and developments within our internal medical infrastructure. Perioperative nursing was at the forefront of designing and updating these institutional screening protocols in addition to participating in the surgical screening of patients. The fears of many caregivers led to the decision by the perioperative leadership team to begin a comprehensive preoperative screening protocol for COVID-19 for all patients while also conserving the supply of PPE to mitigate the risk of potential shortages. Nurses and other healthcare personnel showed grit and adaptability when faced with the continuous changes caused by the COVID-19 pandemic. Important to note is that communication between leaders and frontline staff was imperative to surviving a constantly changing environment like the COVID-19 pandemic. We hope that our experiences with surgical screening and clearance guidelines and discussions regarding opportunities for improvement and outcomes can serve as a reference for other institutions when faced with a highly contagious transmissible disease.




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