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The ACAPS Board has worked diligently to provide Programs, Residents, and Medical Students with COVID-19 related information and resources in one unique spot. Read through and email us if you have any additional questions related to this health-crisis.
Main page for CDC COVID information
Main page for WHO COVID information
UpToDate COVID
Note from ACGME
The ACGME the Plastic Surgery RRC in particular recognize the impact that the COVID pandemic is having on clinical experience. They recognize that the cessation of elective cases will have a noticeable effect on case logs. As such, each program's CCC will continue to evaluate a resident's readiness to advance and/or graduate based on overall competence in plastic surgery. In discussing case logs, and particularly case log minima, it is important to recognize that the ACGME case minima were established for program accreditation. They are used by the surgical Review Committees to determine whether a given program offers a volume and variety of cases (certainly operative cases but, in some instances, non-operative cases, as well) sufficient for education of the complement of residents/fellows for which the program is accredited. The ACGME caselog minima were not designed to be a surrogate for the procedural competence of an individual program graduate and are not utilized in that manner by the Review Committees.
The pandemic is far beyond the control of the programs that the ACGME accredits and will clearly reduce the number of elective operations performed by the residents/fellows in those programs for the foreseeable future. This communication is provided to help answer some of the questions of surgical residents/fellows and programs about the impact of those reductions.
Impact on the individual resident/fellow
ACGME-accredited programs are obligated to graduate only those residents/fellows who have demonstrated the ability to perform the medical, diagnostic and surgical procedures considered essential for the area of practice. It is up to the program director, with input from the program’s Clinical Competence Committee, to assess the procedural competence of an individual trainee as one part of the determination of whether that individual is prepared to enter autonomous practice. A given individual who has not met all case minima may be deemed by the program director as being surgically competent and be allowed to complete the program, as scheduled. Another individual who has exceeded all case minima may not be deemed by the program director as being surgically competent and be required by the program to extend their training until competency can be demonstrated. These considerations apply at all times.
©2020 Accreditation Council for Graduate Medical Education (ACGME)
As a result of the COVID-19 pandemic and its effects on elective surgery, it is certainly possible that some programs will find it necessary to extend the period of residency/fellowship for some trainees. And, of course, the longer the pandemic impacts elective surgery, the more trainees’ periods of residency/fellowship will be extended. Extension of training as a result of the current circumstances must not be viewed as, in any way, reflecting poorly on the affected residents/fellows. It would be a reflection of the program’s obligation to the public, the ACGME and the residents/fellows, themselves, in response to circumstances beyond their control.
The ACGME accredits programs. It does not certify individuals. What an extension of training would mean for a given individual in terms of the board certification process can only be answered by the appropriate certifying board.
Impact on programs
The ACGME and its Review Committees use the standard of substantial compliance, rather than absolute compliance, in making accreditation decisions. Accreditation decisions include the accreditation status of the program but also include the levying of citations and areas for improvement. In making accreditation decisions, the Review Committees thoughtfully consider all available information from and about a program, e.g. caselogs, resident/fellow and faculty surveys and the program annual update. Specific to case logs, the minima will not be waived by the Review Committees in response to the pandemic. But, the case logs of graduates of a program who were on duty during the pandemic (particularly those who were in their ultimate or penultimate years) will be judiciously considered in light of the impact of the pandemic on that program. The program can delineate for the Review Committee how it was affected by the pandemic in the Major Changes and Other Updates section of the Program Annual Update. Programs must bear in mind that they have an obligation, not just to the ACGME, but to public and to their trainees to graduate only those residents/fellows who they believe able to autonomously perform the medical, diagnostic and surgical procedures considered essential for the area of practice. A program that completes residents/fellows who have multiple substantial deficiencies in their graduate case logs may be viewed by the Review Committee as not having met that obligation.
Frequently Asked Questions
- How the virus is spread?
- Airborne, droplet, contact, fomite. Mainly droplet and fomite transmission. In the laboratory setting, aerosolized viral titers can remain elevated for up to 3 hours. It can survive the longest on plastic up to 50 hours, then stainless steel, carboard about 20 hours.
More information
- Is there a vaccine?
- What is available in terms of testing?
- Currently there are multiple PCR based tests based on nasal swabs to determine active infection. Antibody based detection methods are being developed to determine whether or not people have ever been infected in the past.
- How often should we be washing our hands?
- As frequently as possible with soap and water for a minimum of 20 seconds. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol.
COVID-19 Surgical Case Log FAQs
Healthcare Based Statistics
- 2018 data shows 5256 community hospitals in the US with 51.4% delivering ICU care
- 2009 data estimates 62000 full featured ventilators in the US
- A recent AHA webinar on COVID-19 projected that 30% (96 million) of the U.S. population will test positive, with 5% (4.8 million) being hospitalized. Of the hospitalized patients, 40% (1.9 million) would be admitted to the ICU, and 50% of the ICU admissions (960,000) would require ventilatory support. More information
- Based on AHA 2015 data, there are 28,808 intensivists who are privileged to deliver care in the ICUs of U.S. acute care hospitals. Hospitals with telemedicine capacity may also use the technology to connect with expert resources at other locations.
- Fast facts on US hospitals in 2020
Epidemiology
- You can be infected between 2-14 days prior to presenting with symptoms, however, younger patients can be completely asymptomatic and still be vectors for transmission. Time between onset of symptoms and the development of acute respiratory distress syndrome can be as short as 9 days. Viral shedding and infectious transmission may begin 2 days prior to clinical presentation, and patients can continue to shed the virus for up to 2 weeks after the onset of symptoms. Approximately 10% of patients will have negative PCR even though they are actively showing symptoms. More Information
- ~80% of patients present with mild to moderate disease, the majority of which will have mild symptoms of fever, malaise, cough and will improve without intervention
- ~15% with severe disease with dyspnea, respiratory frequency ≥30/min, blood oxygen saturation ≤93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio <300, and/or lung infiltrates >50% within 24 to 48 hours
- ~5% with critical disease respiratory failure, septic shock, and/or multiple organ dysfunction or failure. More Information
- Case fatality begins to increase in ages 50+
- Risk factors include older age, HTN, chronic lung disease, diabetes, obesity.
- Radiological findings: 1) Focal ground glass opacities 2) Septal thickening 3) Consolidation patterns 4) Pleural effusions More Information
- Viral myocarditis is responsible for 7% of COVID mortalities and contributes to 33% of COVID mortalities.
- Labs
- Lymphopenia
- Neutrophil : Lymphocyte ratio > 3
- Platelets < 100K
- D-Dimer > 1 mg/L
- CRP > 60 (tracks with disease and correlates with severity
- Elevated TP
- Elevated BNP
- Ace inhibitor medication will induce upregulation of ACE receptors potentially predisposing to a more rapid early course of disease.
What should Plastic Surgery Residents be doing to prepare?
- ALL elective surgery should be cancelled to limit exposure and preserve PPE.
- Cancel all nonessential appointments at outpatient clinics. Implement telemedicine solutions.
- Platooning the Residents: Click here to view Dr. Marcus’ rational for creating a platoon system for residents.
- Tiered staffing strategy for pandemic
- In this time of low surgical volume prepare for health care worker illnesses by creating teams of minimal number of staff required. Have these teams work in shifts of 7 days and 7 days off. Ideally, a rotation of more than 3 of these teams will allow for a free staff pool that can become available for replacement of sick staff. Use the minimum number of residents for rounding and for necessary cases. PPE will soon become very difficult to come by. Re-use PPE when possible if not contaminated. For absolutely mandatory clinic visits, limit patient interaction to one medical provider.
- What is the proper PPE?
- Use of droplet precautions including gown, eye protection, and mask. When possible use modified airborne precautions which include the above plus an N95 mask or PAPR (powered air purifying respirator). If performing aerosol generating procedures such as intubation, bronchoscopy, open suctioning, BiPAP, or nebulizer treatment require full airborne precautions.
- There is a risk of ocular transmission, therefore eye protection is equally important. Ocular transmission 2019-nCoV transmission through the ocular surface must not be ignored Lu, Cheng-wei; Liu, Xiu-fen; Jia, Zhi-fang The Lancet
- What to do if you are sick
Training
- How to put on and remove PPE
- The Society of Critical Care Medicine (SCCM) has developed a free on-demand training program to help prepare you, ICU staff and those without a background in critical care who may want to provide care for COVID-19 and other ICU-related disasters. More Information
Hospital Logistics
- Negative pressure rooms are strongly recommended, if there is no negative pressure room available cohort the patients together in separate rooms and install HEPA filters into the exhaust ducts.
- Create two independent areas for COVID-negative and COVID-positive surgical patients in the operating room, surgical intensive care unit, and wards.
- For patient transport notify the hospital Command Center of transport so security can escort to clear route including elevators. Patient should wear surgical mask and transporting staff should wear full droplet PPE.
- If intubation required for OR procedure, recommend intubation in negative pressure room prior to OR; avoid intubation in OR.
- Avoid noninvasive ventilation, high flow nasal cannula, Venturi masks, and LMA as all increase airborne particles.
- Minimize airway circuit disconnection, endotracheal tube (ETT) must be clamped if any circuit disconnection planned.
- Extubation should occur in a negative pressure intensive care unit (ICU)/ward room if possible.
- Keep a log of which staff are involved with each COVID case to allow infection control tracking.
- Use of stethoscopes is considered a high risk of contamination. Avoid if possible.
- Test as many people as possible (health care workers, surgeons, patients).
Pregnancy
- In general, pregnant women experience immunologic and physiologic changes that make them more susceptible to viral respiratory infections, including potentially COVID-19. It is reasonable to predict that pregnant women might be at greater risk for severe illness, morbidity, or mortality compared with the general population, as is observed with other related coronavirus infections.
- The currently published data on COVID-19 infection in pregnancy include 2 case series, totaling 18 women, only 1 of whom suffered severe respiratory morbidity requiring intensive care unit admission and mechanical ventilation. Lei D WC, Li C, Fang C, Yang W, Cheng B, Wei M, Xu X, Yang H, Wang S, Fan C. . Clinical characteristics of pregnancy with the 2019 novel coronavirus disease (COVID-19) infection. Chinese Journal Perinatal Medicine 2020;23(3). / Chen H GJ, Wang C, Luo F, Yu X, Zhang W, Li J, Zhao D, Xu D, Gong Q, Liao J, Yang H, Hou W, Zhang Y. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020;395(10226):809-15.
- Data from the SARS epidemic are reassuring, suggesting no increased risk of fetal loss or congenital anomalies associated with infection early in pregnancy.
- Chen et al. found no evidence of COVID-19 in the amniotic fluid or cord blood of 6 infants of infected women as well as no evidence of COVID-19 in the breast milk of 9 infected women.
- While pregnant health care providers may continue to work, facilities may want to consider limiting their exposure to patients with confirmed or suspected COVID19, especially during higher risk procedures.
Minimizing Home Risk
- There is no evidence that the virus can be transported home on your clothes, either for coronavirus or for any other respiratory virus. However, given the data presented on the half life of the virus on various surfaces, it would be prudent to change clothing prior to returning home.
- Decontaminate your phone and other personal equipment used during patient care.
- Wash your hands.
- If you are directly working with COVID-19 positive patients, you may want to consider wearing a mask and limiting the amount of shared fomites at home.
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