Updated 5 26 2020 Slide 22 added revised

Updated 5. 26. 2020 • Slide 22 - added revised scoring tool which allows for 100 cases to be scored Essential/ Elective Surgery Reactivation Toolkit 05. 01. 2020 | Elective Surgery Taskforce & SOCG Created by Elective Surgery Taskforce | Created 05. 01. 2020 | Revised 05. 26. 2020 | Approved by Tim Lineberry, MD

Elective Surgery Reactivation • As the prevalence of COVID-19 grows in certain geographic regions, limited resources are dedicated to managing the crisis. Regions with minimal COVID exposure have idle resources that could support Why is this important? interventional surgical care for patients. • Varying perspectives on which cases should be reactivated creates potential risks to surgeon/proceduralists, team members, and patients. Multiple Factors Driving Decisions Case Requirements PPE COVID Prevalence Goal • Develop recommended timeline for reactivation of surgical procedures. • Develop clinical guidelines for consistent coordination of essential and elective interventional care during and beyond the COVID-19 crisis. Ventilator Capacity ICU Beds Testing

Contents Preparation • Build a Medical-Surgical Local Governance Team: • Recommended committee members include CMO (chair), Surgery Chief, Vice President – • Operations, Chief Nursing Executive, and the anesthesia, oncology, and hospitalist leads Review Triggers: • Internal/External Factors Preparation + Key Points • Review: Joint Statement: Roadmap for Elective Surgery Guidelines Tools • Testing Prioritization Matrix • Operating Room PPE Recommendations • Essential/Elective Surgical Advisory Scoring Tool Support • Elective Surgery Task Force • SOCG Leads: Brandon Gauthier & Loren Hoff Appendix • Elective Surgery Criteria, Advisory Scoring Tool, Testing Prioritization Matrix, (additions)

Notice: This is a living document that will be updated as new information emerges. Amendments will be made real-time and published on the COVID-19 website.

Introduction Video Link to Video: https: //youtu. be/i. Jwf_Ecd. SOw

Elective Surgery Reactivation Process Preparation Build Local Governance Team Review Operational Triggers Review Joint Statement Guidelines Case Review Operations Application of Tools Essential / Elective Surgeries

Preparation

Standard Work Local Governance Team Medical-Surgical Local Governance Team Build Local Governance Team Description Tips • Required Members: CMO (chair), • Coordination with Operations and Chief of Surgery, VP – Operations, Chief Nursing Executive, leads for anesthesia, oncology, and hospitalist • Review guiding principles on page 4 of Essential Case Guidelines in Appendix 8 Support Services • Utilize existing site-based leadership structures & meetings

Standard Work Operational Triggers: Operational Pace of surgical services: Description Watch out/tips • The pace of essential and elective procedures will be largely governed by PPE and Testing availability • • The Taskforce has developed tools for site leadership to prioritize and rank procedures Ensure Medical-Surgical Team has pulse on current/future availability to align resources to demand Testing Capacity Backlog of Essential / Elective Surgeries # of Essential / Elective Surgeries PPE Availability

AAH Adaptation of Joint Recommendations Local Conditions We recommend that prior to initiating or continuing to perform elective procedures at your site, your local and/or regional COVID + rates should be decreasing, stable, or explainable over the last 14 days. Governance Review If your rates are not declining or stable, all potential factors that could increase COVID burden on your site/hospital should be reviewed by local incident command on a twice daily basis (at a minimum) as to whether your site should need to immediately halt all elective procedures. Additional Factors considered in halting elective procedures would include but are not limited to the AAH system supply chainʻs ability to maintain your: • PPE supply • ICU bed capacity • Staffing availability • Ventilator capacity • Testing capacity.

Standard Work Elective Surgery Guidelines Joint Statement on Reactivation of Elective Procedures (1/4) Timing for Reopening of Elective Surgery Description Watch out/tips • • 14 day stability/reduction of new cases Authorized by municipal, county, and state health authorities Safely treat all patients without resorting to crisis standards of care Appropriate number of ICU and non. ICU beds, PPE, ventilators, medications, and surgical supplies Trained and educated staff • Review AAH modified guideline recommendations Availability, accuracy and current evidence regarding tests, including turnaround time for results Frequency and timing of tests Indications and availability of employee health testing Response to COVID-19 positive worker, patient, PUI worker, and PUI patient • Review AAH testing prioritization in the event of a testing shortage (Appendix slide 22) Understand AAH policies surrounding employee exposure/confirmed cases • • • COVID-19 Testing within a Facility • • •

Standard Work Elective Surgery Guidelines Joint Statement on Reactivation of Elective Procedures (2/4) Personal Protective Equipment Description/substeps Watch out/tips • • • Adequate supply of PPE Staff training on proper PPE use Policies for PPE conservation and extended use • • Use AAH Advisory Scoring Tool (Appendix: Slide 22) Develop strategy for extending OR availability time Effective management of increased OR volume • • Reference the COVID-19 Information Center to review most up-to-date PPE information (Appendix: Slide 22) Ensure supply for potential second round of COVID surge Case Prioritization and Scheduling • • • Identify capacity goal prior to resuming Ensure adequate team member/supply availability in all areas of clinical support

Standard Work Elective Surgery Guidelines Joint Statement on Reactivation of Elective Procedures (3/4) Post COVID-19 Issues for Five Phases of Surgical Care Description/substeps • Watch out/tips Policies should consider preoperative, immediate preoperative, intraoperative, postoperative, and post discharge care planning • Close intercommunication between each of the surgical phases to ensure seamless clinical care. Facilities should collect and utilize relevant facility data Quality of care metrics should be utilized in coordination with COVID data • Consider collecting data including COVID-19 prevalence, bed capacity, PPE, ventilator availability, testing capacity, and scoring tool data Collection and Management of Data • •

Standard Work Elective Surgery Guidelines Joint Statement on Reactivation of Elective Procedures (4/4) COVID-related Safety and Risk Mitigation Surrounding Second Wave Description/substeps Watch out/tips • Implement social distancing policy for staff, patients, and visitors in nonrestricted areas in facility Discuss whether periprocedural areas should be further restricted • Create a process to ensure healthcare worker well-being Create scheduling workflows Develop preoperative testing process • • • Consider local, state and national recommendations Consider the number of people that can accompany the patient to the facility Additional COVID-19 Related Issues • • • Engage AAH internal resources to support procedural reactivation (See Covid Website) *Link to Joint Statement Roadmap in Appendix

Tools

Standard Work Testing Prioritization Guiding Principles • Recommend all patients scheduled for medically necessary elective surgeries/procedures undergo testing • Each site must have outpatient testing available 23 -48 hours prior to scheduled surgeries/procedures • Patients are required to self-isolate after testing until day of surgeries/procedure • All patients need to have COVID-19 verbal risk screening in pre-op on day of surgery/procedure. • In event of a testing shortage, testing prioritization recommendations include: • Higher risk surgeries/procedures: All surgeries/procedures that are aerosol generating, as defined by the COVID 19 Information Center, must have pre-op testing. This includes surgeries/procedures requiring general anesthesia and bag masking as well as bronchoscopy, oropharyngeal surgery, laryngoscopy, TEE, EGD/ERCP/EUS, All MAC procedures must also have pre-op testing. • Other surgeries/procedures that may not require testing: local anesthesia, IV sedation without anesthesiologist present, surgeries/procedures where intubation is not anticipated, spinal anesthesia may have testing once adequate testing resources are available. This section differs from current Illinois Department of Public Health regulations, which require that all patients are tested prior to any surgery/procedure. Links to Guiding Principles and IDPH Guidelines in Appendix 16

Standard Work Perioperative PPE Guidelines AAH Perioperative PPE Guidelines Personal Protective Equipment Description/substeps Watch out/tips • • The AAH PPE Committee has developed a set of guidelines for PPE usage for surgeries/procedures Link to AAH PPE Guidelines • Please follow the link below and review PPE guidelines daily to ensure alignment. Maintaining an appropriate supply of PPE for our surgical/procedural teams is essential and will require compliance with these guidelines.

Standard Work Case Review Surgical Wait Priority Scoring System (SWAPS) Scoring Criteria Description • • This standard scoring tool should be used to objectively prioritize surgeries and procedures across specialties Lowest score surgeries/procedures represent lowest risk/highest priority Link to Scoring Criteria, Tool Overview and Scoring Tool located in Appendix 18

Standard Work Case Review Surgical Wait Priority Scoring System (SWAPS) Scoring Categories Description Tips • 110 -150 Points Does not qualify May require a vote • • 51 -109 Points Qualifies, but may require positioning 0 -50 Points Qualifies • Points can be regionally adjusted by facility based on needs/resources Scoring system defers to surgeon’s discretion in determination of urgency of surgical priority Facility review orients towards determination of risk as it influences resource utilization COVID + / symptomatic patients should delay elective surgery until they meet AAH hospital de-escalation criteria Link to Scoring Criteria, Tool Overview and Scoring Tool located in Appendix 19

Appendix

Standard Work COVID-19 Resources Team Member & Physician Information Description/substeps Center • Informational resources and corresponding toolkits are readily available to answer COVID-19 questions. • For the latest information, click the link below: https: //www. advocatehealth. c om/covid-19 -info/ Review the COVID-19 information center as updates are frequently made

Standard Work Site Preparation Resources and Literature • • Illinois Department of Public Health Elective Surgery Guidelines (Control + click) Joint Statement on Reactivation of Elective Cases (Control + click) • SWAPS Tool Overview Essential Case Guidelines • Double Click to Open • SWAPS Scoring Tool • Testing Prioritization Guidelines Double Click to Open • SWAPS Instructions AAH Adaption of Joint Statement • Double Click to Open *PC Users – please use the PDF version of the document, when available. Mac Users – Please use the Word/Excel version of the document, when available. The embedded files are also available on the COVID-19 Information Center. 22