Workflow management of PUI/

Positive COVID-19 patient undergoing

emergency surgery in urology mobile
OT or OT 6 main operating theatre
 Objectives
• To provide designated operating theatre for PUI and positive covid-19
patient undergoing emergency surgery in Hospital Kuala Lumpur
• To provide workflow for PUI and positive covid-19 patient undergoing
emergency surgery in Hospital Kuala Lumpur
 Designated Operating Theatre
• Mobile Uro OT
• To accommodate patient from ED, IKTAR building and COVID ward (28, 21 and
14)

• OT 6 Main Operating Theatre

• To accommodate patient from intensive care ward and general ward located
on 3rd , 4th and 5th floor
• To accommodate cases that required image intensifier

Refer anesthesia team
Ø Specialist to specialist
Ø Provide relevant history, latest Ix, last
meal, weight, height, basic airway
assessment, drug & allergic Hx.
Ø If blood required, use safe O blood and
kept in OT
Ø Pre-op assessment & anesthesia
consent to obtain in OT. If consent from
family to obtain before op
PRIMARY OPERATING TEAM
Ø ASSESS & DECIDE FOR SURGERY
Ø Obtained consent from patient/ family
Informed main GOT counter (6510)
Ø Booking form to be fill outside COVIDward/
ICU and sent to main GOT after anesthesia
team accepted the case
Ø Once booking and operating theatre (urology
mobile/ OT 6 MOT) confirm, ACTIVATE team
Informed Bilik Gerakan (5333/5533) Ø ANESTHESIA TEAM
Ø SURGICAL TEAM
Ø To contact oncall doctor
Ø Dr Oncall ALERT RESPECTIVE TEAMS
Ø ED (Isopod for transfer if required)
Ø RADICARE for decontamination
Ø Polis Bantuan (Securing route)
OR preparation
 OR PREPARATION

ANESTHESIA TEAM OPERATING TEAM

o Consist of 1 Spec, 1 MO, 1 MA & GA nurse o Consist of 1 Spec, 1 MO, 1 scrub, 1
o CHECK AVAILABILITY and FUNCTION of circulating nurse, 1 runner, 1 team
o GA Machine and circuit leader and 1 PPK
o VS monitoring (Non invasive and invasive if required) o Check and ensure equipment for
o COVID airway intubation kit surgery is complete and reconfirm
o Videolaryngoscopy back with surgeon
o PAPR o Once preparation complete, to don as
o Drugs for RSI & Resuscitation: Calculated dosage & label protocol
o Ultrasound for lines or regional if required o Operating team will be waiting in scrub
o Regional anesthesia set if required room to don sterile PPE when patient
o USE Intubation checklist for surgery in patient suspected of positive COVID-19 transfer from ward to OT
o Once preparation complete, to don as protocol
o Requiring GA: Non-sterile fields with PAPR gear for the team managing
airway (3 person)
o Requiring Regional: Full PPE with N95 mask & face shield.
o Intubated patient: Full PPE with N95 mask & face shield.
o PAPR must be available in donning area if regional fail and required intubation
o OR is RED zone. OR team cannot cross red zone once patient been call
 Intubation checklist

** designated specialist should plan decisively the required equipment or drug for before calling the patient
** recommended to prepare extra equipment and drug in red zone
 OR PREPARATION COMPLETED

Team leader (T/L) operating team informed BILIK

GERAKAN OT is ready

BIILK GERAKAN mobilizes respective team

• ED – Isopod for intubated patient
• Polis Bantuan – secure route
• Radicare – route decontamination
• Ward/ICU – patient preparation to transfer

Once route secured and decontamination team

ready, BILIK GERAKAN informed T/L to initiate
patient transfer to OR

T/L informed SN ward/ ICU. Transfer patient to OR

following transfer guidelines
 Transfer guidelines for non-intubated patient from ward to OT

Staff • Involved 2 person: 1 MA ICU and 1 SN in charge (ICU/ward)

• Must done full PPE with N95 mask and face shield
Patient § MUST wear surgical 3ply mask
§ If required oxygen support, use NP 3L/min underneath the surgical 3ply mask
§ If unable to tolerate, anesthesia team need to assess patient for intubation
§ if required intubation, to follow transfer guidelines for intubated patient
Before transfer q Use designated trolley
q Patient preparation as OT checklist
During transfer from ü Transfer from ward straight into OR via the designated route
ward/ICU to OR ü To use modified aerosol box with plastic cover on patient to minimize risk of
aerosolize
ü In the airlock before entering OT, transfer team to wear additional outer layer
(disposable gown and shoe cover)
ü Anesthesia team to receive patient in OR
ü Transfer team to doff after passover
Others v Decontamination to follow by RADICARE
 Transfer guidelines for intubated patient from ward to OT
Staff • Involved 4 person: 1 MO anaes (handling airway), 1 MA (handling equipment
and route), 1 MA ED (lead and assist) and 1 SN in charge ward/ ICU (assist)
• Must done full PPE with N95 mask and face shield
Patient § MUST transfer using ISOPOD. If ISOPOD not available after confirmed with ED
to transfer using modified aerosol box to minimize aerosolize
Before transfer q Use designated trolley
q Patient preparation as OT checklist
q Use ASA standard monitoring
q Check and pre-set ventilator
q Check drug, IV lines and equipment for transfer (infusion pump, monitor)
During transfer from ü Transfer from ward straight into OR via the designated route
ward/ICU to OR ü Minimize risk of aerosolize during changing of ventilator by putting ventilator
on standby mode and clamp ETT with forceps before changing
ü In the airlock before entering OT, transfer team to wear additional outer layer
(disposable gown and shoe cover)
ü Anesthesia team to receive patient in OR
ü Transfer team to doff after passover
Others v Isopod decontamination by MA ED
v Decontamination to follow by Radicare
 Patient arrived in OR

DO
• Keep surgical 3ply mask on patient non intubated
• Minimize aerosolize for intubated patient
• Pre-op assessment & obtain consent
• Ensure good IV line
• Apply ASA standard monitoring
• Modified SSSL checklist
• Role allocation
• Pre-set ventilator
• Double check equipment and drug
• All complete forms seal in 2 plastic bag
• Operating team wait in scrub room until GA/ regional
anesthesia given and secured

DECIDE
• Plan for RA or GA at the discretion of the OR anesthetist
• If GA: nonsterile PPE with PAPR
• If RA: PPE with N95 and face shield
• If RA failed and required GA: Must doff & don PPE with
PAPR
• If perform RA or invasive line, proceeds under aseptic
technique (disposable gown, sterile gloves)
MOBILE OT FLOOR PLAN
Radicare
Store

Store
Store Pantry Sister’s
Donning Doffing Room
Area Area Counter
(Sterile PPE)

Scrubbing Neo
nate
Area
Operation Donning
Theatre Patient Area
Entry
Area
Store
Changing
Air lock
Room
Doffing area for
ward staff

EXT NO: 6272

 GOT FLOOR PLAN
GOT-6 FOR COVID-19 PATIENTS

DONNING AREA

EXT NO: 6510/6508

 OT TEAM ENTRANCE
MOBILE OT

GOT

DONNING
AREA
 Role allocation in uro mobile

monitor DRUG Give Drug/

MA(PPE)

Intubator
Role allocation &
(PAPR)
patient
place of team
before airway
Ventilator GA trolley
Assistant/MO secured
(PAPR)
** designated specialist
decided the role
allocation depends on
cases
GA nurse SURGICAL TEAM
(PPE) + RUNNER

YELLOW ZONE- YELLOW ZONE- SCRUB

INDUCTION ROOM ROOM
 Role allocation in OT 6 MOT

Give Drug/
monitor DRUG MA(PPE)

Intubator
Role allocation &
(PAPR)
patient
place of team
before airway
Ventilator GA trolley Assistant/MO secured
(PAPR)
** designated specialist
decided the role
allocation depends on
cases
SURGICAL TEAM GA nurse Patient
+ RUNNER (PPE)
bed

YELLOW ZONE- SCRUB YELLOW ZONE-

ROOM INDUCTION ROOM
Personal protection equipment (staff)
FULL PPE – FOR REGIONAL ANESTHESIA

1. Surgical Cap
2. Face Shield
3. N95 mask
4. Head Cover
5. Surgical OT attire
6. Water repellent gown
7. Double layer glove
8. Shoe Cover

** FOR GENERAL ANESTHESIA: PPE without

face shield + PAPR
 Intubation guidelines for PUI or positive
covid-19 patient going for surgery
• AIM

• Minimize aerosolization of virus

• Maximize first attempts success

• Reduce personal exposure

 Preparation
• Personnel
• Most experience person should be performed intubation
• Minimize people in the OR during intubation. Limit 3 people (senior
anesthetist, medical officer and GA nurse). MA will be standby outside OR
• All personnel involve in intubation in OR wears full PPE with PAPR as protocol
• Do intubation checklist to ensure all equipment and drug required for intubation
are prepared in OR
• Advance planning and clear communication are paramount
• Pre-set ventilator
• To call patient once preparation for anesthesia and surgery are complete
 Induction and intubation
• Anaesthetic assessment and to obtain consent before induction
• Attach patient with ASA Standard monitoring including capnography
• Avoid high nasal cannulation, NIV BIPAP/CPAP should not be used for pre-oxygenation
• Avoid awake fiberoptic (risk of aerosolizing)
• Robust pre-oxygenation with 100% O2 foe 3 – 5 minutes (aim FeO2 > 90). Use HMEF at
expiratory limb, inspiratory limb and between face mask & circuit
• Rapid sequence induction for apnea and lack of cough. Recommended to use high
dosage of IV rocuronium (1.2 mg/kg). Avoid IV Suxomethoniun.
• 2 person, 2 handed mask ventilation with grip to improve seal. Avoid bag mask
ventilation but if required to bag mask ventilation, should use low tidal volume with tight
seal mask
• Can optimize pre-oxygenation using head tilt chin lift maneuver or airway adjuncts
 Induction and intubation
• Early placement of supraglottic airway device instead of manual bagging for rescue
oxygenation
• May applied cricoid pressure if feasible (risk of coughing and difficult view during
intubation)
• Proceeds with intubation only if patient is paralyzed to avoid coughing
• Use videolaryngoscopy for intubation to facilitate intubation and increase the distance
• Inflate cuff immediately after intubation and clamped ETT before connecting it to
ventilator with HMEF and closed suction between ETT and circuit. Once everything
secured, manual bagging to confirm ETT placement clinically (auscultation, ETT fogging,
chest expansion) and ETCO2
• Tape ETT and take off top layer of gloves after intubation before start the ventilation
• Dispose used and all disposable items that were brought into the OR for intubation into
sealed plastic bag
 Anesthesia maintenance
• Ensure ETT connected to ventilator with closed suction and HMF in
between
• If required to do ETT suction, use closed suction
• If required to do open ETT suction, minimize aerosolize by put
ventilator in stand by mode before ETT suction
• Consider to use low flow
 Surgery finished

Any intraop sample need to recheck, label and confirm with surgical team

Operating staff to leave OR and doff out

Anesthesia team decided for extubate/ ventilate patient

Extubate Keep ventilate

- Follow emergence and extubation guidelines

Monitor in OR minimum 30 minutes Ensure stability post extubation

Arrange for transfer once stable Arrange for transfer once stable
 Emergence & Extubation guidelines
• Has well thought of plan before extubation
• Operating team need to exit OR before extubate
• Limit the number of anesthesia staff to 3 person
• MUST don full PPE with PAPR
• Perform close system suctioning before extubate and oral suction after extubation
• Consider antiemetic prophylaxis to avoid nausea, retching, or vomiting
• Consider to use glycopylorate to reduce secretion
• Extubate with plastic sheet over mask or aerosol box to prevent dissemination of aerosol
• Consider use of NP 3L/min for post extubation oxygen support in OR during recovery.
Avoid use of > 5 L/min
• Keep or use Modified aerosol box with plastic bag to cover patient to minimize aerosolize
• Monitor patient in OR. No PCA usage for patient.
 Patient stable in OR post surgery

Anesthetist informed T/L in charge

T/L informed BILIK GERAKAN

BILIK GERAKAN activate RADICARE, POLIS BANTUAN & ED if required Isopod

Once routes secured and activate team ready, BILIK GERAKAN informed T/L

T/L in charge informed ward/ ICU SN for initiate transfer

Transfer patient from OT to ward according to guidelines

 Transfer guidelines for non-intubated patient from OT to ward

Staff • Involved 2 person: MO anaes OT in charge and SN in charge (ICU/ward)

• Must done full PPE with N95 mask and face shield
• Aneas MO will doff in designated ICU/ ward
Patient § MUST wear surgical 3ply mask
§ If required oxygen support, use NP 3L/min underneath the surgical 3ply mask
Before transfer q Use designated trolley
q SN ward needs to arrive and enter OR
q In the airlock before entering OT, SN in charge need to wear additional outer
layer (disposable gown and shoe cover)
During transfer from ü To use modified aerosol box with plastic cover on patient to minimize risk of
ward/ICU to OR aerosolize
ü After passover, MO and SN ward/ICU transfer patient to ward/ ICU
ü Remaining anaesthesia team to exit OR and doff out
Others v Decontamination to follow by RADICARE
 Transfer guidelines for intubated patient from OT to ward

Staff • Involved 4 person: MO anaes OT incharge (handling airway), 1 MA ICU

(handling equipment and route), 1 MA ED (lead and assist) and 1 SN in
charge ward/ ICU (assist)
• Must done full PPE with N95 mask and face shield
Patient § MUST transfer using ISOPOD. If ISOPOD not available after confirmed
with ED to transfer using modified aerosol box to minimize aerosolize
Before transfer q Use designated trolley
q Use ASA standard monitoring
q Check and pre-set ventilator
q Check drug, IV lines and equipment for transfer (infusion pump,
monitor)
q Transfer team needs to arrive and enter OT
q In the airlock before entering OT, transfer team need to wear
additional outer layer (disposable gown and shoe cover)
 Transfer guidelines for non-intubated patient from OT to ward

During transfer from ü Passover in OR

ward/ICU to OR ü After passover, transfer team exit OR and send patient to ward/ ICU
ü Minimize risk of aerosolize during changing of ventilator by putting
ventilator on standby mode and clamp ETT with forceps before
changing
ü Remaining anesthesia team exit OR and doff out
Others v Isopod decontamination by MA ED
v Decontamination to follow by RADICARE
DOFFING PATHWAY IN URO
MOBILE OT
1. PERSONNEL WORKING IN NON-
STERILE FIELD
i.e : circulating nurse, GA nurse, PPK

• DOFFING PATHWAY IN MOBILE OT

B.
Inner layer gloves
A. Outer layer
Face shield
gloves
Gown
Head cover

Radicar
e Store

Store
Store Pantry Sister’
Donning Doffing s
Area Area Count Room
(Sterile PPE)
Ne er
Scrubbi on
at
ng Area e

Operation Donnin
Theatre Patient g Area
Entry
Area
Store
Changing
Air lock
Room
Doffing area for
ward staff

C.
Boot/Shoe cover
N95
OT cap
2. PERSONNEL WORKING IN
STERILE FIELD
i.e : Surgeons, Scrub Nurse

• DOFFING PATHWAY
B.
Inner layer gloves
Face shield
A. Outer layer Gown
gloves Apron
Head cover

Radicar
e Store

Store
Store Pantry Sister’
Donning Doffing s
Area Area Count Room
(Sterile PPE)
Ne er
Scrubbi on
at
ng Area e

Operation Donnin
Theatre Patient g Area
Entry
Area
Store
Changing
Air lock
Room
Doffing area for
ward staff

C.
Boot/Shoe cover
N95
OT cap
3. PERSONNEL WORKING IN NON-STERILE
FIELD WITH PAPR GEAR
i.e : Anaesthetist, Anaest team

• DOFFING PATHWAY
Anaest team will remove PPEs after patient left OT area
• Doffing of PPE with PAPR gear must be assist by another personnel
• PAPR gear must be sprayed with disinfectant prior to removal of PPE

B.
A. Outer layer PAPR gear
gloves Inner layer gloves
Gown/Coverall
Head cover
Radicar
e Store

Store
Store Pantry Sister’
Donning Doffing s
Area Area Count Room
(Sterile PPE)
Ne er
Scrubbi on
at
ng Area e

Operation Donnin
Theatre Patient g Area
Entry
Area
Store
Changing
Air lock
Room
Doffing area for

C. ward staff

Boot/Shoe cover
OT cap
DOFFING PATHWAY IN OT 6
MAIN OPERATING THEATRE
 1. PERSONNEL
GOT FLOOR WORKING PLANIN NON-
STERILE FIELD
GOT-6 FOR COVID-19 PATIENTS
i.e : circulating nurse, GA nurse, PPK

• DOFFING PATHWAY IN GOT

A. Outer layer
gloves

B.
Inner layer gloves
Face shield
Gown
C. Head cover
Boot/Shoe cover

D.
N95
OT Cap
 GOT FLOOR
2. PERSONNEL WORKING PLAN IN
GOT-6 FOR COVID-19 PATIENTS
STERILE FIELD
i.e : Surgeons, Scrub Nurse

• DOFFING PATHWAY IN GOT

A. Outer layer
gloves
B.
Inner layer gloves
Face shield
Gown
Apron
C. Head cover
Boot/Shoe cover

D.
N95
OT Cap
3. PERSONNEL WORKING IN NON-STERILE
FIELD WITH PAPR GEAR
i.e : Anaesthetist, Anaest team

• DOFFING PATHWAY IN GOT

Anaest team will remove PPEs after patient left OT area
• Doffing of PPE with PAPR gear must be assist by another personnel
• PAPR gear must be sprayed with disinfectant prior to removal of PPE

A. Outer layer
gloves
B.
PAPR gear
Inner layer gloves
C. Gown/Coverall
Boot/Shoe cover Head cover
OT Cap
 TROUBLESHOOT/ ENQUIRY?
Please do contact OT COVID manager:

• Dr Fadhli Suhaimi bin Abdul Sukur - 0123906935

• Dr Zarina bt Abu Kassim - 0197171457