COVID-19 Health Mandate 005, Revised on April 7, 2020 Attachment C Non-Urgent or Elective Procedures and Surgeries Issued: April 7, 2020 By: Governor Mike Dunleavy Commissioner Adam Crum, Alaska Department of Health and Social Services Dr. Anne Zink, Chief Medical Officer, State of Alaska Following ongoing guidance from the Centers for Disease Control and Prevention (CDC) that healthcare facilities and clinicians should prioritize urgent and emergency visits and procedures now, the State of Alaska is clarifying non-urgent or elective procedures that are to be postponed or canceled under COVID-19 Health Mandate 005. These actions can conserve staff personal protective equipment (PPE) and patient care supplies, ensure staff and patient safety, and expand available hospital capacity. Non-urgent or elective procedures include, but are not limited to, those identified by the American College of Surgeons, Elective Case Triage Guidelines for Surgical Care found at https://www.facs.org/covid-19/clinical-guidance/elective-case: 1. Breast Cancer Related: https://www.facs.org/covid-19/clinicalguidance/elective-case/breast-cancer Cases that should be deferred: • • • • • • • • • • • 2. Excision of benign lesions-fibroadenomas, nodules, etc… Duct excisions Discordant biopsies likely to be benign High risk lesions-atypia, papillomas, etc… Prophylactic surgery for cancer and noncancer cases Delayed SNB for cancer identified on excisional biopsy cTisN0 lesions-ER positive and negative Re-excision surgery Tumors responding to neoadjuvant hormonal treatment Clinical Stage T1N0 estrogen receptor positive/progesterone receptor positive/Her2 negative tumors Inflammatory and locally advanced breast cancers Cancer Surgery: See https://www.facs.org/covid-19/clinical-guidance/elective-case/cancer-surgery 3. Cardiac Surgery: See https://www.facs.org/covid-19/clinical-guidance/elective-case/cardiac-surgery Revision April 7, 20202 HEALTH MANDATE 005 Attachment C Page 1 of 5 COVID-19 Health Mandate 005, Revised on April 7, 2020 Attachment C Non-Urgent or Elective Procedures and Surgeries 4. Colorectal Cancer Related: https://www.facs.org/covid-19/clinicalguidance/elective-case/colorectal-cancer Diagnoses that could be deferred three months: • • • • • Malignant polyps, either with or without prior endoscopic resection Prophylactic indications for hereditary conditions Large, benign-appearing asymptomatic polyps Small, asymptomatic colon carcinoids Small, asymptomatic rectal carcinoids Alternative treatment approaches to delay surgery that can be considered: • • • • 5. Locally advanced resectable colon cancer - Neoadjuvant chemotherapy for two to three months followed by surgery Rectal cancer cases with clear and early evidence of downstaging from neoadjuvant chemoradiation - Where additional wait time is safe - Where additional chemotherapy can be administered Locally advanced rectal cancers or recurrent rectal cancers requiring exenterative surgery - Where additional chemotherapy can be administered Oligometastatic disease where effective systemic therapy is available Emergency General Surgery: See https://www.facs.org/covid-19/clinical-guidance/elective-case/emergencysurgery 6. Gynecological Surgeries: https://www.facs.org/covid-19/clinicalguidance/elective-case/gynecology Procedures and surgeries that could be delayed for a few weeks: • • • • • Revision April 7, 20202 Chorionic villus sampling/amniocentesis (CVS is performed between 11 and 14 weeks of gestation; amniocentesis is performed 15-22 weeks of gestation) D&C with or without hysteroscopy for abnormal uterine bleeding (pre- or postmenopausal) when cancer is suspected Cervical conization or Loop Electro-Excision Procedure to exclude cancer Excision of precancerous or possible cancerous lesions of the vulva Surgical abortion - healthcare providers are to postpone surgical abortion procedures unless the life or physical health of the mother is endangered by continuation of the pregnancy during the period of postponement HEALTH MANDATE 005 Attachment C Page 2 of 5 COVID-19 Health Mandate 005, Revised on April 7, 2020 Attachment C Non-Urgent or Elective Procedures and Surgeries Procedures and surgeries that can be delayed several months: • • • • • • • • • • • 7. Sterilization procedures (e.g., salpingectomy) Surgery for fibroids (sarcoma is not suspected) o Myomectomy o Hysterectomy Surgery for endometriosis, pelvic pain Surgery for adnexal masses that are most likely benign (e.g., dermoid cyst) Surgery for pelvic floor prolapse Surgery for urinary and/or fecal incontinence Therapeutic D&C with or without hysteroscopy with or without endometrial ablation for abnormal uterine bleeding and cancer is not suspected Cervical conization or Loop Electro-Excision Procedure for high grade squamous intraepithelial lesions Infertility procedures (e.g., hysterosalpingograms, most elective embryo transfers) Genital plastic surgery Excision of condyloma acuminata (if cancer is not suspected) Metabolic and Bariatric Surgery: https://www.facs.org/covid-19/clinicalguidance/elective-case/metabolic-bariatric May be delayed for months without threat to life or organ damage: • • 8. Bariatric: primary gastric bypass, sleeve, duodenal switch, gastric band Revisions for weight gain Neurosurgery: See https://www.facs.org/covid-19/clinical-guidance/elective-case/neurosurgery 9. Ophthalmology: See https://www.facs.org/covid-19/clinical-guidance/elective-case/ophthalmology 10. Orthopaedic Procedures: See https://www.facs.org/covid-19/clinical-guidance/elective-case/orthopaedics 11. Otolaryngology: See https://www.facs.org/covid-19/clinical-guidance/elective-case/otolaryngology Revision April 7, 20202 HEALTH MANDATE 005 Attachment C Page 3 of 5 COVID-19 Health Mandate 005, Revised on April 7, 2020 Attachment C Non-Urgent or Elective Procedures and Surgeries 12. Pediatric Surgery: https://www.facs.org/covid-19/clinical-guidance/electivecase/pediatric-surgery Circumcisions should be postponed, except for the following: • Documentation of infection with failure of medical management in a child or adult • Newborn circumcision at the bedside in the immediate postnatal period prior to the newborn going home Delay results in minimal patient risk: • • • • • • • • • • • • • • • • 13. Vascular access device removal (not infected) Chest wall reconstruction Asymptomatic inguinal hernia Anorectal malformation reconstruction following diversion Hirschsprung disease reconstruction following diversion Inflammatory bowel disease reconstruction following diversion Enterostomy closure Breast lesion excision (i.e. fibroadenoma) Branchial cleft cyst/sinus excision Thyroglossal duct cyst excision Fundoplication Orchiopexy Bariatric surgery Splenectomy for hematologic disease Cholecystectomy for biliary colic Repair of asymptomatic choledochal cyst Plastic Surgery: See https://www.facs.org/covid-19/clinical-guidance/elective-case/plastic-surgery 14. Thoracic Cancer Surgery: https://www.facs.org/covid-19/clinicalguidance/elective-case/thoracic-cancer Cases that should be deferred: • • • • • Revision April 7, 20202 Predominantly ground glass (<50% solid) nodules or cancers Solid nodule or lung cancer < 2 cm Indolent histology (e.g. carcinoid, slowly enlarging nodule) Thymoma (non-bulky, asymptomatic) Pulmonary Oligometastases - unless clinically necessary for pressing therapeutic or diagnostic indications (i.e., surgery will impact treatment) HEALTH MANDATE 005 Attachment C Page 4 of 5 COVID-19 Health Mandate 005, Revised on April 7, 2020 Attachment C Non-Urgent or Elective Procedures and Surgeries • • • • • 15. Patients unlikely to separate from mechanical ventilation or likely to have prolonged ICU needs (i.e., particularly high-risk patients) Tracheal resection (unless aggressive histology) Bronchoscopy Upper Endoscopy Tracheostomy Urology: See https://www.facs.org/covid-19/clinical-guidance/elective-case/urology 16. Vascular Surgery: See https://www.facs.org/covid-19/clinical-guidance/elective-case/vascularsurgery Revision April 7, 20202 HEALTH MANDATE 005 Attachment C Page 5 of 5