Surgical and Clinical Reactivation for Elective Procedures during the COVID-19 Era: A Global Perspective

Abstract

The coronavirus disease (COVID-19) pandemic has certainly been an unprecedented time. We have had to halt and modify our lives on a local, national, and international level and cooperate in fighting with this “invisible enemy” in every sector (medical, governmental, industrial, economic, educational, and social). Our immediate action in American Association of Gynecologic Laparoscopists has been to organize weekly webinars on subjects related to the pandemic and unite with 8 other professional women's healthcare societies to provide joint statements that guide our membership and others to expand their knowledge and optimize patient care during the COVID-19 crisis. This international and multidisciplinary collaboration with surgeons and medical specialists at the leading edge of the pandemic course has been an invaluable resource for global healthcare providers who are at earlier points on the COVID-19 curve. COVID-19 preparedness has required flexibility because of a lack of diagnostic tools to accurately detect all viral carriers and the absence of effective viral therapy. Most gynecologists have halted most of the “non-essential” office and surgical procedures to protect and mitigate risk for all patients and caregivers, preserve personal protective equipment (PPE), and maintain facility capacity for a surge in COVID-19 cases. Joint statements from the American College of Surgeons and the consortium of 9 women's healthcare societies have provided guidance for resuming surgical practice and reintroducing elective procedures [1American Society of Anesthesiologists. Joint statement: roadmap for resuming elective surgery after COVID-19 pandemic. Available at:https://www.asahq.org/about-asa/newsroom/news-releases/2020/04/joint-statement-on-elective-surgery-after-covid-19-pandemic. Accessed April 17, 2020.Google Scholar,2Society of Gynecologic Surgeons. Joint statement on Re-introduction of hospital and office-based procedures in the COVID-19 climate for the practicing urogynecologist and gynecologist. Available at:https://www.sgsonline.org/joint-statement-on-re-introduction-of-hospital-and-office-based-procedures-in-the-covid-19-climate. Accessed April 28, 2020.Google Scholar]. This special article provides further detailed information necessary for successful surgical and clinical reactivation for elective procedures during the COVID-19 Era, while severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains a viable threat. Financial issues impact the reopening of elective surgical services during the COVID-19 pandemic. Decreased surgical volume has led to a widespread and immediate revenue loss on physicians and surgeons in private practice. The loss of volume has a projected longer-term impact on physicians employed by larger groups or institutions and on the facilities themselves. Disruption of the supply chain also limits return to normalcy. PPE is in high demand, and some small centers are unable to order supplies because of the allocation of PPE to large hospitals and areas with higher infection density. Long-term ventilator use has created a national shortage of medications such as opiates and paralytic agents. While hospitals and ambulatory surgical centers are slowly booking surgical cases, the limited supplies, longer room turnover times, and backlogs of cases are projected to lead to salary reductions, layoffs, and financial distress. Multiple factors influence the timing of reactivation for non-essential surgery. The burden on the healthcare system and reserve capacity limit reactivation of nonessential office and surgical procedures. Chinese data suggest that an appropriate level of hospital resources must be preserved to care for patients with COVID-19 related illnesses. The mortality of COVID-19 in Wuhan, where preparedness was not feasible for obvious reasons, was 5 times higher than in the rest of continental China, where advanced planning made resources more widely available, and the hospital systems were not overwhelmed [3Leung K Wu JT Liu D Leung GM First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment.Lancet. 2020; 395: 1382-1393Abstract Full Text Full Text PDF PubMed Scopus (488) Google Scholar]. Social distancing of patients and healthcare workers to limit viral transmission is another factor in determining the timing of re-entry. Primary care consults increase the proximity and circulation of healthcare professionals and patients, which in turn facilitates viral spread. So far, such visits have been deferred for being seen as nonessential in the short term to decrease the dissemination of the virus [4Cuttler D. How will COVID-19 affect the health care economy?Available at:https://jamanetwork.com/channels/health-forum/fullarticle/2764547. Accessed April 30, 2020.Google Scholar]. Conversely, empty hospitals risk bankruptcy before demand comes; furloughed healthcare professionals are already the second most in need of unemployment insurance in some areas [4Cuttler D. How will COVID-19 affect the health care economy?Available at:https://jamanetwork.com/channels/health-forum/fullarticle/2764547. Accessed April 30, 2020.Google Scholar]. Therefore, a precise modeling method for the pandemic progression is urgently needed. Real-time modeling of the COVID-19 instantaneous reproduction rate [3Leung K Wu JT Liu D Leung GM First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment.Lancet. 2020; 395: 1382-1393Abstract Full Text Full Text PDF PubMed Scopus (488) Google Scholar] is essential to predict the curve in the short term, and anticipate the need for healthcare resources, preparing for a likely second wave [5Xu S Li Y. Beware of the second wave of COVID-19.Lancet. 2020; 395: 1321-1322Abstract Full Text Full Text PDF PubMed Scopus (362) Google Scholar]. Adequate modeling and widespread testing allowed for Germany to minimize COVID-19 mortality rates and its impact on the economy [6Legorano G, Fairless T. Coronavirus widens Europe's North-South economic divide. Available at:https://www.wsj.com/articles/coronavirus-widens-europes-north-south-economic-divide-11588069310. Accessed April 30, 2020.Google Scholar]. Likewise, with good strategy, institutions can increase non–COVID-19 care and reactivate elective surgical practice and office procedures. In that sense, the timing for resuming elective surgical and clinical care should be determined and monitored by a committee of local authorities, clinical leaders, and hospital administration to assess the local viral prevalence, regional success of “flattening the curve,” testing capability, non–COVID-19 care capacity, and PPE supply chain. Experience in continental China shows that a second wave is almost inevitable [3Leung K Wu JT Liu D Leung GM First-wave COVID-19 transmissibility and severity in China outside Hubei after control measures, and second-wave scenario planning: a modelling impact assessment.Lancet. 2020; 395: 1382-1393Abstract Full Text Full Text PDF PubMed Scopus (488) Google Scholar,5Xu S Li Y. Beware of the second wave of COVID-19.Lancet. 2020; 395: 1321-1322Abstract Full Text Full Text PDF PubMed Scopus (362) Google Scholar]. Consequently, careful planning of healthcare resources should take into account a good safety margin for institutional functional reserve. Therefore, local medical and governmental authorities must collaborate to continuously monitor the pandemic's local reproduction rate, determine the hospital's reserve capacity, and develop modeling strategies to continually guide opening, closing, accelerating, or reducing elective clinical and surgical activity. Surgery is considered “elective” or “non-essential” in patients with chronic problems when the procedure can be delayed without significant harm to the patient and without significant change in the prognosis. Although the need for surgery is debatable when pain or functional impairment detracts from the quality of life, the determining principle for nonessential surgery is that delay of treatment does not significantly impact clinical outcomes [7Guy DK, Bosco JA, Savoie FH. AAOS guidelines for elective surgery during the COVID-19 pandemic. Available at:https://www.aaos.org/about/covid-19-information-for-our-members/aaos-guidelines-for-elective-surgery/. Accessed April 30, 2020.Google Scholar]. With this in mind, successful reactivation requires clear prioritization criteria aimed to ensure resource optimization and service to the most patients possible. Therefore, during re-entry, outpatient or same-day procedures should be favored over more complex cases to preserve hospital resources and decrease the risk of patient exposure. Table 1 summarizes our suggested prioritization scoring system, adapted from Prachand et al [8Prachand VN Milner R Angelos P et al.Medically necessary, time-sensitive procedures: scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic.J Am Coll Surg. 2020 Apr 9; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (219) Google Scholar]. In this system, the lower the score, the higher the priority.Table 1Suggested prioritization criteria (Adapted from Prachand et al, 2020)Allocated Prioritization Score12345Procedure factorsScore12345OR time (min)<3031–3061–120121–180≥180Estimated LOSOutpatient<24h24–48h2–3d≥4dRisk of postoperative ICUVery unlikely<5%5%–10%>10%–25%>25%Anticipated blood loss (mL)<100100–250250–500500–750>750Surgical team size (n)1234>4Intubation probability (%)<11–56–1011–25>25Surgical site/accessNone of the followingAbdominopelvic MISAbdominopelvic open surgery, infraumbilicalAbdominopelvic open surgery, supraumbilicalOHNS/upper GI/thoracicDisease factorsNonoperative option effectivenessNone availableAvailable, <40% as effective as surgeryAvailable, 40%–60% as effective as surgeryAvailable, 61%–95% as effective as surgery.Available, 96% to ass effective as surgeryNonoperative treatment option resource/ exposure riskSignificantly worse/not applicableSomewhat worseEquivalentSomewhat betterSignificantly betterImpact of 2-wk delay in treatment outcomeSignificantly worseWorseModerately worseSlightly worseNo worseImpact of 2-wk delay in surgical difficulty/riskSignificantly worseWorseModerately worseSlightly worseNo worseImpact of 6-wk delay in treatment outcomeSignificantly worseWorseModerately worseSlightly worseNo worseImpact of 6-wk delay in surgical difficulty/riskSignificantly worseWorseModerately worseSlightly worseNo worsePatient factorsAge (yrs)≤2021–4041–5051–65>65Lung disease (asthma, COPD, CF)None––Minimal (rare inhaler)>MinimalObstructive sleep apneaNot present––Mild/Moderate (no CPAP)On CPAPCV Disease (HTN, CHF, CAD)NoneMinimal (no meds)Mild (1 med)Moderate (2 meds)Severe (≥3 meds)DiabetesNone–Mild (no meds)Moderate (PO meds only)> Moderate (insulin)Immunocompromised*Hematologic malignancy, stem cell transplant, solid organ transplant, active/recent cytotoxic chemotherapy, anti-TNFα or other immunosuppressants, >20 mg prednisone equivalent/day, congenital immunodeficiency, hypogammaglobulinemia on intravenous immunoglobulin, AIDS.No––ModerateSevereILI symptoms (fever, cough, sore throat, body aches, diarrhea)None (Asymptomatic)–––YesExposure to known COVID-19 positive person in past 14 daysNoProbably notPossiblyProbablyYesCAD = coronary artery disease; CF = cystic fibrosis; CHF = congestive heart failure; COPD = Chronic obstructive pulmonary disease; COVID-19 = coronavirus disease; CPAP = continuous positive airway pressure; CV = cardiovascular; GI = gastrointestinal; HTN = hypertension; ICU = intensive care unit; ILI = influenza-like illness; LOS = length of stay; med = medication; MIS = minimally invasive surgery; OHNS = otolaryngology, head & neck surgery; OR = operating room PO = by mouth. Hematologic malignancy, stem cell transplant, solid organ transplant, active/recent cytotoxic chemotherapy, anti-TNFα or other immunosuppressants, >20 mg prednisone equivalent/day, congenital immunodeficiency, hypogammaglobulinemia on intravenous immunoglobulin, AIDS. Open table in a new tab CAD = coronary artery disease; CF = cystic fibrosis; CHF = congestive heart failure; COPD = Chronic obstructive pulmonary disease; COVID-19 = coronavirus disease; CPAP = continuous positive airway pressure; CV = cardiovascular; GI = gastrointestinal; HTN = hypertension; ICU = intensive care unit; ILI = influenza-like illness; LOS = length of stay; med = medication; MIS = minimally invasive surgery; OHNS = otolaryngology, head & neck surgery; OR = operating room PO = by mouth. Surgical expertise also contributes to the mitigation of risk, with shorter operating times, fewer complications, and fewer readmissions observed in high volume centers [9Bristow RE Zahurak ML Diaz-Montes TP Giuntoli RL Armstrong DK Impact of surgeon and hospital ovarian cancer surgical case volume on in-hospital mortality and related short-term outcomes.Gynecol Oncol. 2009; 115: 334-338Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 10Sung VW Rogers ML Myers DL Clark MA Impact of hospital and surgeon volumes on outcomes following pelvic reconstructive surgery in the United States.Am J Obstet Gynecol. 2006; 195: 1778-1783Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 11Schmidt CM Turrini O Parikh P et al.Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience.Arch Surg. 2010; 145: 634-640Crossref PubMed Scopus (331) Google Scholar]. Therefore, the ideal prioritization for the allocation of operating room resources involves high volume surgical teams with limited learners performing primarily minimally invasive outpatient procedures [12AAGL. Joint statement on minimally invasive gynecologic surgery during the COVID-19 pandemic. Available at:https://www.aagl.org/news/covid-19-joint-statement-on-minimally-invasive-gynecologic-surgery/. Accessed May 1, 2020.Google Scholar]. Conservative management and postponement of surgery, when applicable, should be mandatory during the reactivation process, to allow for prioritized surgical treatment of those who have already failed nonsurgical alternatives. All caregivers and healthcare systems will have to learn how to coexist with COVID-19 once the decision is made to resume clinical and surgical practice. Therefore, specific considerations apply to each phase of perioperative care. All patients who decide to proceed with surgery must be informed that there is a risk of contracting COVID-19 as a nosocomial infection, resulting in greater morbidity and mortality (see Section on Recommended COVID-19 Testing). Advanced directives and postsurgery rehabilitation should be discussed virtually so that the appropriate forms, paperwork, and preauthorizations are completed. Institutions can consider electronic signatures and verbal consents, and all details should be documented in the electronic medical record. In institutions that require a signature by written paper consent, signatures should be obtained on admission to avoid nonessential in-person visits. Processes to minimize interpersonal contact are essential during preoperative care. Only strictly essential in-person interactions should be permitted to mitigate risks for both patients and caregivers. Preoperative requirements should be streamlined so that mostof the steps are accomplished by physician extenders using distance healthcare or online tools. Preoperative education should not require face-to-face interaction. Although local guidelines may vary, U.S. federal guidelines allow the preoperative history to be performed virtually within 30 days of a procedure, and an updated physical examination can be performed at the time of preanesthesia care unit admission. When in-person consultations are unavoidable, patient care areas should be disinfected immediately after use. Thorough disinfection is important because the SARS-CoV-2 virus can be transmitted by respiratory aerosol droplets, close contact, and fecal-oral transmission. Therefore, extra time should be allotted per visit to allow for sanitizing work areas and patient rooms after each patient visit. The facility waiting rooms and examination rooms should be reorganized to optimize social distancing. Patient check-in should be done by smartphone, smart devices, or kiosks that are far from the person assisting at the front desk, and appropriate PPE and/or aerosolization barriers should be used to separate healthcare personnel and patients. Screening questions should be routinely used to identify COVID-19 symptoms. If a patient screens positive for COVID-19 symptoms, she is directed to local COVID-19–specific clinics (see the section on recommended testing). Laboratory testing should be consolidated to decrease unnecessary patient exposure during lab visits, and preoperative laboratory tests can be drawn at the time of COVID-19–specific testing. If available, patient-administered tests to rule out COVID-19 can be obtained at home so that the patient's COVID-19 status is known before obtaining preoperative labs [13Rosenfield R Re-entry: introducing safety protocols into an ambulatory surgical settingAAGL COVID-19 Webinar Series: Resuming elective surgeries after the COVID-19 pandemic: global perspectives.April 30, 2020https://surgeryu.com/public/covid19043020Google Scholar]. A useful algorithm for preoperative decision making is demonstrated in Fig. 1 [14COVID-19 Preoperative Surgery Decision Tree courtesy of the Surgical Reactivation Task Force. Cleveland, OH: Cleveland Clinic. Available at:http://portals.ccf.org/occ/Infection-Prevention/Coronavirus-Disease-2019-COVID-19#13854213898-coronavirus-disease-2019-covid-19-toolkit. Accessed 2 May 2020.Google Scholar]. After preoperative procedures have ruled out COVID-19 just before surgery (see below), the patient may proceed to scheduled surgery. The number of support people accompanying the patient should be limited to 1 individual if the institutional policy allows. This support individual is required to wear a mask and maintain social distancing etiquette. In certain hospitals where patient support people are forbidden, patient status updates are reported by phone or another telecommunication process. Enhanced recovery after surgery [15Pache B Hübner M Jurt J Demartines N Grass F Minimally invasive surgery and enhanced recovery after surgery: the ideal combination?.J Surg Oncol. 2017; 116: 613-616Crossref PubMed Scopus (20) Google Scholar] protocols should be used to optimize intraoperative and postoperative courses. Preoperative and intraoperative surgical checklists should be modified using COVID-19 precautions. Providers should employ the equipment deemed appropriate by their respective institutions. It is recommended that anyone working in the operating room use full PPE, which includes shoe covers, impermeable gowns, surgical or N-95 masks, protective head covering, gloves, and eye protection [16Zhu L. Scheib S COVID-19: impact in New Orleans and my practice Restarting elective surgeries in China. AAGL COVID-19 Webinar Series: Resuming elective surgeries after the COVID-19 pandemic: global perspectives.April 30, 2020https://surgeryu.com/public/covid19043020Google Scholar]. In the operating room and during surgery, considerations should include airflow and containment or reduction of personnel exposure to respiratory droplets during intubation and extubation. Considerations include using the “intubation box” originally designed by Dr. Hsien Yung Lai in Taiwan [17Lai HY. Aerosol box. Available at:https://sites.google.com/view/aerosolbox/home?authuser=0. Accessed May 3, 2020.Google Scholar]; the design is now available in the United States [18Thalia. COVID-19 intubation box 2.0. Available at:https://www.thaliacapos.com/pages/thaliabox. Accessed May 3, 2020.Google Scholar] and was recently shown to be a viable solution for the reduction of respiratory droplet exposure [19Canelli R Connor CW Gonzalez M Nozari A Ortega R Barrier enclosure during endotracheal intubation.N Engl J Med. 2020; 382: 1957-1958Crossref PubMed Scopus (354) Google Scholar]. In addition, the movement of personnel in and out of the operating room should be strictly limited, with efforts made to limit staff breaks midcase when possible. Trainee participation should be limited and include only personnel essential to the safe performance of the operation to avoid exposure and preserve PPE resources [12AAGL. Joint statement on minimally invasive gynecologic surgery during the COVID-19 pandemic. Available at:https://www.aagl.org/news/covid-19-joint-statement-on-minimally-invasive-gynecologic-surgery/. Accessed May 1, 2020.Google Scholar]. Theoretical concerns pertain to the operative technique and relate to viral contamination in the operative field from the smoke plume generated by electrosurgery. Viral particles have been reported in the aerosolized smoke plume created in electrosurgery, and the tools and techniques used in surgery can create particles of various sizes [20Heniford T Deereberg E Shao J Pro-laparotomy: surgical debate in the COVID-19 pandemic. AAGL COVID 19 - Webinar # 3 - minimally invasive surgery versus laparotomy in the era of COVID-19: algorithm, technology aspects and options.April 16, 2020https://surgeryu.com/detail/5132Google Scholar, 21Morris SN Fader AN Milad MP Dionisi HJ Understanding the “scope” of the problem: why laparoscopy is considered safe during the COVID-19 pandemic.J Minim Invasive Gynecol. 2020; 27: 789-791Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 22Cohen SL Liu G Abrao M Smart N Heniford T Perspectives on surgery in the time of COVID-19: safety first.J Minim Invasive Gynecol. 2020; 27: 792-793Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 23Brown J. Surgical decision making in the era of COVID-19: a new set of rules.J Minim Invasive Gynecol. 2020; 27: 785-786Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Although smoke filtration and evacuation are highly recommended during surgery as part of the risk mitigation technique, most smoke evacuators remove up to 88% of small particles. To further reduce the aerosolization risk of viral particles (20–360 nm), the use of active suction is recommended before tissue removal, port exchange, and for desufflation after laparoscopic surgery. In addition, electrostatic charging of the peritoneal cavity can precipitate over 99% of particulate matter ranging from 7 nm to 10 μm in diameter. Such systems deliver a negative electrostatic charge from an ion wand to generate precipitation (e.g., Ultravision, Alesi Surgical). This combination of techniques may be considered for maximum risk mitigation. Optimal facility design incorporates separation of recovery areas for patients who are COVID-19 positive and COVID-19 negative. Enhanced recovery after surgery protocols should be carried out to optimize same-day discharge. A follow-up plan should include standardized surveillance and use of distance health, or telemedicine. Patients should not require a face-to-face visit unless there are complications that require a physical examination. COVID-19 home monitoring programs should be used as deemed appropriate; these include automated thermometers, blood pressure monitors, oximeters, and/or smart device innovations [24U.S. Food and Drug Administration. Coronavirus (COVID-19) update: FDA issues emergency use authorization for potential COVID-19 treatment. Available at:https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-issues-emergency-use-authorization-potential-covid-19-treatment. Accessed June 18, 2020.Google Scholar]. Patients who have COVID-19–positive family members should quarantine themselves in local facilities. Some institutions provide such housing opportunities for patients and/or caregivers. Data from patients who are apparently COVID-19 negative after elective surgery suggests that advanced age, comorbidities, surgical time, and surgical complexity may be risk factors for poor prognosis in the event of postoperative development of SARS-CoV-2 infection. Such patients are at greater risk of intensive care unit admission (44% vs 26%) than paired patients who did not undergo surgery [25Lei S Jiang F Su W et al.Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection.EClinicalMedicine. 2020 Apr 5; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (748) Google Scholar]. Therefore, adequate preoperative screening and diagnosis of COVID-19 infection are essential for the success of any surgical reactivation program. In areas with more than 40 active cases per 100000 inhabitants (see observation at the end of chapter), we suggest that all patients planning to undergo surgery should have a diagnostic test for COVID-19 up to 72 hours before surgery and be quarantined until the time of hospital admission. The reverse transcription-polymerase chain reaction (RT-PCR) test is considered the gold standard for the diagnosis of COVID-19. In clinical practice, its specificity varies between 93% and 98%, but sensitivity can vary significantly from 63% to almost 100%, depending on the prevalence, onset of symptoms, viral dynamics, collection method of the clinical specimen, and transport media [26Procop G. An update on the diagnosis before performing elective surgery. AAGL COVID-19 Webinar Series: Resuming elective surgeries after the COVID-19 pandemic: global perspectives.April 30, 2020https://surgeryu.com/public/covid19043020Google Scholar,27Guo L Ren L Yang S et al.Profiling early humoral response to diagnose novel coronavirus disease (COVID-19).Clin Infect Dis. 2020 Mar 21; ([Epub ahead of print])Crossref Scopus (1036) Google Scholar]. Therefore, the positive and negative predictive value of RT-PCR is high for patients who are symptomatic, but its accuracy may be limited in patients who are asymptomatic. Other methods that can be used for the diagnosis of COVID-19 include the detection of IgA, IgG, and IgM antibodies by enzyme-linked immunosorbent assay and immunochromatography. Initial validation demonstrates a high positive predictive value. The presence of IgG antibodies confirms previous COVID-19 disease [28Zhao J Yuan Q Wang H et al.Antibody responses to SARS-CoV-2 in patients of novel coronavirus disease 2019.Clin Infect Dis. 2020 Mar 28; ([Epub ahead of print])Crossref Scopus (1620) Google Scholar], suggesting that serological IgG testing may be useful for screening, but not triage for surgery. To date, no data exist to support that positive IgG antibodies confer lasting immunity against SARS-CoV-2. There is no formal indication for chest computed tomography (CT) as a screening method in patients who are asymptomatic. However, some COVID-19–free institutions in Europe and China recommend its use in exceptional situations in high prevalence areas, on the basis of its capability for diagnosis in 54% of asymptomatic cases [29Li M Lei P Zeng B et al.Coronavirus disease (COVID-19): spectrum of CT findings and temporal progression of the disease.Acad Radiol. 2020; 27: 603‐608Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar]. Chest CT performed up to 24 hours before hospitalization is therefore considered an option when more accurate tests are not available. If surgery is considered mandatory and diagnostic tests are neither available nor reliable, the patient may be quarantined for 14 days before surgery (if possible). This recommendation is based on the Centers for Disease Control and Prevention statement that the incubation period of SARS-CoV-2 and other coronaviruses ranges from 2 to 14 days [30Centers for Disease Control and Prevention. Clinical questions about COVID-19: questions and answers. Available at:https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html. Accessed May 2, 2020.Google Scholar]. For this strategy to work, patients need to comply with self-isolation and be instructed regarding the development of symptoms. If the patient is asymptomatic and tests negative for COVID-19, surgery can be performed with the use of conventional PPE by the surgical team [16Zhu L. Scheib S COVID-19: impact in New Orleans and my practice Restarting elective surgeries in China. AAGL COVID-19 Webinar Series: Resuming elective surgeries after the COVID-19 pandemic: global perspectives.April 30, 2020https://surgeryu.com/public/covid19043020Google Scholar]. Guidelines for protection should follow individual, institutional standards developed in conjunction with the infection control team. If the patient is symptomatic or has a positive RT-PCR, IgM antibody, or chest CT findings consistent with COVID-19, the procedure must be postponed, and the patient should be referred based on institutional COVID-19 diagnostic and treatment protocols. Surgical rescheduling should require clinical improvement, normalization of chest CT scans, and 2 negative RT-PCR tests to confirm resolution [31Scheib S. Covid-19: impact in New Orleans and my practice. AAGL Webinar # 2 - gynecologic surgery during the COVID-19 pandemic - keeping patients and surgeons safe. https://surgeryu.com/detail/5130. Accessed May 2, 2020.Google Scholar]. Finally, if RT-PCR, rapid serological testing, or chest CT are not available, elective surgery should only be considered if regional prevalence is <40 active cases per 100000 inhabitants. In this case, guidelines for the use of PPE should be the same as those for patients who are COVID-19 positive. Regarding concerns about a resurgence of COVID-19, it is imperative that a centralized monitoring system collects data on the number of patients who are COVID-19 positive, who are asymptomatic in a large healthcare system or defined geographical area. Any rise in the number of asymptomatic COVID-19–positive individuals among elective surgery patients could be a sign of an impending second wave of COVID-19. It is well known that asymptomatic and presymptomatic patients are a major source of community transmission [32Al-Muharraqi MA. Testing recommendation for COVID-19 (SARS-CoV-2) in patients planned for surgery - continuing the service and ‘suppressing' the pandemic.Br J Oral Maxillofac Surg. 2020; 58: 503-505Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 33Arons MM Hatfield KM Reddy SC et al.Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility.N Engl J Med. 2020; 382: 2081-2090Crossref PubMed Scopus (1322) Google Scholar, 34Gandhi M Yokoe DS Havlir DV Asymptomatic transmission, the Achilles’ heel of current strategies to control Covid-19.N Engl J Med. 2020; 382: 2158-2160Crossref PubMed Scopus (685) Google Scholar]. According to Robert Redfield, the director of the Centers for Disease Control and Prevention, 25% of people infected with SARS-CoV-2 are asymptomatic; however, they can still transmit the illness to others [35Whitehead S, Feibel C.CDC director on models for the months to come: ‘the virus is going to be with us’. Available at:https://www.npr.org/sections/health-shots/2020/03/31/824155179/cdc-director-on-models-for-the-months-to-come-this-virus-is-going-to-be-with-us?t=1586065796492. Accessed April 5, 2020.Google Scholar]. Control of COVID-19 is a dynamic and fluid process. Institutions must be flexible in responding and implementing changes in strategies based on the most current assessment of disease prevalence in the community. As we resume nonessential surgeries, we must be cognizant of the need to adjust and adapt according to the disease burden in the community. As the prevalence of COVID-19 decreases in the community, a standardized epidemiologic screening questionnaire should be conducted at a minimum. If the epidemiologic questionnaire is positive, an RT-PCR and a chest CT can be performed [16Zhu L. Scheib S COVID-19: impact in New Orleans and my practice Restarting elective surgeries in China. AAGL COVID-19 Webinar Series: Resuming elective surgeries after the COVID-19 pandemic: global perspectives.April 30, 2020https://surgeryu.com/public/covid19043020Google Scholar,29Li M Lei P Zeng B et al.Coronavirus disease (COVID-19): spectrum of CT findings and temporal progression of the disease.Acad Radiol. 2020; 27: 603‐608Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar]. Some countries are employing novel population-based techniques, such as Quick Response code scanning, to facilitate detection of patient exposure to COVID-19 and contact tracing [36Perez-Alba E Nuzzolo-Shihadeh L Espinosa-Mora JE Camacho-Ortiz A Use of self-administered surveys through QR code and same center telemedicine in a walk-in clinic in the era of COVID-19.J Am Med Inform Assoc. 2020; 27: 985-986Crossref PubMed Scopus (18) Google Scholar]. Despite the strategies summarized above, the revenue generated by healthcare systems is anticipated to remain at much lower levels than usual because of the mandated halting of nonessential procedures. While reactivation will achieve some normalcy, a second or third wave of viral infection may further decrease revenue generation. Therefore, knowledge of available financial support programs is paramount to ensuring the survival of surgical services. In the United States, the Coronavirus Aid, Relief, and Economic Securities Act includes multiple lending programs for physicians and businesses treating patients. These lending programs include the Small Business Association Payroll Protection Plan, Economic Injury Disaster Loans, and Department of Health and Human Services relief. These programs are summarized on the American Medical Association's website [37AMA.COVID-19 (2019 novel coronavirus) resource center for physicians. Available at:https://www.ama-assn.org/delivering-care/public-health/covid-19-2019-novel-coronavirus-resource-center-physicians. Accessed May 2, 2020.Google Scholar]. Businesses with under 500 employees can apply for relief in a forgivable interest-free loan when the funds are used per Small Business Association guidelines. Many physicians in private practice, small group settings, and large group settings qualify for such relief [38United States Department of the Treasury. How the treasury department is taking action - the CARES Act. Available at:https://home.treasury.gov. Accessed May 2, 2020.Google Scholar]. As surgeons and facilities move toward the “new normal” of pandemic recovery, the number of unemployed workers in the United States and abroad will undoubtedly have an impact on insurance coverage. Insurance companies and hospitals will be looking for relief and will be forced to find ways to offset the profound economic implications brought on by the costs associated with COVID-19. It is imperative for physicians everywhere to gain an awareness of these issues and prepare for potential impact on revenue, salary, and job security. In our lifetime, the practice of medicine has never been altered to the extent imposed by the COVID-19 pandemic. We, as surgeons, have had to rise to many challenges to meet the needs of our patients while mitigating risk to all those involved in their care. The postponement of nonessential surgical procedures to preserve resources has created backlogs in our practices that we must address as we coexist with COVID-19. The American Association of Gynecologic Laparoscopists has forged important collaborations among national and international experts and societies to educate caregivers worldwide during this unprecedented time. This article should serve as a supplemental guide for effective reactivation to clinical and surgical practice to optimize care for the women whom we serve.