Situation in Costa Rica
The SARS-COV-2 was first detected in Costa Rica more than 90 days after it was first identified in China. Initial structured and coordinated efforts to mitigate the spread of the disease appear to be successful, with lower death and transmission rates than countries with similar population sizes, gross domestic product and healthcare coverage[13]. Initial measures included suspending all mass gatherings, closing schools, places of worship, public buildings, hotels, bars, casinos and instituting a sanitary restriction on private transportation while encouraging the population to shelter in place. Easter festivities were also banned, as well as access to the beaches and national parks. There was also a closure of the country’s borders, with special emphasis placed on the northern border with Nicaragua, where no containment measures were taken by that country’s government[14], and reliable data has not been available as to the scale of the outbreak. Nicaragua is the only country in Central America not to declare a state of emergency in relation to the COVID-19 outbreak. All international airports in CR have been closed with only cargo and repatriation flights taking place since mid-March with a tentative reopening set for August 1st.
As of June 23rd, there were 2368 confirmed cases, consisting of 1049 females (44.3%) and 1319 (55.7) males. 652 positives cases were foreigners (24.7%) and 1716 (72.3%) were locals. A total of 12 deaths are attributed to COVID-19 in Costa Rica, with a current mortality rate of 0.506%. Most cases are distributed in the capital city and in the largest settlement in the north of the country, San Carlos. In the last 4 weeks there has been a doubling of cases, with a large increase in the northern part of the country. As a measure to increase hospital beds available to treat patients with COVID-19 the National Rehabilitation Hospital was transformed into the countries only COVID center.
All elective surgeries, barring oncology, have been postponed, creating an additional backlog of 22,647 surgical procedures[15]. Three major hospitals closed their outpatient consults due to the outbreak, transferring some of their medical services to teleconferencing or telephone consultations. Due to the shelter in place measures, some communicable disease’s incidence dropped during the initial phase of the COVID-19 pandemic, such as infectious diarrhea, that had a 28% year to year decrease[16].
Local COVID-19 surgical protocol
The burden on healthcare workers during this pandemic has been high[11]. As part of the in-hospital staff, surgeons and surgical personnel have to follow previously defined regulations with regards to limiting and controlling the exposure to patients who are suspected of having COVID-19 or have been confirmed as infected, as to diminish the likelihood of infection to staff and patients. Deferrals and postponements for many types of surgeries have been a widely applied method to limit the exposure to COVID-19 not only to patients, but to healthcare workers as well[17]. Other more traditional methods of reducing exposure have been applied, with the structures use of surgical suite disinfections and strict use of PPE. A locally created protocol utilizing the recommendations emanating from the experiences and guidelines from other parts of the world[18,19,20,21,22] was used in the successful and safe intervention of the first COVID-19 positive patient to require surgery in Costa Rica.
The guideline divides the surgical process into three phases: preoperatory (logistics and planning) surgical and postoperative.
In the first phase, as recommended by Wong et al.(18), prepackaged surgical supply kits are created and stored inside a specially designated OR, in which all patients diagnosed or suspected of having COVID-19 will be operated on. There are signs posted on the door indicating that this is a COVID-19 surgical room. All nonessential items for the surgery should be removed from the OR prior to the initiation of the COVID-19 surgical protocol. Two surgical teams are designated, A notification is sent out to the head of each surgical team prior to the surgery being scheduled. The teams consist of one nurse, one nursing assistant, a surgical technologist, an anesthesiologist and two surgeons. No additional personnel can enter. One of the teams enter the COVID-19 OR prior to the surgery while the other team is on stand-by, with support staff of said team being tasked with logistical duties in case the need arises for additional equipment or medications during the procedure. The anesthesiologist inside the OR is responsible for all the supplies and equipment inside the OR, with special care being placed on the videolaryngoscope, which must be checked and made operational prior to the patient being admitted into the OR. The OR’s ventilation system is placed on negative pressure.
All surgical personnel must wear the appropriate PPE (Fig. 3), which consists of a N95 mask, safety goggles with or without a face shield, a biohazard suit, disposable waterproof boot covers and two pair of sterile globes (nitrile and latex).
Prior to the patient being transported to the OR, an N95 mask is placed on the patient and only removed prior to intubation and is placed on the patient immediately after the surgical procedure. During endotracheal intubation, a clear plastic drape is placed over the top third of the patient, as to provide an additional barrier. Standard patient monitoring is done during the procedure.
After the surgery is performed, the patient is not transported to the regular recovery room, but is instead placed in a special biohazard room, where the second team is charged with continuing care. The first team, initiates decontamination measures once the patient leaves the OR. The part of decontamination involves taking the anesthesia machine canister and immersing it in an enzymatic cleaning solution for 20 min and disposing of all contaminated foam and gauze in the biohazard labelled trash bags that are then triple-sealed. The surgical instruments are placed in a double bin with enzymatic cleaner that is placed by the door of the OR, to be later taken to be sterilized. The technical staff then proceeds to clean the OR for 25 min using chlorhexidine soap and water first, and 0.1% chlorine solution last.
The medical and technical staff then begin removal of the PPE in pairs using a 21-step process, this is done to guarantee that the process is applied under direct supervision. Once all the PPE has been successfully removed, all staff is instructed to shower.