BJS Open, May 2020

Background
The COVID‐19 pandemic poses a critical global public health crisis. Operating room (OR) best practice in this crisis is poorly defined. This systematic review was performed to identify contemporary evidence relating to OR practice in the context of COVID‐19.
Methods
Medline was systematically searched using PubMed (search date March 19, 2020) for relevant studies in accordance with PRISMA guidelines. Documented practices and guidance were assessed to determine Oxford levels of evidence (OLE), and recommendations for practice within five domains were extracted: physical OR, personnel, patient, procedure, and other factors.
Results: Thirty‐five articles were identified, of which 11 met eligibility criteria. Nine articles constituted expert opinion and two were retrospective studies. All articles originated from the Far East (China nine, Singapore two); eight of the articles concerned general surgery.
Common themes were identified within each domain, but all recommendations were based on low levels of evidence, median OLE 5 (range 4 – 5). The highest number of overlapping recommendations related to physical OR (n=8) and procedural factors (n=13). Although few recommendations related to personnel factors, consensus was high in this domain, with all studies mandating the use of personal protective equipment.
Conclusions
There was little evidence to inform this systematic review, but there was consensus regarding many aspects of OR practice. Within the context of a rapidly evolving pandemic, timely amalgamation of global practice and experiences is needed to inform best practice.

BJS, May 2020

Introduction
Operating room (OR) practice during the COVID‐19 pandemic is driven by basic principles, shared experience, and nascent literature. This study aimed to identify the knowledge needs of the global OR workforce, and characterise supportive evidence to establish consensus.
Methods
A rapid, modified Delphi exercise was performed, open to all stakeholders, informed via an online international collaborative evaluation.
Results
The consensus exercise was completed by 339 individuals from 41 countries (64% UK). Consensus was reached on 71/100 statements, predominantly standardisation of OR pathways, OR staffing, and pre‐operative screening or diagnosis. The highest levels of consensus were observed in statements relating to appropriate personal and protective equipment (PPE) and risk distribution (96‐99%), clear consent processes (96%), multidisciplinary decision‐making and working (97%). Statements yielding equivocal responses predominantly related to technical and procedure choices, including: decontamination (40‐68%), laminar flow systems (13‐61%), PPE reuse (58%), risk stratification of patients (21‐48%), open vs. laparoscopic surgery (63%), preferential cholecystostomy in biliary disease (48%), and definition of aerosol generating procedures (19%).
Discussion
High levels of consensus existed for many statements within each domain, supporting much of the initial guidance issued by professional bodies, yet several contentious areas arose, which represent urgent targets for investigation to delineate safe COVID‐19 related OR practice.