Clinical Affairs Committee: Physician Guidance to Thyroid FNA during COVID-19 crisis

A multitude of factors including the wide range of variability in disease activity, resources, and regulations present a challenge as an organization to make specific recommendations regarding timing and process to perform thyroid fine needle aspiration (FNA) during the pandemic. We can provide some general considerations as follows:

1. Timing
   1. The urgency of the FNA should be determined by the patient’s risk factors, the sonographic and structural risk characteristics of the nodule, and the clinical judgement of the treating team. Timing of FNA may also be impacted by local public health directives on societal re-opening.
   2. The following editorial provides some suggestions regarding the timing of FNA during the COVID pandemic: https://www.liebertpub.com/doi/10.1089/ct.2020%3B32.156-158
2. Safety

Clearly, the FNA needs to be performed “safely” without undue increase in risk of exposure to the patient, staff, or the clinician to COVID-19.

1. The following are several resources for consideration:

1-Centers for Disease Prevention Ambulatory Care Settings Guidance
https://www.cdc.gov/coronavirus/2019-ncov/hcp/ambulatory-care-settings.html
2-Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic
https://www.aha.org/system/files/media/file/2020/04/roadmap-from-aha-others-for-safely-resuming-elective-surgery-as-covid-19-curve-flattens.pdf
3-Centers for Medicare & Medicaid Services (CMS) Recommendations for Reopening facilities to provide non-emergent Non-COVID-19 healthcare
https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf

2. In deciding to perform an FNA, one must follow not only the state recommendations but any regulatory agency requirements (licensing agencies) as these requirements supersede local recommendations or allowances. In addition, for employed clinicians, most employers have protocols (e.g. pre-procedure COIVD-19 testing or screening for symptoms) that need to be followed within that organization.
3. Once the decision to perform a thyroid FNA has been made, the main objectives are to avoid exposure of the patient and the health care workers to COVID-19 while at the same time avoiding harm to the patient from delaying a treatable non-COVID related condition.
   1. Ideally, and especially if there has been widespread community-spread of Covid-19 within the local community, pre-procedure testing of clinician, staff and patient may be advised.
   2. If this is not available, preprocedural low-threshold screening for any of the possible symptoms of COVID-19 should be performed for the patient, the clinician, and staff on the day of the procedure.
   3. We also advise to do follow-up monitoring for symptoms after the procedure, including a follow-up call to the patient to inquire regarding symptoms of COVID-19.
   4. The following is a list of symptoms to screen for both pre and post procedure
      1. https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html

4. Use of PPE by the clinician with at least a mask by the patient is highly recommended.
   1. Specific safety questions can be referred to the expert clinician support team at the CDC by calling 1-800-232-4636.
5. Safe processing and handling of the FNA cytology specimen also needs to be considered as detailed in the following link: https://www.liebertpub.com/doi/10.1089/ct.2020%3B32.239-241
6. Consider creating patient education materials such as: “What You Should Know About an Elective Procedure During the COVID-19 Pandemic”. This can be done at the health care system, facility and/or practice level. At a minimum these materials should emphasize that:
   1.  if the FNA is considered an elective procedure (definitions vary by state) that it does not need to be performed at this time and
   2.  there is a risk that the patient could become infected with COVID 19 virus.
   3. Information on testing, PPE and other safety policies could also be included.

3. Consent

1. Consider utilizing a Special Consent Form for An Elective Procedure During the COVID-19 Pandemic
   1. This form should emphasize the shared decision of agreeing to perform an elective procedure and, if the above-mentioned patient education materials were provided, confirm that the patient received and understands the materials.
   2. Consultation with the local institution’s legal division or the physician’s legal advisor (for private practices performing FNA procedures) to review the special COVID-19 consent is recommended (concerning appropriate documentation of efforts to protect the patient from exposure to COVID-19).