Approach to Surgery
Throughout February and early March, our department and hospital
administration were closely monitoring the COVID-19 outbreak, however
there were no changes to clinical operations. On March 16, one HNS case
was cancelled due to blood shortages. UAB administration decided on
March 17 to move to a limited operating room (OR) model, where only 6
ORs were to be opened daily, with 2 additional rooms open as needed for
emergencies. Our freestanding outpatient surgical center was reduced to
3 working ORs with 1 available as needed for emergencies. At this point
all elective cases were postponed indefinitely. For reference, our
institution has 44 total ORs in our main hospital and 16 ORs at our
outpatient center.
The HNS division began meeting virtually at this point to collectively
triage cases. Remote conferences with this goal were held twice weekly
during the limited OR model period. Cases were organized first into
elective versus non-elective cases. Patients requiring non-elective
surgery were defined as having a surgical disease process that will
irreversibly worsen in a way that affects survival or extent of surgical
intervention if surgical intervention were delayed. Elective cases were
postponed indefinitely to be reassessed by each individual surgeon when
conditions allow. Among the non-elective cases, 3 categories were
described and are as follows: cases which should be done within 2 weeks,
cases that should be done within 2-4 weeks, and cases that are
non-elective but can wait >4 weeks. These definitions were
based on the likelihood of significant morbidity or mortality occurring
within the defined time periods. For example, patients with significant
airway concerns such as advanced laryngeal cancers and airway stenosis
were placed in the 2 week category, while most thyroid malignancies were
placed in the >4 week category (Figure 3).
Perioperative leadership including chairs of the surgical departments
met to outline an appropriate triage strategy for operative cases. Per
these institutional guidelines, each case scheduled required department
chairman approval and was subject to review by the Chief of Surgical
Services. This model remains in place. Our division now has a secure
online calendar showing all HNS cases which is accessible by all
faculty. This was used to streamline the chairman approval process.
Figure 2 represents our case numbers during the time period under
investigation. Of the utmost importance in triaging and completing these
cases was a collective willingness in our division to cover cases for
other surgeons in the case of mandated quarantines. Particularly early
in UAB’s response to the pandemic, pre-op testing was not available.
During this time, we recognized there were approximately 5-10 patients
that we considered urgent but also very high risk (endoscopic airway for
stenosis, laryngeal carcinomas with airway compromise, etc.). We decided
collectively that we would not perform these urgent but high risk cases
without pre-op COVID testing or if not made available we would utilize
all necessary PPE (see below) to perform these cases. Particularly, we
met with anesthesia and operating room leadership to discuss the
specific logistics of doing these cases. This decisive action led to
early pre-op testing for our high risk patient population and likely
saved the use of needed PPE.
Availability of COVID-19 testing nationwide has been a major issue
during this pandemic. Initially, we were not able to preoperatively test
our surgical patients. During this time, we were avoiding any procedure
that risked exposure to aerosolized procedures such as tracheotomy and
oral cavity cases. On March 28, our first preoperative COVID-19 tests
were performed for planned operations on outpatients. Initially, we had
only the capacity for 10 COVID-19 tests per day. Therefore, anesthesia
staff selected the cases with highest risk exposures for preoperative
testing. These patients were tested within 48 hours of their planned
surgery. By April 6 we had increased our testing capacity and all
surgical patients were tested once preoperatively within 48 hours of
their surgery. All testing was RT-PCR via nasopharyngeal swab. At the
current time, our institution is not using serologic testing to direct
management.
Personal protective equipment (PPE) is paramount in protecting the
surgeon as well as the patients and limiting disease spread. As the
crisis progressed, we began concerted efforts to conserve essential PPE,
most notably N95 respirators, gowns, gloves, and face shields. Although
the data are conflicting regarding efficacy, N95 respirators are
recommended for healthcare providers dealing with patients with unknown
COVID-19 status during aerosol generating procedures12,13. Per recommendations from the Stanford group we
used tiered PPE depending on the case type 14. Extreme
airborne precautions (PAPR in addition to surgical gowns/gloves) was
used for COVID positive cases and were considered high risk of
transmission (upper aerodigestive tract, sinonasal cases,
mastoidectomy). Enhanced airborne precautions (N95 respirator, eye
protection, surgical gown/gloves) were used in COVID negative cases with
high risk of transmission, any emergent case with unknown COVID status,
urgent cases with COVID status unknown, positive symptoms or high risk
cases. Standard PPE was used in low risk of transmission COVID negative
cases and COVID unknown, asymptomatic patients undergoing urgent but low
risk of transmission procedures. These guidelines are comparable to
precautions outlined by other institutions15-18.
Additionally, we have been extending the use of N95 respirators in
accordance with the CDC’s recommendations and prior data19,20. Our institution has been reprocessing N95
respirators for repeated use using a combination of UV light radiation
and vaporized hydrogen peroxide.21-23.
Notably, once the decision was made to operate we did not alter our
surgical approach for cases. Some data have shown a reduction or
complete cessation in free flap surgeries during the pandemic at other
institutions 24. Free tissue transfer and
tracheostomies were still performed when indicated. We continued holding
weekly multidisciplinary tumor board (MDTB), albeit this was done
remotely via videoconferencing.