Discussion
At the current time (April 26, 2020), there are 943,865 cases of COVID-19 in the United States, 6,213 of which are in Alabama6. For comparison, surrounding southern states Louisiana, Georgia, and Mississippi have 26,512, 23,401, and 5718 cases respectively while New York has 282,143 cases25. These numbers highlight the variability to which the pandemic has affected different states thus far, even within the same geographic region. New York State contains 411.2 people per square mile compared to 168 people per square mile of neighboring Georgia, 94.4 people per square mile in Alabama and 63.2 people per square mile in Mississippi26. While there are many factors involved, the overall low population density, early mitigation in Alabama’s largest urban area (Birmingham), and limitations in testing have contributed to lower COVID-19 case numbers.
Due to the trajectory and distribution of new COVID-19 cases, our department has been able to implement strategies used in other states and countries15,16,18,27-30. The authors would direct you to Patel et al. for a recent description of HNS practice patterns nationwide during the pandemic 24. Since the beginning of the pandemic, the maximum number of COVID-19 patients at our institution has not exceeded 62 and therefore, our institution has not yet experienced ventilator or PPE shortages suffered by other health care centers. We feel that thus far our division has been able to effectively triage HNS patients and complete their oncologic surgeries safely, while simultaneously reducing non-urgent surgeries. We reduced our surgical volume by 55% during the critical time period and this was predominantly by postponing elective, outpatient surgeries. Of note, we feel strongly that a team-based approach toward completing surgical cases is of the utmost importance in this situation. This requires inter-provider consistency with regard to management strategies, a high level of communication, and an understanding between the patient and provider that another surgeon may be involved or primarily responsible for their care. A foundation of trust between the patient and provider is elemental in the success of this model. We would advocate a high level of detail with regard to documentation and completion of the surgical consent with these principles in mind.
An early and constantly evolving response to the COVID-19 crisis remains critical to avoid an overwhelming surge on our medical system. At this time, ORs both at our institution and around the country are beginning to re-open to clear the logjam of semi-urgent and elective cases. We feel the keys to safely moving forward with increased head and neck surgical volume is with widespread, reliable pre-operative COVID testing, adequate PPE and a clear mechanism to triage cases according to urgency and safety via a team-based approach. While our experience may not be reproducible for smaller community hospitals or tertiary centers located in more urban settings, they do serve to highlight the response and experience of a high-volume head and neck cancer tertiary center situated in the deep South.