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.