Operation Theatre arrangement
Amidst the rapidly evolving outbreak of COVID-19, there have been
growing concerns of the climbing caseload, cross infection, safety and
nosocomial infection for patients and healthcare workers alike.
Gleaning from the experience from managing patients during the SARS
epidemic in 2003, hospitals in Hong Kong began to introduce measures in
the operation theatre to protect healthcare workers and patients and in
anticipation of outbreak since February 2020.
Perioperative protective measures
Full sets of PPE including cap, gown, N95 particulate respirator, and
gloves were supplied to all essential staff during aerosol generating
procedures, including during intubation and extubation and for airway
operations.
To reduce contact and conserve PPE, personnel were kept to a minimum
perioperatively for such procedures. During intubation and extubation,
only the anesthetists and other essential staff remained in the
operation room, with the surgeons and operating nurses on standby
outside. Anesthetists used videolaryngoscopes with a transparent
plastic drape to form a closed circuit and a barrier between them and
the patient’s airway as an extra protective measure for decreasing
aerosol spread and contact during intubation and extubation. Only
experienced surgeons were selected for airway operations such as
tracheostomies in order to reduce potential risk and total contact time.
Reduction of operation theatre service
Due to infection concerns, anticipated need for redistribution
of manpower and reservation of hospital beds for potential infectious
cases, operation theatre services have been stripped to emergency and
priority elective operations since February 2020, including head and
neck cancer surgeries.
Whilst vital in combating the spread of the virus, this invariably
introduces inconvenience to patients and runs the risk of delayed
assessment and surgery. This is particularly relevant to head and neck
cancer patients, where longer waiting time could potentially lead to
disease progression and altered prognosis.
The dilemma of balancing between infection concerns from COVID-19
and ensuring appropriate surgical management has been shared by head and
neck surgeons all over the world. Several guidelines have been published
to prioritize the otolaryngologic and head and neck procedures and to
postpone elective procedures during the pandemic(8, 9). The Center for
Medicaid and Medicare Services in the US has recommended all elective
surgeries, non-essential medical, surgical, and dental procedures be
delayed during the pandemic. In the United Kingdom, it was recommended
during this contingency period to prioritise day case surgery and
restriction or cessation of surgical procedures requiring admission to
intensive care unit post-operatively. Suggestions have also made to
reduce the length of surgery by use of local or pedicled flaps rather
than free flaps(9).
For patients in the Hong Kong public healthcare system, they are
referred to our head and neck center where an initial assessment
is made. Investigations and operations are then scheduled into a public
queue. Prior to the COVID-19 pandemic, the waiting time from point of
diagnosis to surgery in our head and neck center was an average of 4
weeks, with 6 dedicated operating lists per month. With the reduction in
operation theatre service, head and neck elective operation sessions
have been decreased to a third of its original number, and with an
ongoing influx of new cases, the waiting time has been lengthened to as
long as 6 months.
To confront the challenge of limited resources and reduced operating
lists, our head and neck center stratified operations into 3 tiers of
priority with 3 targeted waiting times (Figure 2) . They are
divided according to the aggressiveness of the tumor, potential effect
on reconstruction and anticipated complications. With this approach, we
aim to limit the disruption to patient care as much as possible.
Squamous cell carcinomas were prioritized due to its high tumor volume
doubling time and rapid disease progression, with prior studies showing
TNM progression and new lymph node metastases within a 4-week waiting
time(10). High-grade salivary gland tumors were also given high priority
due to their aggressive clinical behavior and relatively favorable
prognosis in early stages of disease(11). Tumors with more indolent
behavior such as papillary thyroid carcinomas or low-grade salivary
gland tumors were given a relatively lower priority.
Early operations were performed for small oral cavity tumors in order to
avoid the potentially more complex reconstruction with delayed surgery,
which may introduce higher morbidity and prolonged hospital stay for the
patient. Similarly, bulky tumors of the larynx and hypopharynx were also
prioritized to avoid the possibility of progression to airway
obstruction requiring an emergency tracheostomy.
In order to achieve the targeted waiting times, our head and neck
department has initiated a collaboration with other ENT units across
Hong Kong to arrange early surgery for more urgent cases in different
hospitals. Tier 1 or 2 patients with an anticipated waiting time beyond
our target were prioritized, and to ensure appropriate perioperative
care, ENT units with head and neck expertise and intensive care units
were selected. A full explanation was given to each patient and if
agreed, they were referred to the partner ENT unit for a preoperative
consultation, then for an earlier surgery. Prior to each referral, there
was extensive communication between the two units to ensure a consensus
for the surgical plan and that an operating list was available.
The distribution of priority head and neck cancer patients between
regional ENT units to provide timely surgery was made possible due to
the proximity of hospitals in Hong Kong and the close-knit local Head
and Neck community.
Since the initiation of this multi-institution collaboration in March,
we have been able to alleviate the number of pending head and neck
cancer operations by 20%. We hope to expand this cooperation in the
coming months to further mitigate the accumulating caseload and obtain
timely surgery for our patients.