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.