Discussion
The recent surge in COVID-19 cases in the United States has caused an
extraordinary demand on our healthcare system. Many institutions have
cancelled all elective and non-urgent procedures to conserve PPE, free
up inpatient beds, and limit exposure of patients and staff. While
operational definitions of elective and urgent categories of surgery
exist, there is a degree of surgeon judgment in these designations. To
ensure that our identification of a surgical patient as “urgent” is
both consistent and evidence-based, we have established a framework to
prioritize patients for the operating room., risk categories for
transmission, and clinical pathways for preoperative evaluation and
transmission mitigation. We employ sequential reviews by division
faculty (± multidisciplinary head and neck tumor board), division chief,
and department chair. The classifications and pathways put forth in the
current paper are meant to be a general guideline for others to use.
Every institution will have its own unique considerations.
As surgeons, we bear the heavy responsibility that our decisions put the
entire operating room team at risk. When a surgeon schedules an urgent
case, the justification for adding it on has to be genuine.
Justifications should not be hypothetical, but rather clearly documented
in the patient’s electronic medical record as a substantial health
threat to the patient over the next 30 days. The surgeon must always
consider each patient’s oncologic situation, comorbid conditions, social
circumstances, and needs. Given the high risk of SARS-CoV-2 nosocomial
transmission in a majority of head and neck procedures, as head and neck
surgeons we have a unique obligation to employ a conservative
operational definition of “urgent”.
At times it is difficult to determine where we are on the “curve” of
the pandemic. During the current exponential growth phase, we need to be
relatively stringent, but we hope that these criteria will gradually
liberalize over time. In the meantime, it is our responsibility to be
thoughtful with our case selection and promote stewardship of health
care resources.