Introduction
Since its initial identification in Wuhan, China, in late 2019, the
novel coronavirus 2019 disease (COVID-19) has rapidly spread across the
world. In recognition the World Health Organization (WHO) officially
designated the COVID-19 outbreak a pandemic on March 11,
2020.1 The rapid rise in COVID-19 cases has caused a
demand surge on the United States healthcare system. Hospitals are
already reporting shortages of necessary equipment and resources
required to care for COVID-19 patients including personal protective
equipment (PPE) for frontline healthcare workers, ventilators, intensive
care unit (ICU) beds, and transfusion capacity.
Surgical procedures increase demands on an already taxed system through
the consumption of a large amount of PPE, use of inpatient beds
post-operatively, and elevated risk of transmission of SARS-CoV-2 to
other patients and staff.2,3 The CDC recommended
cancellation of all elective and non-urgent procedures for Santa Clara
County, California, on March 12, 2020.2 Subsequent
guidelines were released by the American College of Surgeons (ACS) to
curtail the performance of “elective” surgical
procedures4 and the American Academy of
Otolaryngology-Head and Neck Surgery to provide only “time-sensitive”
or “emergent” care.5 While the
ACS6 and the Centers for Medicare & Medicaid Services
(CMS)3 have published general guidelines on priority
classification of cases, it is ultimately the responsibility of the
surgeon to define “elective” and “urgent” surgery. The ACS, working
together with specialty societies, has put forth more specific
definitions of procedural classifications for other surgical
specialties4, including cardiac, colorectal, metabolic
and bariatric, pediatric, and thoracic surgery; however, to date, no
otolaryngology case priority designations exist.
In response to this pandemic, the Division of Head and Neck Surgery in
the Department of Otolaryngology at Stanford University has developed a
process for stratifying head and neck cases by urgency. In the present
commentary, we discuss considerations for case prioritization during the
COVID-19 pandemic, outline our criteria and workflow, define estimated
risk categories of SARS-CoV-2 transmission for patients undergoing
urgent head and neck surgery, and discuss the role of preoperative
COVID-19 screening.