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.