The COVID-19 pandemic has stressed healthcare systems globally and is presenting particular challenges to cancer surgeons and cancer surgery programs.
As New York City quickly became the epicenter of the pandemic in the United States, Memorial Sloan Kettering convened an Operating Room (OR) Executive Committee comprised of leaders from surgery, anesthesia, and nursing. This COVID-19 subcommittee met twice daily to scrutinize all cases to determine whether they were truly essential and to review needs, resources, and ICU availability.
In our paper, published recently in the Annals of Surgical Oncology, we provided our views on best practices for meeting the challenges of providing excellent cancer care to patients in need while balancing the constraints of safety for patients and staff and the demands on resources during the pandemic in advance of the anticipated surge in cases in our region. (1)
Overall, our primary goal was to optimize outcomes for our patients with cancer while being able to respond to an increasing volume of COVID-19 patients. Here are our positions on four key questions on providing cancer surgery during the COVID-19 pandemic.
Is scheduled cancer surgery considered elective surgery?
This question initially arose when state and local governments asked all hospitals to cancel elective surgeries in preparation for an anticipated surge in COVID-19 patients. The American College of Surgeons (ACS) also made a similar recommendation shortly thereafter.
Our immediate response was to distinguish elective surgery from potentially curative cancer surgery, which we have called “essential cancer surgery.”
At MSK, our surgeons manage about 30,000 surgical cases annually across 13 surgical services in the Department of Surgery and Department of Neurosurgery. About 5 to 10 percent of our surgical volume is genuinely elective, including incisional hernia repairs, cholecystectomy for biliary colic, ostomy takedowns, and some plastic and reconstructive procedures. Another 20 to 30 percent of cases are more cancer specific but can be deferred safely for several months, including most reconstructive surgical procedures, prostatectomy for low-grade prostate cancer, pancreatectomy for cystic neoplasms without cancer or high-risk features, and thyroidectomy for low-grade thyroid cancer.
We initially moved these cases off our surgical schedule to comply with government edicts while continuing to perform essential cancer surgeries, such as brain tumor, breast, colon, pancreas, stomach, liver, kidney, bladder, and lung resections. The ACS has subsequently validated this approach, as has the New York State Department of Health.
Our guidelines for prioritizing cancer surgery are as follows: (1)
- Only essential cancer surgery may proceed. These are patients who cannot wait two to three months and are anticipated to have a significant benefit from surgery.
- No surgeries with a readily available, appropriate, and equivalent nonsurgical option are allowed.
- No surgeries that can be delayed two to three months without a negative impact on survival are allowed.
- Select palliative procedures for acute relief of pain and suffering that are not manageable by other means are allowed.
- No elective procedures are allowed.
- True emergencies, such as a perforated viscus, are allowed.
- The COVID-19 Subcommittee of the OR Executive Committee reviews requests for exceptions.
To plan for an unpredictable and escalating number of COVID-19 patients, we looked at a stepwise reduction in surgeries based on competing needs for hospital beds, ORs, ICUs, and ventilators. We considered that staff illness, quarantine requirements, and critical supply shortages might limit our ability to provide essential cancer surgery. We used those inputs to develop planning scenarios that went from managing the full range of essential cases to reducing activity by 25 percent, 50 percent, and 75 percent in the event of diverting resources to caring for COVID-19 patients. Finally, we looked at closing all scheduled ORs and recovery rooms and devoting all anesthesia machines to use as auxiliary ventilators for COVID-19 patients while keeping a small number of ORs available for true surgical emergencies.
We ultimately did convert the majority of our ORs to ventilator or ICU rooms, and for several weeks, we were able to perform only approximately 20% of our regular surgical volume. This required us to work closely across the enterprise to prioritize cases optimally under challenging circumstances.
As required, individual surgeons were contacted to justify medical necessity for cancer surgeries. We also shortened the time for definitive scheduling to 48 to 72 hours, allowing us to respond quickly when we needed to convert ORs and ramp down surgical volume. Service chiefs reviewed weekly schedules and provided a triage list for use in the event of needing to postpone even some of the essential cases.
Q: What OR safety challenges do surgeons, anesthesiologists, and perioperative staff face?
A: Recommendations from the Centers for Disease Control and Prevention and leading professional organizations for best practices to reduce risk for healthcare providers have continued to evolve during the COVID-19 pandemic.
Initially, limitations on testing capacity meant that it was impossible to test all patients for SARS-CoV-2 infection before surgery and to postpone surgeries for those who tested positive. As testing capacity improved (and in the setting of a marked reduction in OR activity), we were able to adopt a universal testing approach, which improved the safety of both patients and staff by markedly reducing the number of asymptomatic or presymptomatic SARS-CoV-2 positive patients moving through our ORs, recovery rooms, and hospital.
Since the disease spreads via respiratory droplets, procedures involving intubation place anesthesiologists and surgeons who work in the airway or area of the head and neck at particularly high risk. To maximize protection, anesthesiologists are provided with N95 masks for all procedures. N95s are optional for other OR staff, and all OR staff leave the OR or maintain a distance of at least six feet during intubation and extubation procedures.
Chiefs in our head and neck, thoracic, and neurosurgery services have worked on guidelines to minimize the especially high risks faced by surgeons in these disciplines. The guidelines include the use of preoperative COVID-19 testing and postponement for infected patients, standard use of N95 masks and face shields or goggles, and selected use of positive-pressure airflow helmets.
Q: How can we best fulfill our mission for patient care while balancing societal obligations?
A: All physicians have an obligation to provide excellent care to their patients. However, the current COVID-19 pandemic has created competing responsibilities with regard to the safety of healthcare professionals, the use of personal protective equipment (PPE), and the allocation of such resources as hospital beds, ICUs, and ventilators.
As surgical oncologists, we found ourselves confronted with needing to decide whether the health benefits and improvements in survival offered by essential cancer surgeries for patients justified the personal risk to OR staff and the use of resources during the pandemic.
However, we felt it important to consider that COVID-19 is not the first nor will it be the last health emergency to strain resources and potentially place healthcare workers and patients at an increased risk. The need to carefully consider underlying cancer treatment goals, patient health issues, staff risk, the use of PPE and institutional resources in triaging procedures was in some ways similar to experiences during the early years of the human immunodeficiency virus epidemic.
We also recognized that there will be more cancer deaths than COVID-19 deaths in the United States next year, even if deaths from COVID-19 reach the level of the highest projections. If essential cancer surgery is not provided to patients, the cancer death rate will climb even higher. Furthermore, COVID-19 will likely persist for many months if not years into the future, until a vaccine becomes available or sufficient infection occurs in the population to achieve herd immunity. Therefore, there will be an ongoing need to continue to provide essential cancer surgeries for patients who need them while minimizing risk to healthcare providers.
The preservation of PPE, hospital beds, and ventilators may also place cancer surgeries in conflict with the response to COVID-19. Most hospitals have only modest reserves of PPE, and the increased demand for N95 masks in particular and the closure of traditional supply chains has strained access to them further. The need for hospital beds and ventilators was not as critical as worst case projections anticipated but was felt at all institutions, including ours, as we reached the peak of the COVID-19 surge.
Overall, there is no simple answer for determining how to trade off patient needs against provider risk and the use of resources. Leaders at each institution need to oversee the process of balancing the provision of care with trends in local disease activity and the availability of resources.
Q: What roles should surgical leaders play in OR decision-making and preparations for the COVID-19 pandemic?
A: The COVID-19 pandemic represents an unprecedented challenge to every institution. Our approach has been to involve surgeons, anesthesiologists, and nurses on our OR Executive Committee to evaluate OR scheduling on a twice-daily basis. We review the appropriateness of cases, the availability of staff to perform and manage the procedures, and the impact of surgeries on patient beds and resources. The OR Executive Committee coordinates recommendations with our Hospital Incident Command System — which includes a representative from our committee among other medical, surgical, and administrative leaders from the hospital — and also meets twice daily.
Clear and frequent paths of information flow and communication continue to be vital to our response at MSK. We hope that the steps we have taken and are continuing to take allow us to optimize care and outcomes for our patients with cancer and our COVID-19 patients while minimizing risk to healthcare staff and conserving patient care resources.
The information presented above represents the collective views of the authors and does not represent an institutional position. The COVID-19 Subcommittee of the OR Executive Committee collaborators include Laura Ardizzone, DNP, CRNA, DCC; Thomas Barber, MD; Jeffrey Drebin, MD, PhD; Gregory Fischer, MD; Elizabeth Jewell, MD; Vincent Laudone, MD; Marcia Levine, MSN, RN, ME-BC; Jeannine Linder, MSN, MPA, RN, CNOR; Brett Simon, MD, PhD; Christopher Stromblad, BS, MS; Viviane Tabar, MD; Martin Weiser, MD; and Shok-Jean Yee, MA, RN, CNOR. The authors declare no conflict of interest.