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\begin{document}

\title{Mitigation of Head and Neck Cancer Service Disruption During
COVID-19 in Hong Kong Through Telehealth and Multi-institution
Collaboration}



\author[1]{Zenon WC Yeung, FRCSEd (ORL)}%
\affil[1]{United Christian Hospital and Tseung Kwan O Hospital}%


\vspace{-1em}



  
  \date{May 21, 2024}


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\selectlanguage{english}
\begin{abstract}
The 2019 novel coronavirus disease (COVID-19) pandemic has been
spreading worldwide at an alarming rate. Healthcare workers have been
confronted with the challenge of not only treating patients with the
virus, but also managing the disruption of healthcare services caused by
COVID-19. In anticipation of outbreak, clinic sessions and operation
theatre lists have been actively cut back since February 2020 to reduce
hospital admissions and clinic attendances. This has severely disrupted
healthcare services, leading to accumulating clinic caseload and
substantial delays for operations. The head and neck cancer service has
been faced with the difficult task of managing the balance between
infection risk to healthcare providers and the risk of disease
progression from prolonged waiting times. We share our experience in
Hong Kong on the mitigation of head and neck cancer service disruption
through telehealth and multi-institution collaboration.%
\end{abstract}%



\sloppy




\textbf{Authors}

\textsuperscript{1}Alex KF Lee MRCS, \textsuperscript{1}Ryan HW Cho
FRCSEd (ORL), \textsuperscript{2}Eric HL Lau FRCSEd (ORL),
\textsuperscript{3}HK Cheng MBBS, FANZCA, FHKAM, \textsuperscript{2}Eddy
WY Wong FRCSEd (ORL), \textsuperscript{1}Peter KM Ku FRCSEd (ORL),
\textsuperscript{2}Jason YK Chan FRCSEd (ORL), \textsuperscript{1}Zenon
WC Yeung FRCSEd (ORL)

\textbf{Author Affiliations}

\textsuperscript{1} Department of Otorhinolaryngology---Head and Neck
Surgery, United Christian

Hospital and Tseung Kwan O Hospital, Hong Kong

\textsuperscript{2} Department of Otorhinolaryngology---Head and Neck
Surgery, The Chinese University of Hong Kong, Hong Kong\textbf{}

~\textsuperscript{3}Department of Anesthesiology, Tseung Kwan O
Hospital, Hong Kong

\textbf{Corresponding Authors}

Zenon WC Yeung, FRCSEd (ORL)

Department of Otorhinolaryngology---Head and Neck Surgery,

United Christian Hospital and Tseung Kwan O Hospital

2 Po Ning Lane, Tseung Kwan O

New Territories

Hong Kong

Email: dr.zenon.yeung@gmail.com

Phone: 852 92734534

~

~

Jason YK Chan, FRCSEd (ORL)\textbf{}

Department of Otorhinolaryngology, Head and Neck Surgery

The Chinese University of Hong Kong \textbf{}

Room 84026, 6/F, Lui Che Woo Clinical Sciences Building,~Prince of Wales
Hospital, Shatin \textbf{} New Territories

Hong Kong

\textbf{Email:} jasonchan@ent.cuhk.edu.hk \textbf{} \textbf{{}}

\textbf{Phone:} +852 97081554

\textbf{Keywords:}

Head and neck, otolaryngology, Hong Kong, COVID-19, telehealth

\textbf{~}

\textbf{Abstract}

The 2019 novel coronavirus disease (COVID-19) pandemic has been
spreading worldwide at an alarming rate. Healthcare workers have been
confronted with the challenge of not only treating patients with the
virus, but also managing the disruption of healthcare services caused by
COVID-19. In anticipation of outbreak, clinic sessions and operation
theatre lists have been actively cut back since February 2020 to reduce
hospital admissions and clinic attendances. This has severely disrupted
healthcare services, leading to accumulating clinic caseload and
substantial delays for operations. The head and neck cancer service has
been faced with the difficult task of managing the balance between
infection risk to healthcare providers and the risk of disease
progression from prolonged waiting times. We share our experience in
Hong Kong on the mitigation of head and neck cancer service disruption
through telehealth and multi-institution collaboration.

\par\null

\textbf{Introduction}

The 2019 novel coronavirus disease (COVID-19) pandemic has affected
millions of people worldwide and paralyzed the health care systems in
different major countries since its onset. COVID-19 originated in Wuhan,
China in December 2019(1-3), the largest and most populous city in
central China, and a major regional transportation hub. The Hong Kong
SAR, being the most densely populated city in southern China and a major
transport hub connecting China to the rest of the world, faced the first
confirmed coronavirus case on 23rd January 2020 imported from Mainland
China. The initial confirmed cases were all imported from Mainland
China, followed later by evidence of community spread with local
transmission on the 2nd February 2020. The number of cases in Hong Kong
rapidly increased in March 2020, with a large proportion of cases being
imported from Western Countries, and as of April 14, there were 1013
confirmed cases(4). During this pandemic, in anticipation of rapid
growth in confirmed cases yet limited resources in the public health
care system, there was a tremendous pressure on reducing hospital
admissions and clinic attendances since early February 2020. Here we
outline the changes in resource allocations and its effect on our
clinical and operating service provision.

\textbf{Clinic Arrangement and Telehealth}

To minimize the possibility of cross contamination and nosocomial
infections within hospitals, the majority of routine clinic appointments
were postponed(5). 80-90\% of outpatient service have been cut to leave
only urgent or semi-urgent conditions to be seen. During this two-month
period, 3800 cases have been rescheduled at the outpatient clinic. The
number of doctors seeing consultations was reduced significantly, with
one dedicated clinician with full personal protective equipment(6) and
fit tested N95 respirator performing aerosol generating procedures such
as a flexible laryngoscopy, to conserve personal protective equipment
(PPE) during clinics. In addition, each doctor sees only 10-15 patients
per consultation session, representing a reduction of caseload by at
least 40\% for each doctor, allowing the time needed for strict
compliance of infection control measures. All doctors wore a gown, cap,
gloves and surgical mask to see patients(5) and all patients were
required to wear a surgical mask before entering the hospital. A
dedicated drug refill clinic was also set up to allow stable patients to
obtain a repeat prescription without consultation and new appointments
were rescheduled based on their clinical condition.

To deal with the accumulation of rescheduled cases, the department may
need to set up extra clinic sessions in the evening or during weekends
once the pandemic is settled. It will take about 44 weeks with an
average of 2 extra sessions per week to tackle the accumulated cases. In
order to avoid excessive rescheduling of appointments, our hospital has
started utilizing tele-medicine in clinical practice during the pandemic
since February 2020. 2 sessions were organized per week for each doctor
with 6 consultations per session. Telemedicine sessions took up to 10
minutes longer when compared to a face to face consultation of usually
less than 10 minutes per patient.

To accomplish these telemedical sessions, Zoom was adopted by the
hospital as an app in compliance with Health Insurance Portability and
Accountability Act Security Standards to ensure the security and privacy
of protected health information. This platform for telemedicine was
endorsed by the Central Credentialing Committee, Hospital Authority,
Hong Kong. The spectrum of telemedicine service included consultations
by doctors and nurses, outpatient wound care, palliative care at home
and academic meetings or multidisciplinary tumor board meetings.
However, there have been recent concerns over the potential
vulnerability with Zoom, in which `Zoombombing' or hijacking during
video conferencing(7), and privacy concerns have been raised. The
Hospital Authority in Hong Kong underwent a series of security
assessments on the updated Zoom client, confirming that data sharing
with social media was no longer allowed. The analysis reported that the
vulnerabilities have been resolved and end-to-end encryption was also
enforced. To protect our patients, the Information Technology department
of the Hospital Authority recommended clinicians and patients to use the
latest version of the Zoom client and to use the Zoom client with a
corporate account to enjoy enterprise security features. Furthermore, a
password should be set for every meeting and the meeting details and
password should be exclusively disclosed to participants only. Finally,
the ``Lock'' function should be enabled once all participants have
joined the meeting to avoid intrusion.

The key to the successful operation of telemedicine consultations was
patient selection.

Ideal cases would be patients with routine follow-up whom physical
examination might not add critical information. Patients' age and
education were also taken into consideration. Patients who were enrolled
into telehealth had to possess a smart device with a web camera and be
able to use the Zoom web conferencing app. In head and neck patients,
telemedicine could be utilized to reduce patient's travel and hospital
attendance to minimize the risk of cross infection. After the initial
attendance for examination and consent, further preoperative
counselling, education of postoperative care, dietary advice and neck
and shoulder exercise recommendations could all be delivered by
telemedicine. In the postoperative phase, simple wound review and
troubleshooting could also be performed.

To ensure the correct patient was seen at the right time using Zoom
tele-conference, the appointment date and time, Zoom conference ID and
password were sent to patient's email and phone using SMS. Two-way ID
verification was then adopted. Patients were asked about their date of
birth or the last 3 digits of their Hong Kong identity card number and
they were asked to show their unique outpatient appointment slip to the
web camera. After each consultation, a new appointment slip and
prescription sheet would be mailed to the patient by post. At the same
time, an electronic appointment slip and prescription would be sent to
patients through e-mail or the hospital telehealth app. Patients could
then go to the Pharmacy within 7 days to obtain the prescribed
medications. \textbf{(Figure 1)}

\textbf{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.

\textbf{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.

\textbf{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 \textbf{(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.

\textbf{Discussion}

COVID-19 has spread across the world, involving 213 countries with at
least 1.8 million confirmed cases and 117,021 confirmed deaths as of Apr
14, 2020(12). Evolving data from China and Italy has shown that
nosocomial infection occurred when there was insufficient protection.
1716 cases of nosocomial infections have been reported in China
including 5 mortalities(13). The fact that a significant proportion of
asymptomatic carriers continue to shed virus during the incubation
period poses increased risk to health care professionals(8). It is
therefore of paramount importance to ensure adequate protection for
health care workers and to prevent the spread of the virus by providing
suitable protective equipment and limiting clinic and operation
sessions. Otolaryngologists have been known to be of notable risk
because of the need to examine the upper aerodigestive tract, which
carries the highest viral load, particularly in the nose and throat(8,
9).

It has been encouraging to see no single case of nosocomial infection in
Hong Kong

despite more than 1000 confirmed cases of COVID-19. This confirms that
the current practice of infection control is successful in preventing
nosocomial infection.

However, these efforts to contain the spread of the virus has given rise
to issues of accumulating caseload in the clinics and operating lists
and diminishing personal protective equipment supplies. Head and neck
surgeons have been faced with the unique challenge of balancing
infection risk and appropriately timed surgery due to the risk of
disease progression in head and neck cancers. Faced with these
challenges, extensive efforts have been made both in the clinics and
operation theatre services to minimize the disruption to usual
healthcare services. Novel methods such as telemedicine and regional
collaboration with other ENT centers have been implemented with some
success, with plans for further development in the coming months.

Despite all the measures taken, a substantial number of patients remain
greatly affected. Lower priority surgeries such as those for low grade
malignancies and benign head and neck tumors have been postponed and
will require resolution as soon as the pandemic settled.

\textbf{References}

1. Wang D, Hu B, Hu C et al. Clinical Characteristics of 138
Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in
Wuhan, China. JAMA. 2020.

2. Novel Coronavirus Pneumonia Emergency Response Epidemiology T. The
epidemiological characteristics of an outbreak of 2019 novel coronavirus
diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi.
2020;41(2):145-51.

3. Khan S, Nabi G, Han G et al. Novel coronavirus: how things are in
Wuhan. Clin Microbiol Infect. 2020.

4. SAR TGoHK. Coronavirus Disease (COVID-19) in HK. 2020.

5. Chan JYK, Wong EWY, Lam W. Practical Aspects of Otolaryngologic
Clinical Services During the 2019 Novel Coronavirus Epidemic: An
Experience in Hong Kong. JAMA Otolaryngol Head Neck Surg. 2020.

6. (HKCORL) THKCoO. The Guide to the Proper Techniques for Gowning and
Removal of Personal Protective Equipment (PPE) 2020 {[}Available from:
https://hkcorl.org.hk/database/files/hkcorl\_video\_20200327.mp4.

7. Toronto TCLUo. A Quick Look at the Confidentiality of Zoom Meetings
2020 {[}Available from:
https://citizenlab.ca/2020/04/move-fast-roll-your-own-crypto-a-quick-look-at-the-confidentiality-of-zoom-meetings/.

8. Zou L, Ruan F, Huang M et al. SARS-CoV-2 Viral Load in Upper
Respiratory Specimens of Infected Patients. N Engl J Med.
2020;382(12):1177-9.

9. Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19
and the otolaryngologist - preliminary evidence-based review.
Laryngoscope. 2020.

10. Jensen AR, Nellemann HM, Overgaard J. Tumor progression in waiting
time for radiotherapy in head and neck cancer. Radiother Oncol.
2007;84(1):5-10.

11. Jang JY, Choi N, Ko YH et al. Treatment outcomes in metastatic and
localized high-grade salivary gland cancer: high chance of cure with
surgery and post-operative radiation in T1-2 N0 high-grade salivary
gland cancer. BMC Cancer. 2018;18(1):672.

12. Organization WH. Coronavirus disease (COVID-19) Pandemic.

13. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the
Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a
Report of 72314 Cases From the Chinese Center for Disease Control and
Prevention. JAMA. 2020.

\par\null

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