This information is intended as a guide for staff working in head and neck oncology and due to the nature of the rapidly changing COVID-19 environment is subject to change. All staff should adhere to policy guidelines within their facility and State/Territory guidelines ^{1, 2.}

These guidelines are intended for staff working within outpatient oncology departments including medical (surgical, radiation and medical oncology), allied health (speech pathology) and nursing staff who are working directly with procedures that are deemed at high risk. It is recommended that ENT/Head and Neck Surgeons also ensure compliance to the Australian Society of Otolaryngology Head and Neck Surgery³ (ASOHNS), Australian Society of Anaesthetists⁴ (ASA) and the NSW Health guideline⁵ for patients requiring/attending surgery during COVID-19 pandemic.

Risk to healthcare workers through transmission of COVID-19 is primarily through droplet spread and data from China, Iran, Italy and most recently the UK suggest that ENT/Head and Neck Surgeons are a high risk population.

Extrapolating from these data and looking at the identified concern for increased transmission

through aerosol generating procedures, clinicians who are involved in the assessment and management of the upper airway including nasal endoscopy, tracheostomy/laryngectomy management and insertion of nasogastric tubes or manometry catheters are also at an increased risk of COVID-19 exposure. All clinicians should adhere to local and facility policies and State/Territory legislation and guidelines regarding whether the procedure should be conducted and if deemed required, ensure the appropriate use of PPE and the management of suspected or confirmed COVID-19 cases.

Overarching recommendations

• Minimise the number of patients attending outpatient clinics, wherever possible, follow up appointments should be made using telehealth/phone consults. These should be appropriately recorded/billed.
• Prior to any procedure, ascertain COVID-19 status and unless emergent, postpone any COVID-19 positive cases, anyone with recent travel history, anyone with potential symptoms of COVID-19 or anyone with COVID-19 contacts.
• Prescreening via telephone calls or digital platforms for COVID-19 symptoms and exposure history prior to planned in-person clinic visits is recommended, if possible.
• For routine care of patients with known or suspected COVID-19 positive infections, follow specific guidance from the Clinical Excellence Committee (CEC)
• All patients with known or suspected COVID-19 positive infections or have acute respiratory symptoms should wear a surgical mask upon presentation and during examination .
• Limit intervention in clinic rooms as much as possible and if necessary based on the acuity of the situation, ensure that PPE for airborne and contact precautions is used for all aerosol generating procedures (AGPs).

Personal Protective Equipment (PPE)

Inadequate personal protective equipment (PPE), improper use of PPE, and poor hand hygiene are potential factors that can lead to transmission.

Online PPE training is mandatory for all NSW Health clinical and support staff who work in and around patient areas. Training is available through My Health Learning.

In all circumstances:

• staff are to ensure that they have completed up to date training on PPE
• staff are to wear prescribed PPE
• any staff member who is concerned about their safety must raise their concerns immediately with their manager.

No staff are to undertake or be expected to undertake tasks requiring PPE if the PPE is not available for use.

All staff should adhere to local and facility policies and State/Territory legislation and guidelines. An information sheet about the use of PPE) during hospital care of people with coronavirus (COVID-19) is has been developed by the Australian Government ⁶.

Patients screened and confirmed COVID-19 negative or unscreened patients with no symptoms

Droplet and contact precautions are recommended.

Patients with known or suspected COVID-19 positive infections

• Routine care: Follow specific guidance from the Clinical Excellence Committee (CEC) i.e. PPE for droplet and contact precautions and Australian Department of Health information Interim recommendations
• Aerosol generating procedures* (AGPs):
• PPE for airborne and contact precautions used. The only modification for airborne precautions, is the use of a particle filter (P2/N95) respirator or equivalent instead of a surgical mask.
• If an AGP is to be performed, the patient should be placed in a negative pressure room (or an isolation room with door closed if a negative pressure room is not available).
  
• Where possible, these procedures should be carried out the end of clinic and/or day in a single room with the doors shut.
• Only those staff who are needed to undertake the procedure should be present and documented.
• Appropriate cleaning and disinfection should be undertaken following an AGP i.e. the space should be left for 30 minutes before a terminal clean is performed, as per local facility protocol.
• Other procedures* that can generate respiratory aerosols, such as the use of high flow nasal oxygen, should not be used unless specific advice is given.
• Follow local policy regarding removal and disposal of PPE and devices e.g. voice prostheses

* Examples of AGPs and other high risk procedures can be found in Guidance on the use of personal protective equipment (PPE) in hospitals during the COVID-19 outbreak.

Management of radiation oncology patients

• In patients who are undergoing treatment (radiotherapy and chemoradiation) and are deemed at high risk of swallow dysfunction, prophylactic gastrostomies should be considered to avoid the need for ongoing NG tube insertions and/or admission to hospital.
• Radiation therapists who need to position head and neck cancer patients should wear PPE in accordance with facility and State/Territory Guidelines. The American Society for Radiation Oncology (ASTRO) support the use of Droplet and contact precautions.⁷
• Droplet and contact precautions (including eye protection) are essential for any patient with positive or suspected COVID-19.

Related community of practice guidance

• Surgical Community of Practice
• Respiratory Community of Practice

References

1. Federal Government Department of Health
2. NSW COVID-19 Advice
3. Australian Society of Head and Neck Surgery: Guidance for ENT surgeons during the COVID-19 pandemic
4. Australian Society of Anaesthetists: COVID-19 Updates
5. Key principles for management of surgery during COVID-19 pandemic Advice for NSW health
   services
6. Guidance on the use of personal protective equipment (PPE) in hospitals during the COVID-19 outbreak Australian Government Department of Health (accessed 11/05/2020)
7. The American Society for Radiation Oncology (ASTRO) COVID Recommendations and Information Summary

Other resources

• ENT UK
• American Academy of Otolaryngology Head and Neck Surgery
• Givi B, Schiff BA, Chinn SB, et al.Safety Recommendations for Evaluation and Surgery of the Head and Neck During the COVID-19 Pandemic. JAMA Otolaryngology–Head & Neck Surgery. 9000;Publish Ahead of Printdoi:10.1001/jamaoto.2020.0780.

Document information

Developed by

• A/Prof Winston Liauw, Cancer Community of Practice
• A/Prof Julia Maclean, Oncology/ENT speech pathologist at St George Hospital, Sydney

Consultation

• Surgical Community of Practice
• Respiratory Community of Practice
• Clinical Excellence Commission (CEC)

Endorsed by

Dr Nigel Lyons, Deputy Secretary, Health System Strategy and Planning

Review date

21 May 2020

For use by

• Cancer and Blood and Marrow Transplant Community of Practice
• Surgical Community of Practice
• Respiratory Community of Practice
• Any other relevant communities of practice.