NTSP Specials (Season 2): Prof Leo Vassiliou discusses the impact of the pandemic at ITS6

Professor Leandros (Leo) Vassiliou, is a head neck reconstructive surgeon with a background in Oral & Maxillofacial Surgery, practising in Manchester University NHS Foundation Trust, in Manchester UK. He is a visiting Professor in the Medical School of the University of Greater Manchester. Leo spoke about the impact the pandemic had on head and neck services at the 6th International Tracheostomy Symposium, held in Manchester UK, in October 2021. This presentation is an extract from that meeting.

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Transcript

SPEAKER_01 0:07

Hello, this episode is part of a series that was recorded for the October 2021 International Tracheostomy Symposium. I'd like to introduce Dr. Leo Vasilio, who's a consultant maxillofacial surgeon working in Great Manchester, United Kingdom. Leo has got various national roles for the British Association of Maxillofacial Surgeons, and we asked Leo to talk about the adaptations he had to make to his head and neck surgical service during the pandemic and what lessons we'd learnt. Over to you, Leo.

SPEAKER_00 0:38

I would like to thank Professor McGrath for the invitation. It is also a pleasure to be with old friends such as Mr. Aurora that I know from London, as well as with international experts in the field of fairway management and tracheostomy, such as Tony Jacob and Gonzalo Hernandez. My presentation today will focus on the adaptation of surgical services during the COVID-19 pandemic, with a special focus on the adaptations on the tracheostomy procedures as well as the overall head and neck cancer services. Starting with the key facts of the COVID-19 pandemic, we all remember in December 2019 that the novel coronavirus was first identified in Wuhan, China. A failure of the initial lockdown to contain the outbreak resulted in worldwide spread with the World Health Organization declaring a public health emergency of international concern in January 2020. Further that, and with continuing spread in March 2020, the World Health Organization has declared a global pandemic, and since then we have seen multiple variants of significant virulence emerging. COVID-19 as of the 15th of September 2021 has infected over 225 million people across the world, and the death toll has exceeded 4.64 million, making it the deadliest pandemic in the history of mankind. COVID-19 consists a crisis and like any crisis there are finite steps on how to address and tackle it. The initial priorities in the healthcare were certain adaptations, first of all, to control the spread by minimizing movement and face-to-face contact with patients and staff. The priority within the healthcare provision was to protect the patients by prioritization of services and instigating certain standard operating policies to protect patients and healthcare personnel. With regards to the clinical staff, we all know that there were major redeployments as well as adaptations, with the most important ones consisting the introduction of personal protective equipment, FFP3 masks, visors, and full body protection became the norm. The main guidance in protecting patients and staff could be summarized as personal protective equipment and the triad of avoid, restrict and abbreviate. In the immediate response of the COVID-19 pandemic, multiple NHS and professional organizations have collaboratively issued guidance and instructions on how to adapt clinical services. COVID-19 is a respiratory tracked infection and it spreads mainly through aerosol. As you can see here, the highest risk procedures are procedures related to airway and especially tracheostomies. Working in one of England's infectious disease hospitals, we were the first to receive and treat COVID-19 patients, and we were the first to be called for tracheostomy in recovering COVID-19 patients in intensive care unit. As you can imagine, we had to revisit and restructure all aspects of tracheostomies, not the actual procedure only, but all aspects of care are bound to tracheostomy from theater setup to patient transfer. We summarized and published that guidance as the key five T's, meaning theatre setup, team briefing, transfer of patients, tracheostomy itself, and team dolphin and debrief. Of course, many teams across the world were facing the same challenges, and Professor McGrath with a multicentre international team has published early in the COVID nineteen pandemic a very comprehensive guidance on the global aspect of tracheostomy procedure and holistic care. As tracheostomies are core procedures in the airway of the patient. The importance was to analyze every potential step where aerosol could potentially be released in the environment, potentially posing risk of infection for the healthcare personnel involved. Things that we considered normal had to be all revisited in depth. And in this slide we can see every potential weak point or point of risk in intubated patients orally or with a tracheostomy. The main modification of an open surgical tracheostomy would consist of switching on or off the ventilation during any airway surgical maneuver. Effectively, the ventilation should be switched off prior to the fenestration of the trachea. The existing endotracheal tube would be pushed further in and the calf would be reinflated. That would allow ventilation again of the patient whence the surgical window would be created. Following the window and any bleeding management, then the ventilation would be again switched off and the ET tube would be slowly withdrawn in order to allow the tracheostomy tube to be inserted. The process had effectively detailed steps in order to avoid any potential leak of aerosol with the possibility of infecting staff involved. Through this step by step strict protocol and internal departmental audit in my unit demonstrated that no clinical staff were infected by performing tracheostomies in COVID-19 patients, but obviously we will hear the COVID track large scale study that has effectively demonstrated the same results. A bit outside the field of the actual tracheostomy, multiple other oral or ENT procedures had to be categorized as whether they were AGP or non-AGP for risk management and planning purposes. Head and neck cancer treatment and surgery provision had to be completely reorganized in order to adapt clinical pathways and services and safeguard safety of the patients and the health personnel involved. A recent study from the UK, the COVID search collaborative led by Professor Otso and Liverpool, demonstrated the national impact of COVID nineteen in the treatment of head and neck cancer patients. The results of this multicentre study, in which over ninety five percent of the UK head andits participated and shared data and information demonstrated that an astonishing 50% of head and neck units capacity and cancer patients were severely compromised by the COVID-19 pandemic. Of these, 50% of compromised head and neck treatments. The breakdown showed that 28% of patients had delayed cancer surgery, which obviously would impact on their overall and further prognosis. 10% had radiotherapy instead of surgery, and 12% had surgery with a compromised treatment plan, either a lesser plan or a plan that did not involve the full gold standard reconstruction with a free flap. The study also demonstrated that the second COVID-19 pandemic had a far more significant impact on the head and neck provision. The map shows with green the units that managed to adapt and survive the COVID-19 crisis and demonstrated a performance almost close to the levels of the pre-COVID-19 pandemic. As you can see, the Liverpool and Blackburn on the northwest of England are green, which means that our performance adequately adapted. In the centers where head and cancer managed to survive the COVID-19 impact, multiple standard operating policies had to be recreated with significant input and team working between surgical teams as well as intensive care units and anesthetic departments. Effectively, the whole hospital service in terms of cancer surgery or elective surgery had to be fully reorganized. Designated areas for COVID free or green surgery had to be assigned, allowing the patients to enter the hospital through a green zone, receive the treatment and surgical procedures in completely COVID free areas, and when it came to major head and neck surgery to be admitted post operatively in ring fenced completely COVID free parts of the intensive care units. As we can all imagine, that project of completely restructuring the whole hospital services and facilities, including infrastructural and clinical policies, was a major task. However, it was the only way forward to continue delivering cancer treatment amidst the raging COVID-19 pandemic. The standard operating policies for admitting and treating head and cancer patients exceeded far beyond the actual changes in the infrastructure and involved strict isolation and COVID testing of the patients prior to admission. The strict upfront reorganization of head and eck cancer service provision and the adaptations in the hospital management and clinical pathways allowed seamless performance and delivery of cancer surgery in over 90 patients in my unit so far. The robustness and efficiency of the adapted clinical pathways can be demonstrated by the fact that zero of the head and patients who underwent major head and cancer surgery developed or contracted COVID-19 during their postoperative period. Meanwhile, apart from the Royal Blackben Hospital head and cancer provision during the COVID-19 pandemic, and landmark and large scale publication from international units providing head and cancer service reflected the same fact that effectively, with the appropriate adaptation in surgical services, head and cancer patients can receive high quality life saving procedures with the risk of contracting COVID-19 the same or as low as the same risk in the community. Moving now forward slowly through the resolution phase of the crisis, NHS England, Public Health England and the Royal Colleges of Surgeons are in the process of devising plans for what we call it recovery in order to cement the robust pathways of the adapted surgical services and also catch up with the backlogs of waiting lists. The COVID-19 pandemic is still ongoing and it has brought certain life-changing practices to our lives. It has transformed the landscape of healthcare as well as our normal lives. The fact that I am talking to you now through a screen rather than in an auditorium is evidence of this. However, I hope that my talk was informative and I will be open to any questions. Thank you very much for attending and watching.

SPEAKER_01 13:49

Thanks to Leo for that overview and description of what you had to do to make your service work in the pandemic. As ever, the views and opinions we discuss on the podcast are our own and don't necessarily represent those of our various employees.