Dear all,
Regarding :
Emergency Management (Appropriate Surgery During COVID-19 Pandemic No 5) Direction 2022 under section 25 of the Emergency Management Act 2004
Can I draw members attention to the announcement made by Grantley Stevens, Commissioner of Police regarding Elective Surgery to be performed in South Australia with effect from 4.1.22. Notably failure to comply with this direction is an offence.
1- Only the following surgical treatment may be performed in the State of South Australia:
(a) emergency surgery and procedures performed for conditions where failure to do so expediently and safely will lead to the following outcomes:
(i) loss of life; or
(ii) loss of limb; or
(iii) permanent disability;
(b) non-emergency but urgent surgery and procedures performed for conditions where a patient would come to harm were surgery to be delayed;
(i) Category 1 surgery as defined in the National Guidelines;
(ii) Category 2 surgery as defined in the National Guidelines which is considered by the treating clinician to be urgent and where a clinical risk assessment and/or peer review indicates a need to proceed;
(iii) Where clinical evidence supports an increased risk of a loss of life or permanent disability should surgery or a procedure be significantly delayed;
Note—
Procedures may, for example, include endoscopy, bronchoscopy, interventional radiology and cardiology.
(c) surgery and procedures of a kind specified in subclause (2);
(d) elective surgery and procedures performed in accordance with the requirements and principles set out in Schedule 1.
(2) For the purposes of subclause (1)(c), the following surgery and procedures are specified:
(a) procedures undertaken in a community setting utilising local anaesthetic by primary health and allied health practitioners within their scope of practice, including such procedures undertaken by dermatologists and plastic surgeons in similar settings;
(b) dental procedures and dental surgical treatments, provided that the risk of disease transmission is managed and personal protective equipment stocks are safely available;
(c) surgical termination of pregnancy;
(d) cosmetic surgery procedures performed in a community setting.
(4) In this clause—
National Guidelines means the Australian Government, Australian Health Ministers’ Advisory Council, National Elective Surgery Urgency Categorisation guideline dated April, 2015 (see attached).
4—Exemptions
(1) A prescribed authorised officer may, if satisfied that exceptional circumstances exist, exempt (conditionally or unconditionally) a person or class of persons from this direction or a provision of this direction.
(2) In this clause—
prescribed authorised officer means the Chief Executive of the Department for Health and Wellbeing, the South Australian Chief Public Health Officer or the South Australian Chief Medical Officer.
Please see also the quoted National Elective Surgery Urgency Categorisation (link)
Notably in this section, the following are noted to be Category 1:
Laryngectomy, Panendoscopy, Radical Neck Dissection
The following are noted to be Category 2:
Microlaryngoscopy, Nasendoscopy, Parotidectomy / Submnandibular Gland Excision of, Pharynx - excision of.
The following are Category 3:
Adenoidectomy, Ethmoidectomy, Functional Endoscopic Sinus Surgery, Mastoidectomy, Myringoplasty / Tympanoplasty, Myringotomy, Nasal Cautery, Nasal Polypectomy, Pharyngoplasty, , Grommet insertion, Rhinoplasty (for reasons other than cosmetic), Septoplasty, Sub-mucosal resection, Tonsillectomy )+/- adenoidectomy), Turbinectomy.
The Guiding Principles are:
In all circumstances it is the responsibility of the treating surgeon to assign the urgency category.
The urgency category should be appropriate to the patient and their clinical situation and not influenced by the availability of hospital or surgeon resources.
The usual urgency category listed in this guide should be used to assign an urgency category unless a patient’s clinical indications require earlier treatment.
If a patient’s clinical indications require the allocation of an alternative category to the usual urgency category listed in the guideline the treating surgeon should follow the escalation principles outlined in their respective State or Territory elective surgery policy.
Where multiple procedures are being performed, urgency category should be allocated to the primary procedure.
Patients with a malignant condition are usually considered to require treatment within 30 days (category 1).
The National Guideline does not attempt to cover every surgical procedure.
The National Guideline does not overrule State or Territory policies or directives and should be used and interpreted in conjunction with any such policies and directives.
Treat in turn principle is to be applied when booking elective surgery patients.
That is, patients are treated in accordance with their urgency category
Summary
As of 4.1.22, surgeons are expected to follow the guidelines indicated above. Failure to adhere to them is termed an offence.
The operation subtypes indicated above do not refer to the clinical level of disease severity or an individual patient's risk requiring surgery. It is up to the surgeon to identify the reasons for performing surgery based on their assessment of risk. Surgeons are encouraged to discuss cases with their peers to confirm if their assessment is acceptable.
It is likely that these standards are going to be maintained until a fall in Covid numbers occurs to a level acceptable to theCommissioner of Police and the Chief Medical Officer. Whilst predictions of the duration of the current outbreak are difficult to ascertain with confidence, at least 6 weeks would be a reasonable period. Thus, if a surgeon felt that delay in surgery for that period would pose an unacceptable health risk to their patient, they may stratify their surgical planning accordingly.
Yours sincerely
Guy Rees MBBS FRCS FRACS MSurgEd
Chair SA Executive
Dear NSW Members,
A/Prof Payal Mukherjee as Chair of RACS NSW released the Update from the RACS NSW State Committee message on 7 January 2022.
We are sure that many of you are receiving multiple emails from hospitals with differing advice.
Payal confirmed that ASOHNS NSW members should importantly note that day surgery will continue at this time, subject to workforce availability, as this will impact much of ENT surgery:
“Day surgery cases will continue on the proviso that this does not take away workforce from critical services.”
Please contact ASOHNS should you have any concerns.
Dear Colleagues,
In response to multiple questions arising from the advice dated 15 September 2021 and the associated DHHS guidelines, further guidance is provided below:
When considering how to apply these to your own clinical practice, there are two issues:
- The risk of you and your staff being infected AND
- The risk of your staff being furloughed if exposed, whether they then get infected or not, and the resulting impact on delivery of clinical care.
Given we all work in multiple and different settings, it is not possible to provide individualised advice. However, I would encourage you to be conservative in your interpretation of these guidelines.
- Assuming an indoor consulting facility, reduce accompanying family member numbers to a minimum, keeping patients outside your rooms/in their cars until the last minute and minimising shared time in the waiting room for different patients are all important measures. If a positive case is at your rooms with these measures in place, and staff are using appropriate PPE, there may only be the need for one patient either side of their visit to isolate (or none if there are gaps between patients).
- Transient versus prolonged contact does not have an easily located definition. To be conservative, it would be reasonable to assume that given that nasendoscopy is an AGP, all these should be done wearing a fit-tested N95, eye protection, and gown/gloves. ICU/ED staff have been wearing one N95 for a shift rather than changing between patients, so it would be reasonable to follow that practice, with appropriate donning and doffing processes. Given we routinely remove patient masks for examination, wearing a N95 for all nasal/oral cavity examinations seems prudent in minimising the risk of being told to furlough, although current clinical guidelines would suggest a standard surgical mask and goggles/gloves provide adequate infection prevention (to my understanding). For patient consultations of any duration, which do not involve upper airway examination, it would be prudent to wear a surgical mask and eye protection at a minimum.
- For Reception/Administration staff: assuming they would be near your waiting room and likely with shared air circulation between indoor spaces, it would be prudent to have them wear eye protection and a surgical mask when in areas of patient contact.
- Break rooms and tea rooms are high risk environments when masks and defences come down. Consider alternative arrangements for your staff.
- Have your staff vaccinated will reduce their likelihood of catching Covid and is a consideration in the Chief Health Officer’s recommendation to furlough an individual staff member or not. However, vaccination status does not replace use of PPE as outlined in this document.
- Effective ventilation within your rooms will possibly reduce your chance of being infected. However, this is not currently a factor in decisions around furloughing. There is no current public health advice about ventilation requirements etc, although this may develop over the next year.
- Mask exemptions - As per the communication (4 August 2021) ASOHNS strongly encourages members not to supply certificates for mask exemptions as there are no OHNS conditions which would fit the criteria. Any requests for certificates should be declined as this is inappropriate
- ASOHNS strongly recommends that members do not certify that patients should have Pfizer over Astra Zeneca as this is not within the expertise of an OHNS surgeon.
Kind regards,
Deborah Amott
Chair, Victorian Section
Dear Colleagues,
As you are aware, there have been multiple Victorian health care services who have had to furlough staff recently due to exposures. One of our Victorian ENT colleagues has unfortunately been directly affected in his rooms, but due to the use of appropriate PPE, has been able to continue working without having to furlough.
Please implement the appropriate measures outlined in the DHHS guidelines (see link below) in your private rooms to ensure you protect your staff, yourself, and your ability to continue to provide clinical care. The other recommendation that our colleague has made, is to photo-document your measures in case of an exposure event, to ensure that you will be able to continue working with minimal disruption.
As per previous recommendations from ASOHNS, we encourage you and your staff to be vaccinated, and to follow the relevant public health guidelines.
Kind regards,
Deborah Amott
Chair, Victorian Section
Healthcare worker furlough guidance COVID-19 health service response Version 1.2
COVID -19: The Delta strain Update and Implications for ORL Practice in Australia
presentation by:
Dr Aydin Mohammadi
Registrar ORL Head and Neck Surgery
Westmead Hospital
ASOHNS - NEW SOUTH WALES SECTION
GUIDELINES FOR CLINICAL URGENCY CATEGORISATION 23 AUGUST 2021
These guidelines have been prepared for members of ASOHNS to utilise as a reference point following the release of new Health Orders in New South Wales to cease non-urgent elective surgery, and “special conditions during the COVID-19 pandemic” for Surgical Class private health facilities dated 19 August 2021.
The current Health Orders state that the listed Critical Operator Facilities must cease all non- urgent elective surgery from August 23, 2021.
Category 1 and Urgent Category 2 surgery may continue.
Category 2 operations are considered urgent “if the patient’s clinical condition indicates that an emergency admission may eventuate if the condition is not treated within 30 days”
The selection of patients to undergo surgery will ultimately be a clinical one. ASOHNS encourages members to review case details with peers should there be any uncertainty on whether to proceed with surgery.
NOTE: To ensure compliance with the Health Orders, it is very important that Category 2 standard cases are not available to be performed unless there are exceptional circumstances.
Category 1
- Surgeries for assessment or treatment of any form of malignancy or suspected malignancy (whether ear, nose, throat or salivary / thyroid)
- Acute fractured nose
- Surgery for acute or severe otologic or rhinologic infections or neck abscess
- Foreign bodies
- Tracheostomy
- Cochlear implant - patients with meningitis for whom there is concern of progressing cochlear ossification
Category 2 Urgent
- Adenotonsillectomy for moderate to severe obstructive sleep apnoea
- Operation for CSOM / cholesteatoma with complication (e.g. non-resolving chronic infection or bleeding), or in patients with immunocompromise e.g. non-resolving infection
- Grommets in children with protracted hearing loss and speech delay
Standard Category 2 (may be considered urgent in exceptional circumstances, assess on a case-by-case basis)
- Cholesteatoma surgery in a child with hearing loss
- FESS for severe sinusitis
- Grommets for recurrent ear infection
- Mastoidectomy for CSOM/ cholesteatoma, without complication (as above)
- Surgery for OSA / SDB. (e.g. septo/turbs/UPPP)
- Tonsillectomy where tonsillitis is particularly disruptive
- Adenotonsillectomy / Adenoidectomy for mild obstructive sleep apnoea / sleep disordered breathing
- Thyroid parotid and submandibular surgery for non-malignant pathology
- Cochlear implant (refer to CI surgical waiting list table below)
Category 3
- Rhinoplasty
- Septoplasty /turbinates for simple nasal obstruction
- Tonsillectomy for standard recurrent tonsillitis
- Routine FESS
- Myringoplasty
- Otoplasty
- Exostosis surgery
- Stapedectomy
References
NSW Health Advice for Referring and Treating Doctors Appendix 2: Reference List – Clinical Priority Categories Feb 2012
National Elective Surgery Urgency Categorisation Guideline April 2015. Australian Health Minister’s Advisory Council
Section 12A Private Health Facilities Act 2007 Special Conditions during the COVID-19 Pandemic
Disclaimer
The Australian Society of Otolaryngology Head and Neck Surgery has developed this information as guidance for its members. This is based on information available at the time of writing and the Society recognises that the situation is evolving rapidly, so recommendations may change. The guidance included in this document does not replace regular standards of care, nor do they replace the application of clinical judgement to each individual presentation, nor variations due to jurisdiction or facility type.
The Australian Society of Otolaryngology Head and Neck Surgery Limited is not liable for the accuracy or completeness of the information in this document. The information in this document cannot replace professional advice.
Cochlear Implant – Surgical Waiting List Categories
The following table outlines the suggested categories for Cochlear Implant surgery associated with Categories 1, 2 and 3.
All aspects of a patient’s background will be considered before deciding upon the category for that person.
|
CATEGORY 1
[within 30 days]
|
CATEGORY 2A
[within 90 days]
|
CATEGORY 2B
[within 90 days]
|
CATEGORY 3A
[within 365 days]
|
CATEGORY 3B
|
|
Patients with meningitis for whom there is evidence of progressing cochlear ossification
|
Children aged
<5yrs for unilateral or simultaneous bilateral implantation
|
Children aged 5- 20yrs with bilateral hearing loss
|
Adults with a significant bilateral hearing loss who rely on hearing for communication
|
Adults with stable hearing for 2nd side CI
|
|
|
Children of any age with recent deterioration in hearing
|
Adults with progressive deterioration in hearing and better ear phoneme score
≤ 55%
|
Children aged 5- 20yrs for 2nd side implantation
|
Adults not relying on hearing for communication
|
|
|
Adults with sudden loss of all useful hearing or risk to vocation
|
Children aged
<5yrs for 2nd side implantation
|
Children aged ≤ 20yrs with unilateral hearing loss
|
Adults with unilateral hearing loss
|
|
|
Children and adults requiring re-implantation
|
|
|
|
The national COVID-19 pandemic continues to impact many of our colleagues, especially those in New South Wales. These are difficult times, but we will get through this together.
ASOHNS’ COVID working group met on Saturday 31 July 2021 to consider recommendations for all members, as it has been some time since the last guidelines were released, and circumstances have changed.
Availability of PPE and vaccination have changed the focus of concerns. The new strains of the virus and limited vaccination still require us to be vigilant in all that we do. We understand from the Australian Society of Anaesthetists that an anaesthetist contracted COVID-19 while attending patients at Liverpool and Campbelltown Hospitals.
State, Territory and Local Health District guidelines should be followed in relation to surgery. In addition, there are more guidelines available relating to surgery and vaccination which have been included at the end of this document.
Hospitals in local government areas with community transmission should be increasing workplace protections through testing and screening patients prior to surgery as well as providing appropriate PPE.
The Commonwealth’s Infection Control Expert Group has recognised that COVID is transmitted via aerosols, recommending the provision of N95s masks and fit-testing to be provided to frontline healthcare workers.
ELECTIVE SURGERY IN NEW SOUTH WALES
There will be a temporary postponement of Category 3 elective surgery in public hospitals in Greater Sydney excluding Illawarra, Shoalhaven and Central Coast Local Health Districts effective from 2 August 2021. We understand that this is largely due to the impact of quarantine on hospital staffing levels. The private hospital system is not currently affected, and the State government has committed funds to catch up on elective surgery once this suspension is lifted.
NSW Health recommends the following guidelines for surgery bookings:
- Clinical priority category 1 - Patients booked for urgent surgery should continue as planned.
- Clinical priority category 2 - Patients booked for semi- urgent surgery should be clinically reviewed and postponed if it is safe to do so.
- Clinical priority category 3 - Patients booked for non-urgent surgery must be postponed.
RECOMMENDATIONS
ASOHNS Recommendations below as of 31 July 2021 have been prepared to support members in their practices. Current Workplace Health and Safety guidelines should also be reviewed and implemented.
ASOHNS strongly encourages members not to supply certificates for mask exemptions as there are no OHNS conditions which would fit the criteria. Any requests for certificates should be declined as this is inappropriate, not legal, and may lead to an AHPRA investigation.
ASOHNS strongly recommends that members do not certify that patients should have Pfizer over Astra Zeneca as this is not within the expertise of an OHNS surgeon.
ASOHNS makes the following recommendations.
1. All members and trainees should be fully vaccinated
2. Staff working in your private rooms should be strongly advised to get vaccinated; remind them that they need to protect not only themselves but also patients coming to the rooms
3. Encourage all colleagues in hospitals, anaesthetists, operating room nurses and registrars to be vaccinated
4. Stringent rules around patients coming to your rooms, including:
-
- Patients and staff advised not to attend if they have any symptoms
- Practice good hygiene
- Face masks to be worn by all staff and patients
- Temperature checks conducted
- Only the patient and one essential carer should come to rooms
- Number of people in waiting area limited to one person per 2 square metres and practice physical distancing
- QR code check-in and check-out compulsory
- Screening questions for patients before their appointment e.g. symptoms, awaiting result of a test, visited restricted areas, household member undergoing testing
5. Wear standard PPE when with patients
6. Supply masks and face shields to front desk staff
7. Hand sanitiser on entry to premises
8. Adequate cleaning of premises
9. Remove toys, books, magazines and unnecessary pamphlets from waiting areas
10.Signage displays for patient awareness of COVID measures
Should you wish to seek advice in a specific area for your practice, please send your questions via email to info@asohns.org.au and the COVID working group will consider whether it is able to advise, or whether there are other resources which are relevant.
Additional Resources / Guidelines
Clinical update regarding TTS, COVID immunisations and vaccines, adverse events of special interest following vaccination - 30 July 202
Highlights and updates:
- Pregnant women are now immediately eligible and prioritised for Comirnaty (Pfizer) vaccine – 23 July - here
- ATAGI statement: response to NSW COVID-19 outbreak – 24 July - here
- ATAGI weekly COVID-19 update – 30 July - here
- COVID-19 vaccine clinical consideration updates - here
- National Centre for Immunisation Research and Surveillance (NCIRS) - AusVaxSafety COVID-19 vaccine safety surveillance weekly report - 25 July - here & COVID-19 vaccination – summary for immunisation providers - here
TTS diagnosis and management key resources:
- THANZ advisory statement for haematologists for suspected TTS – updated 29 June - here
- Primary care guidance on the approach to suspected thrombosis with thrombocytopaenia syndrome (TTS) – published 13 July – here
- The Thrombosis & Haemostasis Society of Australia and New Zealand (THANZ) vaccine-induced thrombosis with thrombocytopaenia multidisciplinary guideline –7 July - here & THANZ specialist testing request form - 17 June 2021 - here
- The Australasian College of Emergency Medicine (ACEM) guidelines – June v2 - here
- Information on informed consent and a discussion tool for weighing up the risks and benefits of COVID-19 AstraZeneca vaccine - 30 June - here
Administering COVID-19 vaccines before or after anaesthesia or surgery – here
General principles for the timing of vaccine administration in relation to surgery, as set out in the Australian Immunisation Handbook, also apply to COVID-19 vaccines.
If elective surgery and anaesthesia are to be postponed after vaccination, some guidelines recommend waiting for 1 week after receiving an inactive vaccine and for 3 weeks after receiving a live attenuated viral vaccine in children. Defer routine vaccines for 1 week after surgery.2
Recent or imminent surgery is not a contraindication to vaccination; however, it is recommended to schedule COVID-19 vaccination more than one week before or after surgery. This will reduce the chance that adverse events following the vaccination, such as fever, are attributed as a complication of surgery, such as a surgical wound infection.
If you suspect possible TTS in the 42 days after vaccination (e.g. thrombocytopenia on pre-operative screening bloods), you should perform investigations for TTS. You should defer surgery until TTS is ruled out, or if TTS is confirmed, until full recovery.
Co-administration of COVID-19 vaccines and other vaccines – here
ATAGI does not recommend routine co-administration of COVID-19 vaccines with other vaccines. The preferred minimum interval between COVID-19 vaccine and other vaccines (including influenza) is 7 days. Shorter intervals may be appropriate (e.g. COVID-19 outbreak and tetanus-prone wound, or where there are logistical issues with scheduling the 7-day interval).
This means that a person may be able to receive another vaccine between their two doses of COVID-19 vaccine. Vaccination should be deferred if the recipient is acutely unwell. Co- or near administration of 2 or more vaccines can lead to higher frequency of mild to moderate adverse events.
Dose 2 vaccination interval for COVID-19 AstraZeneca vaccine - here
On 13 July, ATAGI released advice regarding the second dose interval for COVID-19 AstraZeneca vaccination in the context of the current outbreak of COVID-19 Delta (B.1.617.2) variant. While the recommended interval between the first and second doses of COVID-19 AstraZeneca vaccine is between 4 and 12 weeks, in outbreak situations an interval of between 4 and 8 weeks is preferred. ATAGI has previously issued advice recommending a shorter interval between the first and second doses of COVID-19 AstraZeneca vaccine of 4-8 weeks in an outbreak (versus the routine 12 week interval) so that maximal protection against COVID-19 can be achieved earlier.
ATAGI also reinforces that the interval between the first and second doses of Comirnaty (Pfizer) is 3-6 weeks, providing flexibility in managing available supplies of vaccines, whilst also noting two doses are required for optimal protection. Spacing Comirnaty (Pfizer) to a routine interval of 6 weeks would allow limited vaccine supplies to be redirected to obtain first dose protection in outbreak areas of greatest need.
The protection of vaccines against infection and hospitalisation with the recently emerging Delta variant have been studied internationally. A single dose of COVID-19 AstraZeneca vaccine reduces the risk of symptomatic infection by around 30% (95% CI: 24%, 35%) and hospitalisation by 71% (95% CI: 51, 83%). Two doses of COVID-19 AstraZeneca vaccine reduces the risk of symptomatic infection even further, by 67% (95% CI: 61%, 72%), and the risk of hospitalisation by 92% (95% CI: 75, 97%).
Second dose COVID-19 AstraZeneca vaccine in the setting of a precautionary condition - here
People with a history of specified precautionary conditions (CVST, HIT, splanchnic vein thrombosis, or antiphospholipid syndrome with thrombosis and/or miscarriage), or people who are diagnosed with a precautionary condition post-dose one, who have received a first dose of the COVID-19 AstraZeneca vaccine are recommended to receive an alternative vaccine (currently Comirnaty (Pfizer)) as their second dose. In these instances, Comirnaty should be given at a period of 4-12 weeks following dose one of AstraZeneca.
TGA weekly safety report – 29 July - here
Other resources:
Clinical guidance on use of COVID-19 vaccine in Australia in 2021 (v5.1) – 17 June – here
Disclaimer
The Australian Society of Otolaryngology Head and Neck Surgery has developed this information as guidance for its members. This is based on information available at the time of writing and the Society recognises that the situation is evolving rapidly, so recommendations may change. The guidance included in this document does not replace regular standards of care, nor do they replace the application of clinical judgement to each individual presentation, nor variations due to jurisdiction or facility type.
The Australian Society of Otolaryngology Head and Neck Surgery Limited is not liable for the accuracy or completeness of the information in this document. The information in this document cannot replace professional advice.
SA Health has released a directive relevant to us as medical specialists as to how to conduct your medical practices in a Covid Safe environment as of the 1st December 2020. Some of you would have already read the letter sent from RACS SA Regional Office as to what we need to do. Here is the formal attachment.
https://www.surgeons.org/-/media/Project/RACS/surgeons-org/files/racs-offices/south-australia/EMA-Public-Activities-Act-No-14-30Nov.pdf?rev=f4d216b1416844b49f87a58a24beae24&hash=AE978D7DF923092BF61E301EB6ECD6EE
If you have not read it , I would encourage you to read it and come to your own conclusion as to what needs to be done for your medical practice.
To keep it simple, I have done the following for my practice:
1. Go to the link I provided below and click on the tab that requires you to register the practice address and hence acquire the QR code for that address. Those who have multiple sites would need separate QR code for each address and I guess take it with you when you go there.
https://www.covid-19.sa.gov.au/business-and-work/create-a-covid-safe-plan
2. For patients without mobile phone or those who come in with other siblings / relatives (and for reason cannot be scanned for QR code) you can record them in your electronic schedule appointment time (that is provided your system allows it), otherwise you need to catalog somehow everyone literally who steps into your office in other ways. Please ensure you can retrieve the data.
On a happier note, I am sure you would all like to accompany me in congratulating Associate Professor Alkis Psaltis, University of Adelaide to Professor Alkis Psaltis, University of Adelaide.
Yours sincerely,
Dr John Ling
ASOHNS SA Section Chair
10 August 2020
The ASOHNS’ COVID-19 Working Group has reviewed and supports the new guidelines issued by the Infection Control Expert Group on 6 August titled “COVID-19 Guidance on the use of personal protective equipment by health care workers in areas with significant community transmission”.
These guidelines can be viewed online – click here
The guidelines support increased protection given the current situation in Victoria and can be implemented in any location where there is significant community transmission.
We encourage health care institutions and workplaces to provide a reliable supply of appropriate PPE to clinicians to perform their duties safely.
Further, ASOHNS recommends that where P2 / N95s are not available for aerosol-generating procedures, and deferral of care does not pose an unacceptable risk of harm to a patient, we support our members deferring procedures until the risk of inadvertent exposure is considered at an acceptable level for that clinician, or until appropriate PPE is provided.
RACS communicated to Victorian fellows on Friday 7 August. A copy is included below as it will be relevant for us all to consider for our patients.
We are hopeful that the steps taken in Victoria to reduce community transmission will protect our colleagues.
For members and trainees in Victoria, please know that you are in our thoughts and if we can support you in any way, please let me know.
I am attending a meeting on Thursday 13 August with RACS and Dr Nick Coatsworth, Deputy Chief Medical Officer, and will keep you informed on any changes to guidelines following that meeting,
Kind regards,
Suren Krishnan OAM FRACS
ASOHNS President
Guidance on delay to elective surgery post recovery from SARS-CoV-2 infection (issued on 5 August 2020)
Dear colleagues,
We are pleased to share guidance for elective procedures post COVID. This was agreed to at the Victorian meeting of College state chairs and presidents last week. It provides good guidance for all our members in a rapidly developing field.
Background
The severity and duration of SARS-CoV-2 infection is variable between individuals. There is increasing evidence of an incidence of post infection impairment despite significant gaps in our understanding as to how long the respiratory (1), cardiovascular (2) and other systems may be affected. It appears that infection (communicability) recovery is much quicker than physiologic recovery.
Available evidence suggests patients who had SARS-CoV-2 infection diagnosed within seven days before or up to 30 days after surgery are at significant risk of post-operative complications including increased morbidity and mortality.(3)
There are insufficient additional data to provide universal recommendations on the optimum timing of necessary, planned surgery following recovery from active infection with SARS-CoV-2. Therefore, a cautious approach is recommended. Decisions regarding surgical timing will require careful consideration of the possible sequelae of the infection, the urgency of the required surgery and the expected physiological impact on the patient.
Guidelines
A minimum of eight weeks of being symptom free prior to undergoing all but minor elective surgical procedures is recommended.
Patients should have a formal clinical review prior to surgery that particularly addresses the state of the cardiac and respiratory systems. This is recommended for all patients post known SARS-CoV-2 infection and is especially important in those who have any persisting
Not ready for care?
If, on careful consideration of the nature and severity of any persisting problems, delay is considered the safer course of action for an individual patient, we recommend treatment is delayed until the balance of risks and benefits are more in the patient’s favour, even for a Category 1 (within 30 days) case.
This guidance will be updated when more evidence of the longer term’s effects of infection with SARS-CoV-2 is available.
References
1. Zhao Y, Shang Y, Song W, Li Q, Xie H, Xu Q, et al. Follow-up study of the pulmonary function and related physiological characteristics of COVID-19 survivors three months after recovery. EClinicalMedicine. 2020 Jul;100463.
2. Puntmann VO, Carerj ML, Wieters I, Fahim M, Arendt C, Hoffmann J, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol [Internet]. 2020 Jul 27 [cited 2020 Aug 3]; Available from: https://jamanetwork.com/journals/jamacardiology/fullarticle/2768916
3. Nepogodiev D, Bhangu A, Glasbey JC, Li E, Omar OM, Simoes JF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet. 2020 Jul;396(10243):27–38.
Kind regards
Dr Tony Sparnon Mr Matthew Hadfield
President Chair, Victorian State Committee
Disclaimer
The Australian Society of Otolaryngology Head and Neck Surgery has developed this information as guidance for its members. This is based on information available at the time of writing and the Society recognises that the situation is evolving rapidly, so recommendations may change. The guidance included in this document does not replace regular standards of care, nor do they replace the application of clinical judgement to each individual presentation, nor variations due to jurisdiction or facility type.
The Australian Society of Otolaryngology Head and Neck Surgery Limited is not liable for the accuracy or completeness of the information in this document. The information in this document cannot replace professional advice.
21 August 2020
Due to the evolving nature of the pandemic, we have added links below for current COVID-19 resources for members and trainees:
- RACS email sent on Wednesday 18 August 2020 - Click here
- International Registry of Otolaryngologists - Head and Neck Surgeons with COVID-19 - Young Otolaryngologists - International Federation of Otolaryngologic Societies (YO-IFOS) - Click here
- Neurosurgery guideline - Click here
28 April 2020
This resource was developed arising from yesterday’s webinar with Dr Coatsworth, hosted by RACS.
In the webinar, Dr Bridget Clancy identified an opportunity to help rural surgeons understand what their local prevalence is, by linking to resources with this information to add to the COVID-19 resources hub at RACS.
Australian state and territory health jurisdictions provide maps and charts of confirmed cases by locality classifications, whereas others provide tabulated data.
Summarised below is a list of resources which will be useful for surgeons to gauge their local regional prevalence of positive cases.
Queensland
New South Wales
Australian Capital Territory
Victoria
Tasmania
South Australia
Western Australia
Northern Territory
24 April 2020
ASOHNS GUIDELINES ADDRESSING THE COVID-19 PANDEMIC –
THE RE-INTRODUCTION OF ELECTIVE SURGERY
Please click here for PDF version
The Minister for Health, The Hon. Greg Hunt MP announced on Tuesday 21st April 2020, the easing of elective surgery restrictions imposed on the 26th of March 2020. The Australian Government, States and Territories, have made this decision after close consultation with peak surgical bodies and key stakeholders including The Australian Society of Otolaryngology, Head and Neck Surgery.
This decision is made recognising the effect on the lives and well-being of patients who have had their elective surgery deferred. The planned re-introduction of elective surgery is to be conducted in a staged and controlled process. It will balance the need to maintain capacity to treat COVID-19 patients with the need to increase the availability of elective surgery in a safe and equitable way, taking into account the well-being of patients and health care workers.
ASOHNS continues to monitor the daily progress of the pandemic and its impact on the community. In conjunction with the Royal Australasian College of Surgeons and with regular consultations with the office of the Chief Medical Officer, the Society reviews the evolving scientific information related to the virus and the threats it poses to patients, its members and trainees.
Alerted by the international experience with COVID-19, which has been grave with high incidence of disease and serious morbidity and mortality, the Australian Government introduced a range of restrictions and public health policy.
The rapid and effective response of the people of Australia to abide by rules of social distancing, hand and surface hygiene and quarantine when advised, has led to excellent levels of virus containment.
Public Health data shows that the prevalence of the SARS Covid-2 virus in the Australian community at present is about 6 per 100,000 of population. The advice from the office of the Chief Medical Officer suggests that these are very low levels and that using triage symptoms to assess patients will very accurately predict the ability to identify a patient with COVID-19 disease. The risk of a patient with no triage symptoms, subsequently developing COVID-19 positivity is estimated at 1 per 100,000.
However, the office of the Chief Medical Officer has acknowledged the concerns of surgeons, anaesthetists, theatre nurses and other hospital staff, and supports conducting a study into asymptomatic carriage of COVID-19 in elective surgery patients to further inform testing policy.
In lieu of this current low prevalence of disease the office of the Chief Medical Officer has recommended that there is no indication to conduct COVID-19 testing preoperatively in patients with no triage symptoms of COVID-19.
However, we recommend that all hospitals, day surgeries and practices should have established risk management procedures to identify any patients that have respiratory symptoms that may indicate COVID-19 such that surgery or procedures are deferred where possible and COVID-19 testing requested.
Personal protective equipment is a critical element of staff safety and the use of PPE should be in accordance with national guidelines. In summary these are:
- In asymptomatic patients standard universal precautions and a standard surgical mask worn well with careful donning and doffing techniques is sufficient for all procedures.
- Current evidence suggests that viral load in aerosol generating procedures is low and droplet precautions with standard surgical masks is sufficient.
- Patients with acute respiratory symptoms either fever > 38 degrees OR acute respiratory symptoms (eg. Cough, shortness of breath, sore throat)
- COVID-19 positive patients should have surgery deferred until they recover from COVID-19 disease.
- COVID-19 positive patients having aerosol generating procedures should have maximal PPEs, which include N95 masks and eye protection and PAPR where available and staff are trained and supervised in their use.
ASOHNS encourages members to consider either innovation or modification of techniques to minimise aerosol exposure. For example, advice from international experience is regularly provided including a 2 Microscope Drape method to reduce aerosolization in mastoid surgery from ENT UK.
https://www.entuk.org/sites/default/files/Safer%20FESS%20in%20the%20COVID%20Era%20for%20ENTUK%20.pdf
The Australian Government recognises that the selection of patients to undergo elective surgery will ultimately be a clinical one.
The following guiding principles have been recommended by the Australian Health Protection Principal Committee (AHPPC) and endorsed by National Cabinet:
- Procedures representing low risk, high value care as determined by specialist societies
- Selection of patients who are at low risk of post-operative deterioration
- Children whose procedures have exceeded clinical wait times
- Assisted reproduction
- Endoscopic procedures
- Screening programs
- Critical dental procedures.
We recommend you access guidelines produced by the Department of Health, including “Restoration of Elective Surgery” due for release on 23 April 2020.
The executive of ASOHNS agree with government that that the selection of patients to undergo elective surgery will ultimately be a clinical one. ASOHNS encourages members to understand disease prevalence in their region and be aware of and alert occurrence of new clusters of COVID-19 and incorporate public health messages into their clinical judgement and decision making.
ASOHNS, in response to enquiries from members, has widely consulted with the presidents and representatives of the various sub-specialty societies. These include the New Zealand Society of Otolaryngology, Head and Neck Surgery, the Australia & New Zealand Society of Paediatric Oto Rhino Laryngology, the Australasian Rhinologic Society, Australasian Academy of Facial Plastic Surgery and the Australia and New Zealand Head and Neck Cancer Society.
The following guidelines are provided as procedures considered to represent low risk and high value care:
PAEDIATRICS
Category 1
Urgent airways including foreign bodies
Malignancy
Bleeding not controlled with conservative treatment
Infection not responding to conservative treatment
Category 2
Chronic suppurative otitis media with complication /cholesteatoma
Tonsillectomy / Adenoidectomy for moderate-severe OSA
Middle Ear Ventilating Tubes +/_ adenoidectomy for protracted hearing loss
Cochlear implant - following meningitis or after failed implant
Parotid, Thyroid, other head and neck lumps
Category 3
Infective or Inflammatory Disease treatable by medication
e.g. Recurrent Acute Tonsillitis / Sinusitis / Allergic Rhinitis
OTOLOGY
Category 1
Malignancy involving Temporal Bone
Category 2
Chronic suppurative otitis media with complication /cholesteatoma
Middle Ear Ventilating Tubes for protracted hearing loss
Category 3
For patients over 18 category 3 cases would include
Surgery for implantable hearing assistive devices
RHINOLOGY (SINO-NASAL SURGERY)
Category 1
Paranasal sinus malignancy,
Examples:
- SCC/ adenocarcinoma/ adenoidcystic carcinoma
Inflammatory disease with complication or at high risk of complication.
Examples:
- Orbital abscess, brain abscess, mucoceles
- Trauma e.g. Fractured skull and CSF leak
- Fungal sinusitis in immunocompromised patient
Category 2
Sinus conditions that cause disability or could compromise the health of the patient if left for longer than 90 days;
Examples:
- Benign tumours of the paranasal sinuses e.g. Inverting papilloma/JNA
- Unilateral disease with suspicion of malignancy
- Sphenoid sinusitis
- Inflammatory disease-causing disabling pain or discomfort and/or compromising overall health and wellbeing of a patient
Examples:
- Facial pain requiring regular potent analgesia
- Severe sinusitis in brittle asthmatic
- Nasal obstruction in patient OSA and unable to use CPAP
- Functional rhinoplasty to facilitate use of CPAP in patient with OSA
Category 3
For patients over 18 category 3 cases would include
Long standing Septal deviation
Turbinate surgery
Surgery for recurrent acute sinusitis without complications.
Cosmetic rhinoplasty
LARYNGOLOGY, HEAD & NECK SURGERY
Category 1
Endoscopy for suspected malignancy
Surgery for Malignancy of the Upper Aero Digestive Tract
Airway obstruction
Bleeding from Head and Neck lesion
Infective/ Inflammatory diseases requiring surgical drainage
Category 2
Surgery for benign Head and Neck Lesions
e.g. Parotidectomy / Thyroidectomy / Removal of benign lesions
Category 3
Procedures of a cosmetic nature
e.g. Revision of scar, Cosmetic rehabilitation of facial palsy
These guidelines will be regularly reviewed and will be subject to change depending on the COVID-19 disease prevalence, the impact on health and safety of members and the impact on health facilities having to deliver elective surgery and maintain public health measures such as social distancing and hand and surface hygiene.
This first stage of reinstating elective surgeries will require health administrators to monitor supplies of personal protective equipment (PPE), ICU and bed capacity, while preparing for the next phase. To limit the volume of procedures performed, the government has asked that facilities cap operating lists volumes at 25 per cent of volume prior to 26 March 2020. Members are asked to liaise with their local health facilities.
The Australian, states and territory governments have put in place clear timeframes to monitor and review the situation. An overall review will be undertaken at two weeks and at four weeks based on:
- The number of positive cases, in both healthcare workers and patients, linked to increased activity
- PPE use and availability
- The volume of procedures and hospital/system capacity.
30 March 2020
Effective from 6 April 2020
All services provided using the MBS telehealth items must be bulk billed for Commonwealth concession card holders, children under 16 years of age, and patients who are more vulnerable to COVID-19.
For all other patients, bulk billing is at the discretion of the provider, so long as informed financial consent is obtained prior to the provision of the service.
More information on these items is available at: http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/Factsheet-TempBB.
These services are for non-admitted patients.
27 March 2020
COVID-19 for ENT Surgeons - Dr Nathan Creber - Click here or on image below
22 March 2020
Statement from ASOHNS dated 22 March 2020
please read all the way to the end.
This is in addition to the guidance from Friday 20 March,
ASOHNS GUIDELINES ADDRESSING THE COVID 19 PANDEMIC
PDF Version - Click here
The Australian Society of Otolaryngology, Head and Neck Surgery is aware of the serious threat and implications of the COVID 19 pandemic. The society continues to monitor the daily progress of the pandemic and its impact on the community.
The Society is regularly reviewing the evolving scientific information related to the virus and in particular, the threat it poses to its members and its trainees.
Today the executive, in conjunction with representatives from council and the chair of the board have constituted a COVID 19 Committee. This committee will comprise the President, the Vice President, the Immediate Past President, the Secretary and the CEO. This committee will meet regularly and respond to enquiries from members, represent the interests of the community at large and the interests of its members and its trainees. The committee will provide regular updates and guidelines and links to informative resources.
The international experience to date suggests that oto-rhino laryngologist, head and neck surgeons are among the most susceptible health professional group to the COVID 19 virus. There have been recent reports of one death and two ventilated members of the otolaryngology, head and neck surgical community in the United Kingdom. There have been reports of the dissemination of infection from a patient of unknown COVID 19 status to 14 members of an endoscopic skull-base surgical team in China. There are also reliable reports of multiple deaths in ENT surgeons in Italy, Iran and China.
These recent events have added to the information that the executive has had to consider. The following guidelines have been formulated with the interests of members and trainees, their families and their medical, nursing and allied health colleagues in their workplace, and patients in mind.
IMPLICATION FOR PATIENTS
Patients will only be provided with time-sensitive or emergent care
- This includes both office-based and surgical care
- The Society recognises that “time sensitivity” and “urgency” is determined by individual surgeons, recognising that surgeons need to be aware of the potential risks to both themselves and to their staff
- This judgment must always take into account each individual patient’s medical condition, social circumstances, and needs.
IMPLICATION FOR MEMBERS
It is imperative that members are aware that individual decisions made have potential risks to both themselves and their staff.
In Private Practice
- Delay all routine elective clinic visits
- Where possible use telephone and video consults and be familiar with criteria for specialist Medicare billing item numbers
- Use PPE and masks, particularly when performing endoscopy
- Delay elective and non-urgent admissions
- Delay inpatient and outpatient elective surgical and procedural cases
- When providing time-sensitive or emergent care undertake precautions such as using P2 N95 masks and adhering to anaesthetic standards advised by the ASA. Ensure that staff providing post-operative care undertake precautions
- Although not absolutely definitive, preoperative COVID 19 testing and knowledge of COVID 19 status may assist in surgical plan and post-operative care. In the absence of confirmed COVID 19 negative status (by 2 tests more than 24 hours apart), it should be assumed that patients are COVID 19 unknown and should be treated as though they are positive.
In Public hospital practice
- Undertake only Emergency and Urgent Category 1 cases, such as cancer, threatened airway and bleeding
- Delay all routine elective clinic visits
- Where possible use telephone and video consults
- Divide teams to minimise contact and risk of transmission of virus
- Although not absolutely definitive, preoperative COVID 19 testing and knowledge of COVID 19 status may assist in surgical plan and post-operative care
- It is important that members unite and work with the general population, medical community and regulatory agencies to minimize the risk of the COVID 19 virus transmission from human to human in order to limit the development of new cases.
- It is emphasised that this strategy provides the best chance to not overwhelm facilities with a limited supply of hospital beds, ICU beds, ventilators, and other critical supplies.
- Disposable medical supplies and protective equipment are scarce, where protection cannot be guaranteed, procedures must be avoided, as we must conserve these for use where they are needed most.
- Avoid congregation and ensure social distancing and the 1.5m rule
- All clinical and academic meetings should be conducted using electronic applications
IMPLICATIONS FOR TRAINEES
The COVID 19 pandemic will have significant implications to training. It will limit clinical experience in managing outpatients, ward inpatients and training in surgical skills.
At all times the safety and well-being of trainees is important. At all times ensure you are in a safe working environment. The guidelines provided by ASOHNS relating to COVID 19 also apply to trainees. Where there is a shortage of PPE, do not perform any upper airway examinations.
If you have any concerns about the safety of your working environment, please contact the SET Program Administrator, ASOHNS.
Evidence regarding COVID 19 as it relates to pregnancy is still being collected. We strongly recommend that pregnant trainees should not continue to work at this time.
Specific implications to training include:
- The possibility that competencies may not be met and that time spent in training may be increased.
- The possibility that new applications to the training program will not be considered for the year beginning 2021.
- The final fellowship examinations will be cancelled in May 2020 by RACS and a decision on the September 2020 fellowship examination will be made in June.
- Above all maintain self-safety utilising PPE when consulting and performing procedures
- Apply ENT UK tracheostomy guidelines
- Delay all non-urgent emergency hospital procedures
SUMMARY
These are surreal and challenging times for all. The Society will try to address issues as best we can pre-emptively. Necessarily, it will respond to the issues identified as this epidemic evolves. It will continue to represent the interest of its members and already has contacted state and federal jurisdictions as well as the office of the Chief Medical Officer.
Our current position is to recommend “Limiting all non-essential planned surgeries and procedures, until further notice” based on preservation of needed resources and the safety of patients and medical personnel.
Above all stay safe, practice social distancing, regular hand hygiene and the 1.5 m rule.
Let’s work together and support each other.
20 March 2020
PDF Version - click here
The information contained in this document is subject to change due to the rapidly changing environment. This guidance is intended to complement rather than replace existing advice. These are challenging times and we are concerned about the health and safety of members, trainees and patients.
Most importantly, protect yourself and prevent the spread through the practice of
- good hygiene (cover cough, wash hands, avoid touching your face)
- stay at home if you are sick,
- self-isolation, and
- social distancing and avoid shaking hands
Risk to healthcare workers through transmission of COVID-19 is primarily through droplet spread. Otolaryngologists are exposed to a high reservoir of viral load as we are dealing with the nose and airway. 1, 2, 3
There is reliable information coming from the US indicating that otolaryngology is a high-risk group from COVID-19 infection. There is anecdotal evidence that a single endoscopic case in China reportedly infected 14 people who were in the operating room. There is a presumed high risk in any procedures involving the airway. The current recommendation is to reconsider the need for non-urgent surgery in particular sinonasal, tonsils and oral cavity.
Current US advice is that pre-operative COVID-19 status should be prioritised for all procedures involving the upper and lower respiratory tract, and eventually all patients requiring endo tracheal intubation. In COVID-19 positive patients, endoscopic sinus cases should be conducted only with PAPR (Powered air-purifying respirator).
The Australian Society of Anaesthetists guidelines are supported and are very much aligned with procedures for ENT surgeons as they are experts in airway management. 4
National and local guidelines from the Department of Health and others should be adhered to. State and Territory guidelines as well as individual hospital advice will also be frequently updated. 5
RACS advice for all fellows, trainees and IMGs as at 18 March is available here:
https://mailchi.mp/surgeons/racs-covid19-update-326446?e=6f1443f171
ENT may not seem to be in the frontline with COVID-19 but we do have a key role to play, and this must be planned. All the data from China, Iran, Italy and most recently the UK suggests that ENT surgeons are an extremely high-risk group therefore we need to be vigilant to protect ourselves.Hospitals need to ensure ENT surgeons are supplied with the necessary PPE in order to avoid fatalities.
In response to pressures on the health system, elective surgery will be curtailed. Non-elective patients will continue to need care. We should seek the best local solutions to continue the proper management of these patients whilst protecting ourselves through proper supply of protective equipment. We understand that resources are under pressure for the response to COVID-19, however the experience overseas highlights the necessity for PPE for ENTs.
We will be involved in airway management. We may also need to work outside of our specific areas of training and expertise, in the exceptional circumstances we may face.
We need in particular to consider patients who are vulnerable to the consequences of catching COVID-19, including those with a tracheostomy or respiratory compromise and patients with immune suppression – such as patients with head and neck cancer – either during or soon after treatment.
There are multiple resources of information and we will need to make decisions based on our own personal circumstances within our practices, depending on the size of the rooms, waiting areas, staffing, etc. Signs on the door of your room and messages confirming appointments should communicate to patients who are feeling unwell to stay home and not attend their appointment. Telehealth options are available through the MBS for vulnerable / isolated patients.
Important recommendations:
- Avoid powered atomisation – use actuated pumps sprays or similar soaked pledgets for topical anaesthesia
- Elective airway surgery patients (sinonasal, nasopharyngeal, oropharyngeal, laryngeal and tracheal) should be tested for COVID-19, where and when available, and be shown to be negative before proceeding; for acute cases specific PPE should be utilised; patients should be advised to practice hand hygiene and social distancing prior to surgery
- Limit intervention in the clinic/rooms as much as possible and wear appropriate protection
- Postpone any COVID-19 positive cases, anyone with recent travel history, anyone with potential symptoms of COVID-19 or anyone with COVID-19 contacts
- Advice should be given to all COVID-19 negative patients undergoing elective surgery to practice social distancing and hand hygiene between the time of testing until the time of surgery.
Personal Protective Equipment (PPE)
We also need to protect ourselves and the appropriate use of personal protective equipment (PPE).
Any clinician assessing patients suspected or confirmed to be infected with COVID-19 should wear appropriate PPE. Training on the use of PPE is important to reduce the risk of transmission of COVID-19. Most hospitals are conducting PPE sessions, please attend.
The highest regime for PPE for negative COVID-19 tested patients would be a fluid resistant surgical mask, single-use impermeable disposable gown, gloves and eye protection if blood and or body fluid contamination to the eyes or face is anticipated. This applies to examinations including flexible and rigid nasendoscopy.
P2/N95 masks are recommended for COVID-19 positive patients / suspected positive patients requiring aerosol generating procedures – this includes intubation, open suctioning, tracheostomy, high speed drilling and bronchoscopy. Please also refer to guidance from your Local Health District and consult with your local infectious diseases team if in any doubt and note that guidance on this may change.
We have attempted and are continuing to attempt to gain selective access to PPE, but this is proving to be very difficult. We will continue to assist our members as much as possible.
Sterilisation of equipment practices are unchanged from standard procedures.
The following table outlines levels of precaution for different scenarios in the hospital environment:
| Patient Category |
Precautions |
Example |
| Community precautions |
Hand hygiene
Avoid hand shaking
Cough etiquette |
|
| Non-COVID-19 proven patients in theatre or in rooms |
Hand hygiene
Standard PPE |
Hat
Mask
Gloves |
| Routine care of COVID-19 patient |
Droplet precautions |
Inpermeable gown
P2/N95 mask
Disposable hat
Goggles
Gloves |
| Procedures in COVID-19 patient |
Airborne precautions |
P2/N95 mask
Disposable hat
Face shield
Gloves |
References:
1. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group, Med J Aust 16 March 2020, David J Brewster, Nicholas C Chrimes, Thy BT Do, Kirstin Fraser, Chris J Groombridge, Andy Higgs, Matthew J Humar, Timothy J Leeuwenburg, Steven McGloughlin, Fiona G Newman, Chris P Nickson, Adam Rehak, David Vokes and Jonathan J Gatward
https://www.mja.com.au/journal/2020/212/10/consensus-statement-safe-airway-society-principles-airway-management-and
2. ENT UK
https://www.entuk.org/advice-ent-examination-reduce-chances-droplet-spread-and-viral-transmission
3. American Academy of Otolaryngology Head and Neck Surgery
https://www.entnet.org/content/academy-supports-cms-offers-specific-nasal-policy
4. Australian Society of Anaesthetists (ASA)
The ASA has developed guidelines based on current evidence and may be subject to change as more information becomes available. They are intended for anaesthetists in Australia. For the latest version, please visit https://asa.org.au/covid-19-updates/
5. Department of Health information
Federal Government Department of Health
https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert?utm_source=health.gov.au&utm_medium=redirect&utm_campaign=digital_transformation&utm_content=health-topics/novel-coronavirus-2019-ncov
ACT COVID-19 Advice
https://www.health.act.gov.au/health-professionals/chief-health-officer-alerts
NSW COVID-19 Advice
https://www.health.nsw.gov.au/Infectious/diseases/Pages/coronavirus.aspx
NT COVID-19 Advice
https://health.nt.gov.au/health-alerts/novel-coronavirus-covid-19
QLD COVID-19 Advice
https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/novel-coronavirus-qld-clinicians
SA COVID-19 Advice
https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+topics/infectious+disease+control/novel+coronavirus+%282019-ncov%29+infection+for+health+professionals
TAS COVID-19 Advice
https://www.dhhs.tas.gov.au/publichealth/communicable_diseases_prevention_unit
VIC COVID-19 Advice
https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-coronavirus-disease-covid-19
WA COVID-19 Advice
https://ww2.health.wa.gov.au/Articles/A_E/Coronavirus
Disclaimer
The Australian Society of Otolaryngology Head and Neck Surgery has developed this information as guidance for its members. This is based on information available at the time of writing and the Society recognises that the situation is evolving rapidly, so recommendations may change. The guidance included in this document does not replace regular standards of care, nor do they replace the application of clinical judgement to each individual presentation, nor variations due to jurisdiction or facility type.
The Australian Society of Otolaryngology Head and Neck Surgery Limited is not liable for the accuracy or completeness of the information in this document. The information in this document cannot replace professional advice.