A “Forward Triage” Model in Telemedicine for Head and Neck Oncological Patients During the COVID-19 Era

Introduction

Coronavirus Disease 2019 (COVID-19) has profoundly impacted on health care system worldwide. Massive concentration of resources in the assistance of affected patients has led to an unprecedented need to differentiate an “urgent” from a “deferrable” clinical situation, through careful triage regulating patients’ access to medical services. ¹ In this perspective, head and neck oncological patients (HNOPs) represent a unique population and determining their clinical priority might be difficult, both for challenges related to their cancer treatments and immunological fragility. ²

In this scenario, Telemedicine ³ plays a key role in delivering virtual care for HNOPs reducing hospital access and thus Otolaryngological clinical procedures potentially conditioning viral transmission ⁴ ; moreover, COVID-19-positive health care providers, in quarantine, are able to distantly take care of patients ¹ ; lastly, overcrowding in medical centers as well as costs for antiseptic materials and personal protective equipment are both reduced. ^5,6

Among all the available information and communication technologies, ⁵ videoconference technology enables to have a distant observational assessment of patient’s condition.

Discussion

Head and neck oncological patients require a well-scheduled follow-up program after curative treatments, both on oncological disease monitoring and care management. Patients who previously received oncological radical surgery, unable to preserve organ function (eg, total laryngectomy, mandibulectomy, glossectomy, etc), face demanding individual problems about social isolation and psychological burden, swallowing disorders or dysphagia, stoma care and respiratory distress, neck mobility, and status of voice (in case of voice prosthesis holder).

In this context, telemedicine appears to be a reliable tool available to Otorhinolaryngologist, in order to distantly guarantee a proper surveillance. ^1,7 Thus, we propose a strategic model designed on 4 definite parameters, aimed rationally to evaluate patients who actually need a face-to-face medical examination rather than a virtual consultation (Figure 1).

Figure 1.

The “Forward Triage” model. The figure shows the “Forward Triage” model based on 4 well-defined parameters: surgical outcome, patient’s psychological attitude, oncological risk, and technological skills. The left part of the figure refers to criteria (at least one) which address to a face-to-face evaluation; the right one refers to criteria which encourage virtual consultation. HNOPs indicates head and neck oncological patients; ICTs, information and communication technologies.

In our daily clinical practice, we adhere to this model and multidisciplinary a team evaluate each week the eligibility criteria for each case. Once established that a given patient fits telemedicine criteria (Figure 1), we provide a video physical assessment, educating about stoma care, swallowing rehabilitation, or any other functional disorder. Speech barrier might be successfully overcome thanks to caregivers. Radiological surveillance is remotely performed, excluding any sign of disease persistence/recurrence and confirming the stationary oncological status.

Despite being a useful instrument, telemedicine presents some limitations. Virtual assistance is not accessible to all and the quality of video consultation isn’t comparable with face-to-face evaluation, although it seems not to significantly impact on clinical evaluation. ⁷ Moreover, patients’ satisfaction should be investigated through dedicated questionnaire, in order to reveal their personal perspective. We adhere to this practice as well, submitting dedicated questionnaire and demonstrating, as reported in previous studies, that oncological patients feel gratified. ⁸ Furthermore, a well-structured telehealth system requires an adequate financial support. Lastly, telemedicine does not substitute a conventional direct physical examination at all, so that an oncological surveillance must be directly performed, even though less frequently.

Whenever a patient is considered an ideal candidate according to our model, telehealth could really improve patient’s quality of life. The current pandemic represents an unprecedented scenario to promote a standardized use of telemedicine program and virtual health care.