key: cord-0777968-wxiran8c
authors: Hanrahan, John Gerrard; Burford, Charlotte; Adegboyega, Gideon; Nicolaides, Marios; Boyce, Louis; Wong, Kendra; Sideris, Michail
title: Early responses of neurosurgical practice to the COVID-19 pandemic: a rapid review.
date: 2020-06-26
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.06.167
sha: fb6419d3c7987bfba4f35684f60a3fb300fb0ed7
doc_id: 777968
cord_uid: wxiran8c

Abstract Introduction The novel coronavirus and subsequent pandemic have drastically transfigured healthcare delivery. Surgical specialties have seen severe alterations or reductions to practice, neurosurgery being one example where staff and resource reallocation has occurred to meet wider public health needs. This review summaries the published evidence detailing early experiences and changes to neurosurgical practice in response to the COVID-19 pandemic. Materials and methods A systematic review was conducted up until 21st April in accordance with PRISMA guidelines, searching Medline, EMBASE, Pubmed, Scopus, Cochrane Central and Web of Science Core Collection databases. Individual studies were qualitatively assessed to outline core themes detailing changes to practice. Iterative analysis allowed themes to be developed and applied to all studies included in the review. Results 13 themes from 18 studies were identified, grouped into three overriding themes: logistics, human resources and clinical delivery. Studies originated from three of the most affected countries (USA, China and Italy), comprising of expert opinions, letters to the editor, editorials, case reports or perspective pieces. The commonest themes discussed include cancellation of elective operations, reduction in outpatient services and pandemic rotas. Discussion This review summaries the early responses of the neurosurgical community to the COVID-19 pandemic and presents a menu of interventions to be considered in future pandemic response, or in recurrent outbreaks of COVID-19. Whilst our review is limited by the low quality of evidence and rapid rate of change in our understanding of COVID-19, it provides a valuable summary of initial responses by the neurosurgical community to a global pandemic.

The novel coronavirus and subsequent pandemic have drastically transfigured healthcare delivery. Surgical specialties have seen severe alterations or reductions to practice, neurosurgery being one example where staff and resource reallocation has occurred to meet wider public health needs. This review summaries the published evidence detailing early experiences and changes to neurosurgical practice in response to the COVID-19 pandemic.

A systematic review was conducted up until 21 st April in accordance with PRISMA guidelines, searching Medline, EMBASE, Pubmed, Scopus, Cochrane Central and Web of Science Core Collection databases.

Individual studies were qualitatively assessed to outline core themes detailing changes to practice. Iterative analysis allowed themes to be developed and applied to all studies included in the review.

13 themes from 18 studies were identified, grouped into three overriding themes: logistics, human resources and clinical delivery. Studies originated from three of the most affected countries (USA, China and Italy), comprising of expert opinions, letters to the editor, editorials, case reports or perspective pieces. The commonest themes discussed include cancellation of elective operations, reduction in outpatient services and pandemic rotas.

This review summaries the early responses of the neurosurgical community to the COVID-19 pandemic and presents a menu of interventions to be considered in future pandemic response, or in recurrent outbreaks of COVID-19. Whilst our review is limited by the low quality of evidence and rapid rate of change in our understanding of COVID-19, it provides a valuable summary of initial responses by the neurosurgical community to a global pandemic.

The emergence of the novel coronavirus-19 (COVID- 19) 1 and subsequent pandemic has seen the shape and delivery of healthcare rapidly change. A worldwide refocusing of health system priorities towards virus detection and response has triggered diversion of resources towards managing the growing burden of medical patients admitted to hospitals with respiratory compromise 2 .

The COVID-19 pandemic has substantially impacted health systems globally. In developed health systems providing specialised services for patients with complex conditions, urgent reallocation of resources has been required to meet wider public health needs. A classic example is neurosurgical care provision, which often require significant resources, such as multidisciplinary teams and intensive care settings. Such gravid changes in health needs require significant adaptations to service delivery and surgical practice.

We conducted a systematic review to summarise the published evidence outlining the early experiences and initial changes to neurosurgical practice in response to the COVID-19 pandemic.

A scoping review was performed to capture published evidence on early responses to the COVID-19 pandemic in neurosurgery, performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 3 The keyword is detailed in supplementary appendix 1.

Each study was assessed by two independent reviewers (JH/GA). The origin, design and subspecialty of each study was noted. Studies were assessed for themes outlining interventions or changes to practice enacted by neurosurgical departments conducted in response to the pandemic. Interventions conducted in response to the pandemic were extracted iteratively from each article, with the final compilation agreed upon by the authorship.

Each study was then re-analysed with the full compilation of interventions. Data were grouped to thematic axes; each axis represented an action or intervention or change to surgical practice.

We supplemented the search with policy statements and guidelines from international neurosurgical and surgical bodies providing guidance for service delivery during the pandemic.

Due to the heterogeneity in study design and reporting, quality assessment was performed via structured critical appraisal and synthesis of the data from three authors (JH/CB/MS). Results were accordingly incorporated in the discussion thematic axes.

We selected 18 studies 4-21 ( Figure 1 ). Table 1 * provides a summary of the origin, design and subspecialty of each study. The majority (N = 9, 50%) were published from the United States, jointly followed by China and Italy (N = 4, 22.2%) comprising of perspective pieces, editorials, expert opinions or letters to the editor. Therefore, a formal quality assessment was performed via critical appraisal of the included manuscripts. Half of the studies provided experiences from the general neurosurgery perspective, with others detailing subspecialty experiences and related recommendations, the most common being neuro-oncology (N = 4, 22.2%).

An array of 13 discrete thematic (intervention) axes were identified from critical synthesis of the literature ( Isolation of suspected/confirmed COVID cases 10 studies described measures to isolate suspected or confirmed COVID patients 7,10-12, [14] [15] [16] 18, 19, 21 , achieved most commonly through designated wards 7, 10, 11, 14, 19 and intensive care units to manage COVID patients 14, 16, 18 . Other studies described hospitals allocated to admit suspected COVID patients 12, 21 or to manage non-COVID neurosurgical cases 15 . Isolation often began before admission in non-emergency cases and emergencies were treated as suspected COVID 14, 21 . In some centres, confirmed COVID patients were separated from suspected COVID patients 10, 11 .

Intensive care unit (ICU) capacity Eight studies outlined interventions to optimise ICU capacity 4, 6, 9, 10, 14, 16, 18, 19 with most outlining a need to increase capacity 4, 9, 14, 16, 18 . Resources were reallocated from operating theatres 14 and previously designed neurological ICUs reallocated to manage COVID patients 16 . Expectation for paediatric resources to supplement the disproportionate disease burden in adults was also noted 4 . Postponement or cessation of elective operating, alongside post-operative recovery in alternative care settings was also initiated to preserve ICU capacity 9,18,19 .

Three studies all of Italian origin detailed a reorganisation of national neurosurgical networks to establish hub centres to deal with specific emergencies 13, 14, 17 .

Introducing pandemic rotas to restructure clinical teams has been proposed to reduce avoidable staff interaction, reducing viral exposure 7, 9, [19] [20] [21] [11] [12] [13] [14] [15] [16] [17] [18] . This was achieved by cohorting teams into separate, alternating groups 4, 7, [11] [12] [13] [14] 19 or encouraging non-essential workers, particularly in the administrative or research faculty, to work from home 15, 18 . However, some studies discussed the importance of maintaining essential research facilities such as long-term experiments, employing dual clinical and research staff to continue research duties. This was underpinned in another through the importance of ongoing clinical trials in their later stages 9 .

To maximise the capability of providers to manage the growing burden of medical admissions, neurosurgical staff were reallocated to other departments 13, 14, 16, 17, 20 . One hospital in Italy saw 75% of their team redistributed to medical teams at one point 14 , justified as a rationalization of resources 13 . This was mostly to support ward cover 13,14,16 but one study saw allocation of neurosurgeons to the emergency department 16 . In the same study, researchers refocused their efforts from neurosurgery to COVID-19 16 .

A number of studies acknowledged the global shortage of adequate PPE and thus the need to preserve them as much as possible [8] [9] [10] [11] 18, 19, 21 . Specific guidance on the level of PPE spanned from level 1 for suspected COVID patients which included surgical cap, surgical face mask, protective gown and gloves to level 3 for confirmed cases, which requires the addition of an N95 mask as well as a face shield and full-face piece respirator 10, 21 . A particular concern on the rate of false negatives was the focus of two studies, urging staff to consider PPE especially in presumed COVID-negative cases 8, 19 .

Most studies discussed cancellation of elective surgeries as a priority 4, 5, [16] [17] [18] [19] [20] [21] 6, 8, 9, [11] [12] [13] [14] [15] . This was due to the growing wider public health needs compared to elective surgical care 4, 9, 17, 20 . Others highlighted the added risk to patients during the pandemic 6,19-21 . However, one study criticised the dichotomy of emergency and elective care in decision making, due to the anticipatory harms of delay in those with presently stable disease 4 . Two studies raised the higher risk of transmission to clinicians from surgery 8, 11 . One study highlighted the future need for increased capacity following the pandemic to meet the back-log of delayed elective surgical cases 20 .

Several alterations to outpatient care were detailed, with most studies describing a reduction in outpatient services 4, 6, 18, 20, 8, 9, 11, [13] [14] [15] [16] [17] . Most studies only allowed urgent or emergency appointments 4, 6, 8, 13, 14, [16] [17] [18] , some with triaging or screening systems in place 9,11,18 . Burke et al. scaled provision of clinics depending on pandemic severity 15 . Reductions in services were often compensated with telemedicine alternatives 9, 15, 16, 18, 20 . Disinfections strategies for outpatient departments and patient education on PPE were also implemented 11 , and changes to practice including administration of medications and use of certain procedures were curtailed 8 . However, closer outpatient monitoring of potentially aggressive low-grade gliomas was described as an alternative to standard surgical care 9 .

The responsibility of physicians to educate their patients during this time has been highlighted by the literature.

Mohile and colleagues detailed the need to underpin the importance of handwashing and social distancing measures during patient contact hours 6 . Also, emphasis was placed on communication of potential added vulnerability of certain neurosurgical patients 6, 9 .

Several studies limited visitors 4, 8, 9, 16, 18 , some prohibiting them entirely 4 

Reducing personnel within an operation theatre was a common strategy to reduce viral exposure 4, 9, 10, 15, 21 , with specific reference to endonasal interventions 4, 8, 9, 12 . Five studies suggested the use of negative pressure operating theatres to contain airborne pathogens and prevent cross-contamination 10, 12, 16, 19, 21 . Advocation of alternatives to surgery, such as radiosurgery or conservative observation through imaging were put forward 5, 9 . Intraprocedural antifogging agent for eye protection 21 as well as the use of double gloves 10 were pointed out by two different studies to ensure accuracy and safety during interventions. Reduced drilling speed was proposed to minimise bone aerosol exposure 10 in addition to the renunciation of non-essential intraoperative neuromonitoring 9 .

Unnecessary patient interaction was decreased by the use of dissolvable sutures and discharge planning to home rather than care settings 9,18 .

Telemedicine was discussed as a solution to reducing social contact to mitigate viral exposure 4, 6, 11, 15, 16, 18, 20 .

Video conference sites such as Zoom, Skype and WeChat have all been put forward as a possible means of secure telehealth platforms for clinical visits and follow-up 4, 11 . Criticisms included socioeconomic barriers posed by this switch, including language barriers, low technical literacy or little to no internet access 4,6 .

Strict intubation directives aimed to minimise clinician exposure to patient aerosols 4, 9, 11, 19, 20 . Prophylactic as opposed to intraprocedural intubation was favoured in most of the literature, with minimal staff present during the procedure 4, 9, 19, 20 . Mandatory 30-minute delay between intubation and entrance of other operating room staff was trialled by two studies to reduce viral particulate exposure 4, 20 .

This systematic review summarises the early published responses of neurosurgical departments to the COVID-19 pandemic. It provides a menu of interventions developed and implemented to reduce the spread and impact of the virus. These early experiences provide insights into the initial pandemic responses from healthcare systems globally, highlighting the common themes in neurosurgical responses during a pandemic. Identifying core themes provides insights to inform responses to future pandemics, or indeed, provide additional considerations in the short term for recurrent outbreaks of COVID-19. 

The identified interventions in our review can be grouped into wider over-riding themes: logistics, human resources and clinical delivery.

Isolating suspected and confirmed cases 7,10,11,14,19 required organisational restructuring of hospitals. This requires judicious infection control practices or division of the multidisciplinary team. With more specialised team members, such as the surgeon or anaesthetist, complete team division may be difficult in resource-limited settings, likely exacerbated by staff redeployment. Such cross-coverage may risk contamination of non-COVID wards. Others designated hospitals for COVID and non-COVID patients 12, 21 , which may be more effective in preventing contamination but requires a greater pool of resources. This was seen in Italy, where cooperation between centres nationally allowed establishment of hub centres to concentrate specialist resources 13, 14, 17 . Whilst our review does not compare their efficacy such approaches should be considered in the context of local resources.

Health systems internationally saw a need to redirect significant resources towards acute medical admissions, particularly ensuring critical care facilities for ventilatory support were made available for COVID patients 22 .

Rationalisation and competition for resources meant providers had to minimize avoidable usage of these facilities, through postponing elective surgery. Capacity for COVID admissions was increased through means such as repurposing operating theatres 14 or reallocation of NICU beds 16 . Accounting for the wider public health need, it is incumbent on the neurosurgical team to be perceptive of surges in demand for these facilities in decision-making and patient communication 6 due to competition for high-level resources.

Human resource management played an important role in the early responses in this review. The focal role of clinicians providing care means the consequences of healthcare workers becoming infected is great. Pandemic rotas optimise staffing whilst maintaining clinician reserves to replace those who develop symptoms, often through minimizing hospital staff attending work or division of teams. Yet, the long-term allocation of clinicians should account for both the pandemic response and the increasing burden of surgical patients who have had interventions cancelled or delayed 20 . Reduced staffing may also risk the quality of care provided by teams during the pandemic, with temporary staff or absence of routine team members impacting continuity of care.

Redeployment of neurosurgical teams to support COVID admissions mirrored the reduction in neurosurgical activity. The impact is likely disproportionately affecting junior staff, where more senior team members were required to manage emergency surgeries to reduce intraoperative time and therefore exposure 10 . Disruption to training programmes follows, with implications on the education and progression of trainees. Solutions have been found through online platforms in the continuation of grand rounds, educational conferences and teaching 10, 16, 18, 20 , supported by several webinar series and online lectures provided by international neurosurgical bodies, such as the World Federation of Neurosurgeons (WFNS).

Our review saw several significant changes to neurosurgical practice. Triaging of emergencies and urgent cases was seen throughout the literature, requiring centres to carefully select patients to delay intervention. Several studies stated their criteria for such cases, outlining which presentations required emergent management. The

(EANS) produced triage guidelines modified from the ACS, who propose a 3 Tier system, whilst SBNS have produced more detailed sub-specialty guidance. However, Wellons and colleagues highlighted the simplification of pathologies to urgent and non-urgent, instead advocating for prioritization based upon anticipated harm of delays 4 . This provides an additional complexity where some disease may become inappropriate for intervention if delayed. Some studies described COVID-multidisciplinary team who were responsible for such decisions 9,10,13 . A consequence of triaging is the cancellation of elective surgeries. Whilst necessary to allow redirection of resources towards the wider medical needs, the morbidity and mortality of such delays is yet to be seen, alongside the future management of these patients when normal services resume.

Similarly, a large reduction in outpatient services to provide only essential clinics or treatments was described as another measure to reduce viral exposure. This saw a rapid reliance on telemedicine to provide various aspects of outpatient care. This unprecedented transfiguration of neurosurgical care may have lasting effects on outpatient care. Criticisms to these alternatives focus on the reliance on technology and the disproportionate socioeconomic impact on those who do not have access to such services, alongside the inferior human interface needed for sensitive or significant interactions between neurosurgeons and their patients 4, 6 . Comparisons of these novel services, chiefly focusing on patient outcomes (both clinical and patient-reported outcome measures) to traditional outpatient services will allow true determination of their benefit. It does, however, demonstrate innovation in times of crisis.

Clinical practice was also modified in direct response to the pandemic. Cautions to providing particular surgeries, such as endonasal surgery, intubation protocols and advocation of alternative treatment strategies are examples of early changes to practice. These reflect concerns in the wider literature prompting strategies to minimize transmission intraoperatively 23 . These alterations serve to protect both patients and providers, meaning some actions are not solely patient-centred. Some studies attempted to avoid ICU admissions following certain surgeries, to preserve ICU beds for COVID patients 9, 18, 19 . Again, the impact of this is unclear. It may identify cases that can be managed in lower-intensity settings, improving efficiency of resource use. On the other hand, this may put patients who required critical care facilities at increased risk of complications or deterioration.

This review aimed to characterise the scope of the early responses of the neurosurgical community to the COVID-19 pandemic. Thus, the steep learning curve means clinical practice is changing rapidly as more is learnt about the virus, impacting the sensitivity of the search. The quality of evidence in this systematic review was limited, formed of editorials, expert opinions and letters to the editor providing mostly institutional experiences in addressing the pandemic. This was unsurprising due to the proximity of the search to the pandemic outbreak. Further, the external validity of experiences discussed depend on local resource settings and thus may not be globally applicable. However, there is value in corroborating these experiences to inform the wider community on how institutions responded.

This review provides a summary of published evidence outlining the initial responses of the neurosurgical community to the COVID-19 pandemic. It provides a menu of pandemic response interventions conducted by countries initially with the highest disease burden of COVID-19 for consideration in response to future pandemics or, in the short term, further peaks in the COVID-19 pandemic. Compiling the early experiences offers healthcare providers insights into the modelling of neurosurgical units, internationally, to improve service provision and patient safety during a public health crisis.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Ethical approval: For this type of study formal consent is not required. 

Letter to the Editor Regarding Effects of the COVID-19 Outbreak in Northern Italy: Perspectives from the Bergamo Neurosurgery Department, and the Role of Radiosurgery as a Minimally Invasive Procedure in the Pandemic Outbreak

Effects of the COVID-19 Outbreak in Northern Italy: Perspectives from the

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm

Letter: News From the COVID-19 Front Lines: How Neurosurgeons Are Contributing

Letter to the editor by Dobran Mauro, Paracino Riccardo, and Iacoangeli Maurizio regarding

Letter: Academic Neurosurgery Department Response to COVID-19 Pandemic: The University of Miami/Jackson Memorial Hospital Model

Society of NeuroInterventional Surgery recommendations for the care of emergent neurointerventional patients in the setting of covid-19

COVID-19 and spinal surgery

Experiences of practicing surgical neuro-oncology during the COVID-19 pandemic

A safe approach to surgery for pituitary and skull base lesions during the COVID-19 pandemic

Strategies to Inform Allocation of Stockpiled Ventilators to Healthcare Facilities During a Pandemic

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Urgent considerations for the neuro-oncologic treatment of patients with gliomas during the COVID-19 pandemic

Letter: COVID-19 Infection Affects Surgical Outcome of Chronic Subdural Hematoma

Letter: Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic

Inpatient and outpatient case prioritization for patients with neuro-oncologic disease amid the COVID-19 pandemic: general guidance for neurooncology practitioners from the AANS/CNS Tumor Section and Society for Neuro-Oncology

Preliminary Recommendations for Surgical Practice of Neurosurgery Department in the Central Epidemic Area of 2019 Coronavirus Infection

Letter: Strategies for Prevention and Control of 2019 Novel Coronavirus Infection Among Medical Staff

Early lessons in the management of COVID-19 for the pediatric neurosurgical community from the leadership of the American Society of Pediatric Neurosurgeons

A new coronavirus associated with human respiratory disease in China

A COVID-19 Patient Who Underwent Endonasal Endoscopic Pituitary Adenoma Resection: A Case Report

Neurosurgery during the COVID-19 pandemic: update from Lombardy, northern Italy

First Author Country of origin Study design 1 2020 Bernucci et al. 5 Italy Perspective 2 2020 Burke et al. 14 United States Letter to the editor 3 2020 Eichberg et al. 17 United States Letter to the editor 4 2020 Fraser et al. 18 United States Expert opinion

AANS