key: cord-0809802-6725jg29 authors: Field, Nicholas C.; Platanitis, Kelsey; Paul, Alexandra R.; Dalfino, John; Adamo, Matthew A.; Boulos, Alan S. title: Decrease in Neurosurgical Program Volume During COVID-19: Residency Programs Must Adapt date: 2020-06-25 journal: World Neurosurg DOI: 10.1016/j.wneu.2020.06.141 sha: 326270bfbcaaf2256bb132c6f0e47ca8943cd8fe doc_id: 809802 cord_uid: 6725jg29 nan To the Editor: The COVID-19 pandemic has had wide-reaching impact on medical care across the globe, both in outpatient and inpatient settings. In the United States, it remains unknown how long and to what degree we will remain in the new status quo of "social distancing" and state-by-state lockdown. However, the short-term impact on neurosurgical resident and medical student education has begun to be realized, and the long-term implications on residency training could be vast. In order to demonstrate the degree of change, we wish to report the dramatic decrease in operative, outpatient clinic, and consult volume at our institution, Albany Medical Center, an Academic Level 1 Trauma Center in upstate New York. The first case of COVID-19 in New York State was reported on March 1, 2020. By March 8 th there were 106 confirmed cases and a state of emergency had been declared. On March 14 th the first deaths were confirmed and were soon followed by closure of the public-school system and a statewide stay-at-home order known as "New York State on PAUSE." 1 Elective cases were mandated to stop on March 25 th . While our region has not suffered an overwhelming surge in COVID-19 cases, local concern, hospital and statewide policies, and concern for departmental safety have led to a noticeable change in our practice. Since the first case was reported, we have tracked our operative, clinic, and consult volume, which we report here. Similar to reports by other groups, we have seen a significant decrease in outpatient clinic visits, necessitating the need for alternative methods of administering patient visits. 2 We rapidly trialed and implemented a video conference telehealth system by the end of March and have seen a dramatic shift in our clinic practice while continuing to provide appropriate patient care ( Figure 1 ). Overall, new patient visits, which are a reflection of referrals, have dropped by 38% and established patient visits have only dropped by 27%. Despite reassurances about the safety of emergency room care, the public continues to avoid hospital visits and there has been widespread news coverage about the decrease in hospitalization for stroke and myocardial infarctions. At our center, this trend has held true for all neurosurgical consults except those for shunt failure and intraparenchymal hemorrhage, which have shown a minimal increase. In particular, as the highest volume trauma center in New York State, there has been a marked decrease in consults for traumatic brain (22%) and spine (35%) injuries, presumably due to decreased motor and recreational vehicle activity (Figure 2 ). Despite a 23% reduction in large vessel occlusion stroke consults, the rate of thrombectomy has increased dramatically. Overall, there has been a 27% reduction in all consults since the New York State stay-at-home order, compared to the same period in 2019. The most noticeable change to the residency has been the decrease in both elective surgery volume (53%) and total surgical procedures (42%). Our resident service was split into an on-call and backup team due to the decrease in case volume, and also to limit exposure to COVID-19, and provide coverage in the Neuro ICU. Neuroangiography has seen a similar decline. Bedside procedures, such as placement of ventricular drains, have remained stable. Of note, despite the overall decline in stroke consults, thrombectomies have increased by 21%. Operative cranial traumas have decreased by 18%, which is consistent with the decrease in consults. Most neurosurgical residency programs are located at academic hospitals in urban or suburban centers--the areas hardest hit by COVID-19. Our program has seen a significant reduction in consults and operations over the past three months despite being in a region with a linear case rise that has not been overwhelmed by the pandemic. 3 While short-term fluctuations in volume are normal, the long-term consequences of a sustained decrease in volume will significantly impact resident education. If COVID-19 persists, or future case surges occur, programs could see a reduction in patients of well over 25% over the course of a year. Individual programs will be affected differently, and we propose consideration of the following mitigation strategies: • Intern year rotations may need to shift to incorporate more neurosurgical experiences, as they will likely be exposed to fewer neurosurgical patients over the course of their year. • Increase resident and medical student participation in clinic. • All non-emergent cases should require pre-operative testing. These cases could be considered relatively safe for residents to "double scrub" while still limiting possible COVID-19 exposure. • Mentorship models for junior residents may provide a means of distributing consult, clinic, operative, and neuroangiography experiences. • Programs should invest in and consistently utilize dissection labs to teach, learn, and reinforce surgical approaches. • Virtual conferences can be utilized for didactic sessions using platforms such as Microsoft Teams or Zoom. These also provide an inexpensive way to invite guest lecturers from other programs to speak. • Utilize online academic resources, such as the Virtual Visiting Professor 4 series being hosted by the CNS and the Resident Education Courses 5 produced by the AANS and NREF. The COVID-19 pandemic has led to a dramatic decline in elective neurosurgical procedures, consults, and clinic visits. The long-term implications of the outbreak are unclear, but neurosurgical residency programs must consider the long -term effects on resident education and develop an internal roadmap moving forward. New York State on PAUSE Implementation of a Neurosurgery Telehealth Program Amid the COVID-19 Crisis-Challenges, Lessons Learned, and a Way Forward Virtual Visiting Professor Primary Campus Clinic Visits