key: cord-0880258-hfoo1bxh
authors: Sarpong, Kwadwo; Dowlati, Ehsan; Withington, Charles; Chesney, Kelsi; Mualem, William; Hay, Kathryn; Zhou, Tianzan; Black, Jordan; Shashaty, Matthew; Kalhorn, Christopher G.; Nair, Mani N.; Felbaum, Daniel R.
title: Perioperative COVID-19 Incidence and Outcomes in Neurosurgical Patients at Two Tertiary Care Centers in Washington, DC During a Pandemic: A 6-month Follow-up
date: 2020-11-30
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.11.133
sha: 9fb596c9f7fef9be8160ea40145268be3da5aefe
doc_id: 880258
cord_uid: hfoo1bxh

Objective Coronavirus disease 2019 (COVID-19) continues to affect all aspects of healthcare delivery and neurosurgical practices are not immune to its impact. We aim to evaluate neurosurgical practice patterns as well as perioperative incidence of COVID-19 in neurosurgical patients and their outcomes. Methods A retrospective review of neurosurgical and neurointerventional cases at two tertiary centers during the first three months of the first peak of COVID-19 pandemic (March 8-June 8) as well as following three months (post-peak pandemic; June 9-September 9) was performed. Baseline characteristics, perioperative COVID-19 test results, modified Medically Necessary Time Sensitive (mMeNTS) score, and outcome measures were compared between COVID-19 positive and negative patients through bivariate and multivariate analysis. Results 652 neurosurgical and 217 neurointerventional cases were performed during post-peak pandemic period. Cervical spine, lumbar spine, functional/pain, cranioplasty, and cerebral angiogram cases were significantly increased in the post-pandemic period. There was a 2.9% (35/1,197) positivity rate for COVID-19 testing overall and 3.6% (13/363) positivity rate postoperatively. Age, mMeNTS score, complications, length of stay, case acuity, ASA status, length of stay, and disposition were significantly different between COVID-19 positive and negative patients. Conclusion A significant increase in elective case volume during the post-peak pandemic period is feasible with low and acceptable incidence of COVID-19 in neurosurgical patients. COVID-19 positive patients were younger, less likely to undergo elective procedures, had increased length of stay, had more complications, and were discharged to a location other than home. The mMeNTS score plays a role in decision making for scheduling elective cases.

(35/1,197) positivity rate for COVID-19 testing overall and 3.6% (13/363) positivity rate 23 postoperatively. Age, mMeNTS score, complications, length of stay, case acuity, ASA status, 24 length of stay, and disposition were significantly different between COVID-19 positive and 25 negative patients. 26 27 Conclusion: A significant increase in elective case volume during the post-peak pandemic period 28 is feasible with low and acceptable incidence of COVID-19 in neurosurgical patients. COVID-19 29 positive patients were younger, less likely to undergo elective procedures, had increased length of 30 stay, had more complications, and were discharged to a location other than home. The mMeNTS 31 score plays a role in decision making for scheduling elective cases. The coronavirus disease 2019 (COVID-19) pandemic continues to affect every aspect of 35 society, especially healthcare systems, across the globe. As of November 17, 2020, there have 36 been over 53.7 million cases with more than 1.3 million deaths, with the United States accounting 37 for 19% of cases and deaths worldwide. 1 As the pandemic continued to surge, elective cases were 38 canceled mid-March. 2 In line with phase one of re-opening, on May 31, 2020, the District of 39 Columbia (DC) Department of Health issued guidance for elective cases to resume. 3 During the 40 first three months in Washington, D.C., an analysis of neurosurgical case volumes and COVID-19 41

incidence was done at two tertiary medical centers providing an objective measure of impact and 42

As the pandemic continues to impact healthcare delivery with a daily increase of about 44 60,000 confirmed cases in the United States alone, 5 and elective cases resumed in most centers, 45 many hospital systems continue to find difficulty in evaluating the risk of nosocomial infection 46 among surgical patients and deploying enough resources efficiently to support the acute medical 47 needs of patients. There have been estimates of the financial impact and lasting effects in patient 48 backlog for elective cases. 6,7 Additionally, within neurosurgery, many surgical procedures are 49 time-sensitive yet not necessarily non-elective-patients treated sooner may benefit most from 50 surgical intervention. 8, 9 Hence, weighing the risks and benefits of continuing with a full-time 51 elective practice is of utmost importance, especially amidst predictions of a second and third 52 "wave" projected to occur in the next few months. 10 These risks and benefits remain to be clearly 53 elucidated as there is a lack of literature addressing perioperative incidence and nosocomial 54 infection risk of In this study, we aim to study patients and neurosurgical practices at two tertiary hospitals 56 in Washington, D.C. as a three-month follow-up to our initial study. We compare the nosocomial 57 incidence rates of COVID-19 among neurosurgical patients during the cancellation and 58 resumption of elective cases. Furthermore, we evaluate assigned acuity and modified medically 59 necessary, time-sensitive (mMeNTS) scores to determine the risk stratification of COVID-19 and 60 outcomes among patients who underwent either neurosurgical or neurointerventional care. We 61 hypothesize that there is a small risk of COVID-19 positivity in lieu of a large elective practice, 62

and that the mMeNTS score may help risk stratify these patients and help improve outcomes 63 among neurosurgical patients. Hospital in Washington, DC, spanning two study periods: the first peak of pandemic period 71 (March 8-June 8) and the post-peak pandemic period (June 9-September 9) which represents time 72 period after the first peak. Elective cases were canceled between March 19 and May 31, 2020 73 within the peak pandemic period (Figure 1 ). Comparisons were made between the two study 74 periods to evaluate effects of COVID-19 on neurosurgical practice patterns as well as patient 75 A total of 405 operative neurosurgical cases for 386 patients were performed during the 107 peak pandemic period and 652 cases for 610 patients were performed during the post-peak 108 pandemic period. There was a 61.0% increase in case volume (p=0.0012) during the post-peak 109 period ( Figure 2A ). There were significantly greater proportion of lumbar spine (25.9% vs 33.0%; 110 p=0.0190), functional/pain (5.7 vs 9.0%; p=0.0451), and cranioplasty procedures (0.0% vs. 2.9%; 111 p=0.0001) performed in the post-peak period. Elective cases made up a significantly larger 112 proportion of cases in the post-peak period (30.4% vs. 73.3%; p<0.0001). Mean mMeNTS score 113 was lower in patients operated on in the post-peak period (8.2 vs. 7.5; p<0.0001) ( Table 1) . 114

There was a significantly lower frequency of postoperative complications (19.0% vs. 115 12.6%; p=0.0059) and more patients were discharged home (70.4% vs. 76.2%; p=0.0367) during 116 the post-peak period compared to peak pandemic period. There were no significant differences in 117 LOS and 30-day readmissions between the patients of the two time periods (Table 1) . A total of 26 118

(2.9%) cases were canceled due to a positive COVID-19 test (14/26) or due to patient's fear of 119 COVID-19 contraction (12/26). 120 121

A total of 121 neurointerventional cases for 112 patients were performed during the peak 123 pandemic period and 217 cases for 180 patients were performed during the post-peak pandemic 124

period. There was a 79.3% increase in case volume (p=0.0002) during the post-peak period 125 ( Figure 2B ). Similar to neurosurgical cases, mean mMeNTS score was lower in patients 126 undergoing neurointerventional cases in the post-peak period (9.0 vs. 7.8; p<0.0001) ( Table 2) . 127

There was a significant difference in case types with a greater proportion of diagnostic cerebral 128 angiograms (32.2% vs 47.5%; p=0.0081) performed in the post-peak period. There was a greater 129 proportion of cases that were done electively in the post-peak period (13.2% vs. 31.3%; p<0.0001) 130 (Table 2) . 131

There was a significantly lower frequency of postoperative complications (47.9% vs. 132 23.5%; p<0.0001) and more patients were discharged home versus other settings (40.5% vs. 133 51.6%; p=0.0498) compared to the peak phase of the pandemic. There were no significant 134 J o u r n a l P r e -p r o o f differences in LOS and 30-day readmissions between the patients of the two time periods (Table  135 2). 136 137

Cervical/cervicothoracic, lumbar/thoracolumbar, functional/pain and cranioplasty neurosurgical 139 cases had the most significant increase in volume ( Figure 3A ). When dividing surgical cases into 140 spine and cranial, total spine neurosurgical cases had a significant increase with an average of 17 141 spine cases/week during peak pandemic period versus 28 spine cases/week during the post-peak 142 period (p=0.0101). There was no significant increase in volume of cranial cases (11 cases/week vs. 

In the peak pandemic period, there were 18/334 (5.4%) patients who tested positive 150 perioperatively. Of these patients, 13 were positive preoperatively (13/180 patients tested; 7.2%), 151 and five were positive postoperatively (5/154 patients tested; 3.2%). In the post-pandemic period, 152 for both surgical and neurointerventional patients, there was a significant increase in pre-operative 153 COVID-19 testing with 100% of patients being tested before their procedure (p<0.0001). There 154 was also an increase in postoperative testing for the surgical patients (28.4% vs. 34.5%; 155 p=0.0422). There was an overall 2.9% (35/1,197) perioperative positive incidence for all 156 perioperative tests performed (Table 3) . Preoperative tests were conducted for a total of 869 cases 157 and 2.5% (22/869) tested positive, significantly lower than the peak pandemic period (p=0.0014). 158 13 patients (13/363 patients; 3.6%) tested positive postoperatively, not significantly different from 159 the rate during the peak pandemic period. Two of these patients tested positive both pre-and 160 postoperatively, meaning the percentage of new positive postoperative patients was 3.0% 161 (11/363). Neurointerventional patients had a higher rate of positive testing than neurosurgical 162 patients (6.9% vs. 3.1%; p=0.0165) ( Table 3) . COVID-19 were on average younger (51.1 vs. 58.4 years; p=0.0054). They were more likely to be 167 of Hispanic ethnicity (35.7% vs. 5.2%; p<0.0001) and less likely to consider themselves as white 168 (25.0% vs. 48.6%; p=0.0194). They were more likely to undergo emergent or urgent procedures 169 (p<0.0001). There were only five patients (5/790; 0.6%) undergoing elective procedures who 170 tested positive. There was a higher proportion of patients who underwent diagnostic angiograms in 171 the positive group (24.2% vs. 11.5%; p=0.0481). There were no significant differences in 172

proportion of other case types. Positive patients had higher mMeNTS scores assigned to them (9.0 173 vs. 7.5; p<0.0001) and higher ASA status (median 3 vs. 4; p<0.0001) ( Table 3) . With regards to 174 outcomes, they had increased LOS (27.5 vs. 9.1 days; p<0.0001), were more likely to incur an in-175 hospital complication (57.6% vs. 13.3%; p<0.0001) and end up in a setting other than home after 176 discharge (p<0.0001) ( 2.154; p=0.0020) were all independently associated with COVID-19 positive patients (Table 4) . In this regional study, we present a follow-up analysis of trends in neurosurgical practices 186 at two tertiary care centers after the peak COVID-19 pandemic wave and upon resumption of 187 elective cases. The incidence of perioperative COVID-19 in this population remains low at 2.9%, 188 with a 3.6% positive rate, postoperatively. Measures to minimize nosocomial spread continue to 189 be prioritized to keep these rates low despite significant increases in case volumes. The incidence However, all our patients who tested positive, tested while still in the hospital, which affirms that 207 their COVID-19 diagnosis was hospital-acquired. This study provides further evidence that it is 208 possible to safely support a robust elective case volume without increasing nosocomial COVID-19 209 infection rates among patients or providers given proper screening and safety measures. feasible. The patients' preclinical status was therefore a likely contributor to the increased LOS 237 that was subsequently observed. 238

The noted improvement in overall outcomes in the post-peak period with regards to 239 complications and disposition are likely due to the increase in number of elective cases during this 240 period compared to the majority urgent and emergent cases during the first peak. The patients in 241 the peak period were more likely to be ill with greater risk factors and worse comorbidity profiles. 242

However, overall outcomes between COVID-19 positive patients during the peak period and those 243 during the post-first peak period were similar. have been a number of studies suggesting neurosurgery-specific stratification tools, which may be 288 useful alone or in combination with the mMeNTS system. Such scoring systems can include 289 neurosurgery-specific elements for both cranial and spine cases such as presence of neurological 290 deficit, radiographic parameters, and need for ICU stay 9,36,37 Despite limitations, our previous 291 study as well as this current one shows that there is a clear difference in mMeNTS score between 292 COVID-19 positive and negative patients ( Figure 4E ), suggesting that patients with higher scores 293 are more prone to contracting the virus and more likely to have poor outcomes. The fact that only 294 2.3% (18/790) of patients undergoing intervention in our study had a mMeNTS score greater than 295 10, suggests that those with higher scores are not undergoing procedures given higher risk profile. 296

Ultimately, acceptable guidelines specific to neurosurgical practice may be needed to increase the 297 objectivity of this tool as we prepare for a potential subsequent wave of the COVID-19 pandemic. 298

Limitations 300

This is a two-center, retrospective study of COVID-19 that may not be generalizable to 301 other regions given the varying degrees of impact the pandemic has on different regions as well as 302 the variability in methodology of triage and patient care. Furthermore, it only included patients 303 undergoing procedures under general anesthesia, thus excluding inpatients not undergoing 304 procedures as well outpatient encounters. All patients in the post-peak pandemic period were 305 tested for COVID-19 pre-operatively, compared to about two-thirds of those in the peak pandemic 306 period; this complicates the ability to risk stratify patients based on COVID-19 incidence and 307 outcome measures from one time period alone. The assignment of mMeNTS score and case acuity 308 was completed by the surgeon and/or providers, which could be biased and based on the 309 circumstances provided for each patient case. Larger, multi-center and multi-regional studies are 310 warranted in order to improve further strategic planning for optimal patient care and to provide a 311 more representative view of the perioperative COVID-19 risk in the neurosurgical population. Table 1 . Baseline characteristics and outcomes of patients undergoing neurosurgical procedures during peak pandemic (March 8-June 8) and post-peak pandemic period (June 9-September 9). 

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NIR: Neurointerventional Radiology; ICH: intracranial hemorrhage; CVA: cerebrovascular accident; CSF: cerebrospinal fluid; AVM: arteriovenous malformation; MMA: middle meningeal artery; HTN: hypertension; DM: diabetes mellitus; CAD: coronary artery disease; CKD: chronic kidney disease

COPD: chronic obstructive pulmonary disease; DVT: deep venous thrombosis; PE: pulmonary embolism; TIA: transient ischemic attack; mMeNTS: modified Medically-Necessary, Time-Sensitive Procedures; LOS: length of stay

The authors whose names are listed immediately below 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.

Tianzan Zhou, MD