key: cord-0901710-vin7rjn6
authors: Noureldine, Mohammad Hassan A.; Pressman, Elliot; Krafft, Paul R.; Greenberg, Mark S.; Agazzi, Siviero; van Loveren, Harry; Alikhani, Puya
title: Impact of the COVID-19 Pandemic on Neurosurgical Practice at an Academic Tertiary Referral Center: A Comparative Study
date: 2020-05-23
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.05.150
sha: d1ebab74a5d1e34c60c59ffee09666d2ea190621
doc_id: 901710
cord_uid: vin7rjn6

Abstract Background Neurosurgical services are affected by the COVID-19 pandemic, and several departments reported their experiences and responses to the COVID-19 crisis in an attempt to provide insights from which other impacted departments can benefit. Objective The goals of this study are to report the load and variety of emergent/urgent neurosurgical cases after implementing the ‘Battle Plan’ at an academic tertiary referral center during the COVID-19 pandemic and to compare these variables to previous practice at the same institution. Methods The clinical data of all patients who underwent a neurosurgical intervention between March 23, 2020 and April 20, 2020 was obtained from a prospectively maintained database. Data of the control group was retrospectively collected from the medical records to compare the types of surgeries/interventions performed by the same neurosurgical service before the COVID-19 pandemic started. Results Ninety-one patients underwent emergent, urgent and essential neurosurgical interventions over a 4-week period during the COVID-19 pandemic. Patient screening at teleclinics identified 11 urgent surgical cases. The implementation of the ‘Battle Plan’ led to a significant decrease in the case load, and the variation of cases by subspecialty is evident when compared to a control group comprised of 214 patients. Conclusion Delivery of optimal care and safe practice and education at an academic neurosurgical department can be well maintained with proper execution of crisis protocols. Teleclinics proved to be efficient in screening patients for urgent neurosurgical conditions, but in-person clinic visits may still be necessary for some cases in the immediate postoperative period.

Background: Neurosurgical services are affected by the COVID-19 pandemic, and several departments reported their experiences and responses to the COVID-19 crisis in an attempt to provide insights from which other impacted departments can benefit.

Objective: The goals of this study are to report the load and variety of emergent/urgent neurosurgical cases after implementing the 'Battle Plan' at an academic tertiary referral center during the COVID-19 pandemic and to compare these variables to previous practice at the same institution.

March 23, 2020 and April 20, 2020 was obtained from a prospectively maintained database. Data of the control group was retrospectively collected from the medical records to compare the types of surgeries/interventions performed by the same neurosurgical service before the COVID-19 pandemic started.

Results: Ninety-one patients underwent emergent, urgent and essential neurosurgical interventions over a 4-week period during the COVID-19 pandemic. Patient screening at teleclinics identified 11 urgent surgical cases. The implementation of the 'Battle Plan' led to a significant decrease in the case load, and the variation of cases by subspecialty is evident when compared to a control group comprised of 214 patients.

Conclusion: Delivery of optimal care and safe practice and education at an academic neurosurgical department can be well maintained with proper execution of crisis protocols.

Teleclinics proved to be efficient in screening patients for urgent neurosurgical conditions, but in-person clinic visits may still be necessary for some cases in the immediate postoperative period.

The 2019 corona virus disease (COVID-19) has taken a heavy toll on various aspects of the society. In pandemic regions, healthcare systems are being shaped by the numbers of COVID-19 patients requiring urgent medical attention. 1 Hospitals are improvising and continuously revising protocols to maintain an efficient level of functioning amidst significant shortages in facilities and equipment. [2] [3] [4] Neurosurgical services, albeit not directly concerned with managing COVID-19 complications, are affected by the pandemic as well due to the precautionary need to preserve resources. Several departments have reported their experiences and responses to the COVID-19 crisis in an attempt to provide insights from which other impacted departments can benefit. [5] [6] [7] [8] [9] We recently published our response, the 'Battle Plan', at the University of South Florida Department of Neurosurgery, 10 which has so far been successful in sustaining optimal management of patients with urgent/emergent neurosurgical conditions and a safe environment for all personnel involved in the care of these patients.

The goals of this study are to report the load and variety of emergent/urgent neurosurgical cases after implementing the Battle Plan 10 at an academic tertiary referral center during the COVID-19 pandemic and to compare these variables to previous practice at the same institution.

The clinical data of all patients who underwent a neurosurgical intervention between March 23, 2020 and April 20, 2020 was obtained from a prospectively maintained database at a Level I Trauma Center, to which adult and pediatric patients are transported from 23 surrounding counties. The academic center at which the study was conducted houses more than 1000 beds, and the neurosurgical service is covered by 12 full-time neurosurgeons with variable expertise in various neurosurgical sub-specialties (spinal surgery; skull base surgery; neuro-Oncology; traumatology; neurovascular surgery; functional surgery; pediatric neurosurgery). Only interventions that were deemed necessary to save a patient's life or preclude neurological deterioration were carried out during the pandemic, 10 the urgency of which was classified as:

Emergent, requiring immediate transfer to the operating room (OR), e.g. head/spinal cord trauma, cauda equina syndrome, acute hydrocephalus; Urgent -within 1 day (i.e. Urgent) (e.g.

brain tumors with mass effect, progressive spinal cord myelopathy) or Urgent -within 1 week (i.e. Essential) (e.g. carotid endarterectomy following a middle cerebral artery stroke; cord decompression and cervical spine fusion following trauma leading to central cord syndrome), where the intervention should be performed within 1 day or within 1 week, respectively, to preserve neurological function.

Per the 'Battle Plan' protocols, 10 inpatients as well as new neurosurgical cases were presented in a daily 6 AM meeting of the covering team, and the new cases were scheduled per rank of urgency. Emergent cases presenting to the emergency department (ED) were admitted per judgement of the attendings on-call and staffed for surgery without any delay in management.

The 'Battle Plan' also required that all urgent and essential cases to be intubated in a negativepressure operative suite that is separate from the OR with anesthesia personnel in full PPE to protect the team and to diminish the chance of in-hospital "community spread". Emergent cases were usually already intubated in-transfer or in the ED, potentially placing "first responders" at risk of exposure. Other aspects of the 'Battle Plan' included minimizing face-to-face contact between different teams, followed by two weeks off-service in relative social isolation after a week of service, which was consistent with the Centers for Disease Control and Prevention (CDC) quarantine recommendations to prevent potential spread of COVID-19 among all personnel of the neurosurgery department. 10 Key elements of the 'Battle Plan' are summarized in Table 2 .

Data of the control group, patients who underwent neurosurgical interventions over a 6-month period (January 1-June 30, 2019), was retrospectively collected from the medical records to compare the types of surgeries/interventions performed by the same neurosurgical service before the COVID-19 pandemic started; the 6-month data of regular practice was averaged to 4 weeks for the purpose of comparison to the 4-week data collected after implementing the Battle Plan. 10 The institutional review board (IRB) approved the study protocol (IRB# STUDY000784).

Obtaining patient consent was waived by the IRB due to the retrospective nature of the study.

The demographic and clinical data of 91 patients who underwent neurosurgical interventions over 4 weeks after implementing the 'Battle Plan' 10 during the COVID-19 pandemic are summarized in Table 1 . All patients were admitted through the ED; the initial evaluation of most of the patients (72.5%) was performed in the ED, whereas direct referral from teleclinic and transfer from another institution accounted for 12.1% and 11% of the patient population, respectively. Four (4.4%) patients underwent an intervention after an in-hospital consult evaluation. There were 57 (62.6%) open surgeries requiring an OR and 34 (37.4%) endovascular procedures requiring an angiography suite. Emergent interventions were conducted in 17 (18.7%) patients; 65 (71.4%) required an urgent intervention within 24 hours; and 9 (9.9%) patients were categorized as "essential", who are in need of surgery within 1 week but able to be delayed by a few days or even in some cases benefited from several days delay in whom a delay, e.g. carotid endarterectomy following a middle cerebral artery stroke; cord decompression and cervical spine fusion following trauma leading to central cord syndrome. The median age at 

The impact of the COVID-19 pandemic on different aspects of the neurosurgical service at our main academic center was similar to experiences reported at other institutions' experiences. [6] [7] [8] [9] Crucial practice modifications, collectively referred to as the 'Battle Plan', 10 extended to inhospital service coverage, surgical staffing, clinic evaluations, and educational and research activities ( Table 2) . Although the shelter-in-place was not officially implemented in Florida until April 2 nd , March 23 rd was chosen as the starting date for the implementation of 'Battle Plan' at our department due to a sharp rise in the number of COVID-19 cases in our community in the prior week; this also coincided with the issuance of CDC recommendations in the second week of March.

As expected, these modifications affected the neurosurgical case load and variety as evident in Figure 1 . The total number of cases dropped by more than half (214 versus 91 over a 4-week period), which was a direct consequence of the rigid stratification of possible nerusorugical interventions into specific categories of emergent, urgent and essential. Cases were stratified first by the neurosurgery service and then submitted for review to a multidisciplinary OR Governance Committee to assure proper selection and equitable distribution of OR time and space. Only emergent, urgent and essential cases were admitted and staffed, the majority of whom presented to the ED directly. Teleclinic patient screening by the Battle Plan Teams who are in social isolation was surprisingly efficient in identifying urgent and essential cases (11 patients in total: 10 requiring an intervention within 1 day and 1 requiring an intervention within 1 week). We predict that telemedicine will be heavily incorporated into neurosurgical practice after the pandemic ends, especially since most personnel at academic centers have attained experience in evaluating patients in the telemedicine format nearly as effectively as during in-person clinic visits. Several limitations still exist, especially those related to obtaining imaging studies performed at institutions/radiology centers outside of our hospital system and workflow related to incorporating residents, fellows, advanced practice providers (APPs) in the telemedicine visits for purposes of education and efficient clinical practice. Rapid and efficient cross-institutional "sharing" of imaging studies will be resolved in the era of high-speed internet, where remote access to these imaging studies can be granted to providers. 10 Workflow issues will require redefining the roles, duties, and job descriptions of the non-faculty providers. Only 17 of the 91 cases were classified as emergent, including strokes, ruptured aneurysms, hematoma evacuations, etc., whereas most of the cases (65/91) required an urgent intervention within 1 day, such as angiograms, unstable vertebral fractures, spinal cord compression and progressive myelopathy, brain lesions with mass effect and neurological deficits, shunt revisions, etc.

Our data shows that among various subspecialties and patient populations, the adult functional and epilepsy subspecialty was the most impacted by practice modifications during the pandemic (18.1% versus 5.5%) (Figure 1) , not surprisingly, since most of the functional/epilepsy interventions are classified as elective, which was an exclusion criteria for surgical staffing per the 'Battle Plan'. 10 The endovascular subspecialty witnessed an 11.5% increase in the case load, with various procedures ranging from stroke interventions and diagnostic angiograms to embolization of aneurysms and arteriovenous malformations, among others. Although less common than other subspecialties, adult open vascular cases more than doubled compared to regular practice (2.4% versus 6.6%) (Figure 1) ; these included carotid endarterectomies, resection of vascular malformations, and vascular bypass procedures. One would have expected that the numbers of adult spine cases would significantly decrease due to their mostly elective nature; however, only a small drop (2.9%) in the relative case load was evident in this subspecialty, with an uptick in unstable traumatic fractures at different vertebral levels constituting 11 of 21 adult spine cases and 2 of 2 pediatric spine cases (Figure 1) .

The median length of hospital stay of 5 days is especially low for this patient population with seemingly critical conditions; we believe that the enhanced efficiency in evaluating in-hospital patients for discharge planning is a consequence of the transfer of care strategy followed by the 'Battle Plan' teams 10 ( Table 2) . Most of the patients (46 of 91) were discharged to their homes, while 7 succumbed to their complicated conditions. The mortality rate (7.7%) is quite high in this patient population, most probably due to the shift from a regular practice consisting of a mixture of elective and emergency surgical cases to a solely emergency practice during the pandemic. Teleclinic was again the preferred medium for follow-up, yet in-person clinic visits were necessary in some cases to ensure delivery of optimal postoperative care.

The patient population is relatively small, albeit unavoidable, due to the short period (4 weeks) after implementing the 'Battle Plan', which may reduce the power of this study. Our experience with the 'Battle Plan' is limited, and self-appraisal is an ongoing process during the pandemic. 10

During a viral pandemic, implementation of crisis protocols will impact the case load and variety of neurosurgical cases, but delivery of optimal care and safe practice and education at an academic neurosurgical department can be well maintained with proper execution of such protocols. Teleclinics proved to be efficient in screening patients for urgent neurosurgical conditions, but in-person clinic visits may still be necessary for some cases in the immediate postoperative period.

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Proper PPE is provided to personnel examining new patients in the ER as well as consults who are either COVID-19 positive or of indeterminate status All hospital personnel wear surgical masks to avoid in-hospital community spread All scheduled cases undergo COVID-19 testing regardless of presence/absence of disease manifestations Patients are intubated/extubated in a designated negative-pressure OR room, with anesthesia team in full PPE Teleclinic

All new and most of follow-up clinic visits are conducted through telemedicine by faculty of the teams that are quarantined at home Patients are screened for urgent/emergent conditions prior to setting an appointment Patients requiring urgent (but not emergent) in-person evaluation are directed to the APP clinic service, which is also on rotation, and subsequently seen by the covering attendings as necessary Postoperative visits are also conducted through telemedicine, unless in-person visits are necessary Only the patient is allowed into the clinic during the in-person visit, although guests are welcomed into a telemedicine format Education/Research Activities Grand rounds, journal clubs, and all other conferences are organized through videoconference applications, and attendance of all Battle Plan teams members remains mandatory Residents continued to conduct their research remotely (chart reviews, manuscript write-up, etc.) The 2-week home quarantine is an excellent opportunity for residents to read neurosurgical references and prepare for board exams Abbreviations: APP, advanced practice providers; CDC, Centers for Disease Control and Prevention; COVID-19, 2019 corona virus disease; ER, emergency room; PPE, personal protective equipment.

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