key: cord-1013557-fmbc16rb
authors: Jayakumar, Nithish; Kennion, Oliver; Villabona, Alvaro Rojas; Paranathala, Menaka; Holliman, Damian
title: Neurosurgical referral patterns during the COVID-19 pandemic: A United Kingdom experience
date: 2020-09-02
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.08.162
sha: 7ac983bc8532f07b3e2076980920b9e6d0293798
doc_id: 1013557
cord_uid: fmbc16rb

Background COVID-19 is a severe respiratory viral illness that has spread rapidly across the world, but the United Kingdom has been particularly affected. Evidence suggests that stroke, cardiac, and spinal presentations fell during the pandemic as the public avoided seeking care. The impact on neurosurgical presentations and referrals during COVID-19 is unclear. Our aim, therefore, was to describe the referral patterns to a high-volume neurosurgical department in the United Kingdom during the COVID-19 pandemic. Methods Electronic referrals were identified from the referrals database for the period between 01/01/2020 and 31/05/2020, inclusive, with the month of January used as a baseline. Demographics and referral diagnoses were captured on Excel (Microsoft). Statistical analyses were performed on SPSS v22 (IBM). Differences between referral volumes were evaluated by chi-square goodness-of-fit tests. Results A total of 2293 electronic referrals were received during the study period. Median age was 63 years. Overall, referrals fell significantly in volume during the study period (χ2(4)=60.95; p<0.001). Patterns in daily referrals as the pandemic progressed are described. There was a statistically significant reduction in the volume of referrals for degenerative spine cases and traumatic brain injuries (p<0.001). Conclusions Referrals for degenerative spine and traumatic brain injuries fell significantly during the pandemic which can be explained by the lower vehicular traffic and patient avoidance of healthcare services, respectively. The risk of neurological deterioration and increased morbidity and mortality, as a consequence, is of concern and neurosurgeons worldwide need to consider optimal strategies to mitigate these risks as the pandemic eases.

COVID-19 is a severe respiratory illness transmitted by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which has spread rapidly worldwide in the first half of 2020 since the first cases were detected in Wuhan, China. At the time of writing, there were more than 10 million cases worldwide and over half a million deaths. (1) The United Kingdom (UK) has been severely affected, with more than a quarter of million cases, (2) causing substantial strain on the National Health Service (NHS).

As COVID-19 cases rose, the UK government advised the public to avoid non-essential travel and to self-isolate if symptomatic. (3) A country-wide lockdown (4) was instituted on the 23 rd of March to reduce community transmission and prevent NHS resources from being overwhelmed.

To aid this, all non-urgent operations were postponed, (5) and services reorganised, which included opening 'Nightingale' hospitals (6) to cater for the burgeoning COVID-19 cases.

Lockdown measures were continued until the 13 th of May.

The Society of British Neurosurgeons (SBNS), in conjunction with the UK Royal Colleges of Surgeons, published guidelines (7) -similar to published practice around the world (8) -on optimising resource allocation during this crisis. The guidelines also offered guidance on prioritising elective neurosurgical operations to ensure patients at risk of life-and sightthreatening deterioration could be treated promptly. Therefore, and as part of our institution's COVID-19 response, our department halved the neurosurgical operating workload, postponed J o u r n a l P r e -p r o o f non-urgent operations, converted a thirty-bedded neurosurgical ward to a 'COVID-19' ward, and reallocated junior medical staff to medical specialties.

As both the lockdown and the pandemic progressed, it was apparent that there was a drastic fall in patients presenting to the Emergency Department (ED), including stroke and cardiac patients, (9) likely due to patient anxieties about infection and over-burdening healthcare services.

Similar concerns, especially with the fall in stroke admissions, were echoed across the world. (10) (11) (12) Within neurosurgery, the numbers of admissions or presentations for spinal pathologies have dropped significantly in volume during this time in Italy (13) (14) (15) and Germany. (16) On the other hand, road traffic collisions were reported to be lower during the pandemic, (17) as the public avoided non-essential travel. Nevertheless, there was an underlying concern among neurosurgeons that neurosurgical patients may suffer from neurological deterioration if access to treatment and operations are delayed. (18) (19) (20) Although the fall in spinal and trauma patients was noted during this time, it is unclear if any other neurosurgical conditions have been similarly affected. There is also no data available on these presentations during the pandemic from the UK.

Our aim, therefore, was to quantify the referral patterns to our neurosurgical department during the COVID-19 pandemic. The study timeline was set from the 01/01/2020 -roughly a month before the first UK cases were diagnosed -to the 31/05/2020 -which includes the two weeks after the lockdown was eased (21) -to identify the trends in referrals from the beginning of the UK experience, through the lockdown, and after the lockdown was relaxed.

J o u r n a l P r e -p r o o f

Our institution is a level I trauma centre in the North East of England, serving a population of over 3 million people. A total of 71 inpatient neurosurgical beds are spread over two wards and a day surgery unit. On-call spinal services are provided by both orthopaedic and neurosurgical spinal consultants. Four neurosurgical operating theatres are run on weekdays, including a dedicated emergency theatre.

Referrals for both emergency and non-urgent referrals are received via the referapatient (Bloomsbury Health Ltd.) website. (22) All referrers are encouraged to use the website to ensure that all referrals are logged, monitored, and responded to in a timely manner, unless it is a lifethreatening emergency. For such emergency referrals, referrers are encouraged to send a retrospective electronic referral. Referrers are required to provide patient demographics, clinical details including relevant history, examination, and imaging reports. Referrals are read and responded to by the on-call resident. Follow-up queries by either the referrers or the residents can be sent through the same platform.

All referrals recorded on referapatient between 01/01/2020 and 31/05/2020 were reviewed under the auspices of service evaluation. Duplicate referrals were excluded. Referrals for spinal trauma, Statistical analyses were performed on SPSS v22 (IBM). Differences between referral volumes were evaluated by chi-square goodness-of-fit tests; statistical significance was set at the 95% level (p=0.05).

A total of 2293 electronic referrals were received between 01/01/2020 and 31/05/2020, inclusive.

Median age was 63 years and males represented 50.5% of all referrals. Table 1 shows the total volume of referrals for each month of the study period.

Most referrals were received on either a Friday (17.2%) or a Wednesday (15.8%), with the weekends being the least busy. Figure 1 illustrates the daily referrals in comparison to UK-wide COVID-19 cases and deaths, respectively.

Overall, referrals fell significantly in volume during the study period (χ 2 (4)=60.95; p<0.001).

Referral volume in the baseline month of January and during the early phase of the COVID-19 pandemic -between the first cases of COVID-19 in the UK (31/01/2020) to the UK government's advice to the public to self-isolate if they have symptoms (12/03/2020) -were consistently between 15-20 referrals per day. Referral volume subsequently fell gradually as J o u r n a l P r e -p r o o f COVID-19 cases increased and the NHS decided to postpone all elective surgery (17/03/2020) and schools were ordered to close (18/03/2020). A steeper decline in referrals was noted when the UK government announced a lockdown to limit community transmission (23/03/2020), to a 7-day rolling average of 10 referrals per day. Referral volume was steady at around 10 daily referrals for the subsequent 4 weeks, as COVID-19 cases and deaths rose significantly. On 25/04/2020, attendances to EDs were shown to have halved and the public were encouraged to seek healthcare if needed. Daily referrals thereafter increased to an average (7-day rolling) of 15 referrals per day, well before the lockdown was eased (13/05/2020). This pattern has held steady for the rest of May. Figure 2 illustrates the referral volume by diagnosis during the study period.

Overall, the most common reasons for referral to neurosurgery during these months were: (1) degenerative spinal disease including suspected or confirmed cauda equina syndrome (24.3%);

(2) traumatic head injuries (24.0%); (3) intracranial and intradural spinal tumours (16.1%); (4) spontaneous intracerebral haemorrhage and ischaemic stroke (10.6%); (5) spontaneous subarachnoid haemorrhage and other neurovascular lesions (7.6%); (6) chronic subdural haematomas and subdural collections (7.4%); (7) hydrocephalus and shunt-related issues (7.2%);

and (8) There was a statistically significant reduction in the volume of referrals for degenerative spine cases and traumatic brain injuries (p<0.001).

Referrals for degenerative spine fell by 56.4% between January and April but rose by two-thirds Referrals for traumatic brain injuries fell by almost half (49.6%) from January to April. Similar to degenerative spine referrals, head trauma referrals fell steeply between January to April but have increased from April to May by 18.3%.

There were no statistically significant differences in the referral volumes across the study period for any of the other referral categories.

Oncology-related referrals appeared to fall from January to March but rose in April and May to the same level as January. Likewise, referrals for stroke syndromes fell by 26.3% from January to February and remained consistently around 40 referrals till April before volume increased to a similar level as January. Referral patterns also differed by gender. Referrals for females with degenerative spinal diseases fell by 64.9% between January and April compared to males, where it fell by 40.4% for the same study period. There was also a slightly greater fall in male traumatic brain injury referrals compared to females between January and April (50.6% vs 48.2%, respectively). Oncological referrals were also in stark contrast between the genders. Referrals for intracranial and intradural spinal tumours rose by 7.9% in males between January and April but fell by 32.6% in females for the same time period. A similar pattern was apparent in referrals for chronic subdural haematomas. Other referral categories generally noted a comparable fall in volume between males and females.

We report the neurosurgical referral patterns to our department over a 152-day period as COVID-19 infections spread throughout the UK. Traumatic brain injury referrals fell significantly during the study period. The lockdown, combined with the public avoiding non-essential travel, were likely to be behind sizeable reduction in head injuries. As road traffic volume fell by more than 70% (23) during the pandemic, the public health gains -from the standpoint of head injuries -is of great interest. Trauma accounts for 9% of the worldwide deaths and is predicted to become one of the leading causes of death by 2030, (24) and road traffic accidents remain the primary mechanism of injury in these cases. (25) The benefits of lockdown and travel restrictions -although necessary in a pandemicin reducing head injuries can be seen in these results ( Figure 2 ) yet road traffic increased again as the lockdown was eased. (26) As the world progresses towards a COVID-free era, the advantages of restricting road traffic and encouraging the public to work from home, where possible, should be strongly considered by health services as a key mechanism in reducing the burden of traumatic brain injuries. Arguably, a worldwide restriction on vehicular traffic could do more to reduce head injury-related morbidity and mortality than any advances in neurosurgical or neurocritical care have accomplished thus far. In contrast to vehicular traffic, alcohol sales during the pandemic increased disproportionately even as restaurants and bars were closing J o u r n a l P r e -p r o o f down. (27) Falls and violence related to alcohol use may be the underlying cause of head injuries during this period.

Referrals for degenerative spinal conditions similarly fell significantly over the study period.

Published literature is also consistent with this finding, with authors reporting comparable reduction in spinal case volume in other parts of the world during the pandemic. (13) (14) (15) (16) (28) Of grave concern, however, was the decline in referrals for suspected or confirmed CES from January to March, which may suggest that patients with critical neurological symptoms were avoiding health services despite their condition. The proportion of spine referrals that were suspected/confirmed CES also fell from a fifth of cases in January to 7.7% in February; this proportion increased subsequently to 10.2%, 18.5%, and 13.0% of spine referrals, respectively, in March-May. This fluctuation may well reflect a natural variation in the proportion of CES referrals in spinal cases but there remains a worry that patients with CES symptoms were not presenting to healthcare services. Inappropriate allocation of this diagnosis code may also play a part in over-or under-estimating these CES-related referrals.

For those who chose to stay at home, there remains a lingering concern of further neurological deterioration while they wait for health systems to recover, which might mean that neurological damage may be irreversible. (19) (29) (30) There are also inherent medicolegal and financial implications. Although it could be argued that appropriate triage of these cases during the pandemic would have ensured that such patients were operated on regardless, it is not unreasonable to assume that a few patients may, unfortunately, 'slip through the net' and thus suffer. With the pandemic appearing to be under control, elective operations are being increasingly performed but the backlog of patients on waiting lists (31) will mean that a number of J o u r n a l P r e -p r o o f patients would have their treatment delayed considerably with a potential knock-on effect on neurological function.

The lockdown also restricted most physically demanding occupations from continuing their trade and most of the working population was restricted to their home, which could also explain the lower rates of spinal referrals. (13) It is not possible to comment yet on whether any patients with degenerative spinal diseases deteriorated during this period however, if one assumes that there was no such neurological worsening, it reassures us that patients could tolerate conservative management and appropriate patient selection for spinal surgery continues to be of paramount importance. Authors elsewhere have also commented that patients with back pain may improperly access healthcare services at hospitals (13) (15) bypassing primary care providers in "normal" times, which may also explain the fall in these referrals during the study period.

Referrals for stroke syndromes fell from the baseline month of January to April. This is in keeping with the published literature suggesting that stroke admissions had fallen significantly across the world, (10) however, caution must be taken to extrapolate neurosurgical referrals for strokes to the admission or treatment patterns for stroke patients in general.

The potential for tumour patients' neurological function to deteriorate is ever-present and it was worrying to note the decline in referrals during the pandemic-affected months. This phenomenon may reflect a few scenarios: firstly, new presentations for tumours may be delayed as patients chose to isolate at home and avoid presenting to primary or secondary care; secondly, access to cancer therapies, e.g. chemoradiotherapy, were severely curtailed during this time to avoid immunosuppressing this cohort during the pandemic (32) and, as such, the decline in referrals may reflect the reduced volume of treated oncology patients; and, finally, the restricted operating J o u r n a l P r e -p r o o f capacity also meant that oncology patients with stable neurological symptoms or non-life or vision-threatening symptoms were deferred.

Concerns about infection and travel restrictions may raise doubts in patients' minds about the suitability of seeking medical attention for symptoms that may seem innocuous, for example, headaches. Referral volume for subarachnoid haemorrhage and neurovascular cases were steady during the initial months of the pandemic but fell in April, which may well reflect seasonal variation. However, it is concerning to note this decrease in referrals as patients may have elected to suffer with their headaches at home, leading to delayed presentations. (29) The risks of rebleeding, hydrocephalus, electrolyte disturbances, and delayed ischaemic neurological deficits are considerable, if these patients remain untreated, with consequent risks of morbidity and mortality. Likewise, patients with shunts may have chosen to manage non-distressing symptoms at home as best as they could which may explain the lower referral rates in April. The pandemic may have also discouraged the "worried well" from exposing themselves to infection by attending hospitals. The fluctuating referral rates for post-operative complications may be attributed to the greatly reduced operating workload of the department however this group of patients -who are at risk of infective complications after major neurosurgery -may have also chosen to suffer at home; the potential for a worse post-operative outcome if they do so is of concern.

In the future, as the COVID-19 pandemic slows down, neurosurgical centres need to be prepared to deal with an increased demand on resources as referrals and operative volume inevitably increase to pre-COVID levels. Strategies (33) to tackle this may include adding extra operating J o u r n a l P r e -p r o o f lists, extending working hours of elective theatres, and utilising spare theatre capacity at other regional neurosurgical centres or in private hospitals. At our institution, operating capacity has been expanded by using available theatres at private hospitals and consultants have been encouraged to reduce their waiting lists by utilising these additional operating theatres.

Discussions are also ongoing on adding extra elective operating lists at the weekend. Patients are advised to self-isolate for 2 weeks prior to elective procedures and are required to have a negative viral swab pre-admission. Emergency admissions are managed as suspected COVID-19 cases and are isolated until a viral swab is negative. Outpatient consultations continue to be held via telephone while appropriate social distancing measures and personal protective equipment protocols are in place to limit transmission. At the time of writing, all inpatient neurosurgical beds and dedicated neurosurgical theatres are available for use by the department. Nevertheless, sickness and fatigue among the workforce, a lack of critical care beds, the persistent risk of new infections, and the added financial burden of extra operating lists are some of the key issues that may impact delivery of neurosurgical care in the forthcoming months.

We have reported the referral patterns from a busy neurosciences centre during the pandemic's rise, its peak, and as it plateaus across the UK. The large number of referrals allows for meaningful comparisons and conclusions to be drawn from the dataset. As such, this is the first study of its kind to report referral patterns from the UK and we hope that this is of assistance to colleagues around the world as they plan on how to rebuild their services as the pandemic wanes.

There are a few limitations to this study. As a single-centre study, it is not possible to extrapolate these patterns to the rest of the UK, or the world, however there are parallels in the published J o u r n a l P r e -p r o o f

In conclusion, we have described the pattern of neurosurgical referrals and how they changed as COVID-19 spread throughout the UK. Referrals for degenerative spine and traumatic brain injuries fell significantly during the pandemic which can be explained by the lower vehicular traffic and patient avoidance of healthcare services, respectively. We also noted a non-significant decline in referral volume for stroke syndromes, subarachnoid haemorrhage, and tumour cases during the pandemic months. The risk of neurological deterioration and increased morbidity and mortality, as a consequence, is of significant concern and neurosurgeons worldwide need to consider optimal strategies to mitigate these risks as the COVID-19 pandemic eases.

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The authors wish to acknowledge Mr Syed Shumon for his valuable comments on the manuscript.J o u r n a l P r e -p r o o f Jayakumar