The coronavirus (COVID-19) pandemic has created a worldwide public health and economic crisis. Facing challenges from a critically overextended health care system, academic neurosurgery departments continue to treat emergent and urgent neurosurgical conditions, while ensuring the safety of departmental staff, and minimizing viral transmission throughout the hospital and community.
To this end, during the initial COVID-19 case surge, and again during the subsequent second wave in Florida, we postponed all elective surgeries. However, we continue to perform emergent and urgent cases. Although emergent surgeries such as clipping of ruptured aneurysms, decompressive hemicraniectomy for acute traumatic brain injury, mechanical thrombectomy for acute stroke, and decompression for cauda equina syndrome are relatively noncontroversial, defining which surgeries are considered urgent (resection of malignant brain tumors and decompression for cervical myelopathy, etc.) may necessitate discussion to ensure optimal health care resource utilization and minimize operating room staff viral exposure. For this reason, a small, multidisciplinary panel of senior neurosurgeons has been authorized to review surgical indications and approve urgent surgeries.1 All patients are tested preoperatively for COVID-19. For those with a COVID positive test result, surgery is delayed for a minimum of 14 days; in addition, two negative COVID tests must be obtained. Heightened precautions, such as a second negative COVID-19 test, are taken for patients undergoing surgeries with greater risk of disease transmission, such as endoscopic endonasal skull base surgery and retrosigmoid craniotomies.2 Finally, to facilitate remote telemedicine postoperative clinic visits, incisions are closed with dissolvable sutures, avoiding the need for in-person suture removal.3,4
Postoperative in-person clinic visits are only scheduled if a patient’s physical presence is required for a procedure, such as suture removal or shunt programming. All other clinic visits have been replaced by remote telemedicine visits.5,6 Health Insurance Portability and Accountability Act-compliant telemedicine technology incorporated into the electronic medical record is utilized to allow neurosurgeons to securely communicate with patients in a video conference. Verbal consent to treatment by telehealth should be obtained before such visits. Recent regulatory changes have made properly documented telemedicine visits reimbursable, enabling remote clinic visits to be both a medico-legally and financially feasible solution. Clinic patients are pre-screened to identify patients with potentially urgent pathologies; such patients may be scheduled for in-person visits. Prior to clinic entry, all patients undergo screening questions and temperature assessment. Family and friends are not allowed to accompany the patient.
To minimize resident viral exposure, only the fewest residents and/or fellows necessary for patient care are permitted to round or operate. We have created a rotating resident schedule of active duty “first responders” and a stay-at-home “healthy backup” group to stay home unless the first responders become ill, ensuring there is always a reserve of healthy residents to assist with patient care. Only operative consults are seen in-person by residents, and adequate personal protective equipment (PPE) is provided and required to be worn by all residents seeing consults.
Although surgical case volumes had decreased by 75% during the first wave of the pandemic, on-call duties for the multiple hospitals covered continued to be demanding. To diminish attending exposure, the call schedule has been altered so that one attending covers multiple subspecialties and hospitals, with complementary subspecialty second and third backup call. Attendings greater than 60 years of age are not included in the call pool, as this age group is at greater risk for severe COVID-19 symptoms and mortality. Our administrative staff in part work from home, as the department has purchased laptop computers for all staff that can work remotely.
Multiple precautions are taken to ensure the safety of our postoperative patients, many of whom may be medically fragile. Neurosurgery postoperative patients are transferred to the ICU or floor settings that are physically distanced from areas treating patients for COVID-19. Further, no visitors are allowed to the hospital. If beds are in short supply, postoperative patients that have undergone uncomplicated endoscopic skull base surgeries or craniotomies are transferred to the step down unit instead of the ICU, in order to preserve ICU beds for COVID-19 patients. Finally, safe discharge home on postoperative day one is attempted for all patients.7
In summary, elective cases should be postponed while urgent and emergent surgeries should continue to be scheduled throughout the COVID-19 pandemic. Clinic patients should be seen by remote telemedicine visits whenever possible. All staff should have adequate PPE, and only the minimal number of required residents for patient care should be in the hospital. Alternative call schedules will reduce staff exposure and ensure a healthy backup contingent. Thus, with a suitable COVID-19 protocol, academic neurosurgical departments are able to continue to deliver excellent patient care while protecting departmental staff and the community.
References
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1. Eichberg DG, Shah AH, Luther EM, et al. Letter: Academic Neurosurgery Department Response to COVID-19 Pandemic: The University of Miami/Jackson Memorial Hospital Model. Neurosurgery. 2020.
2. Zacharia BE, Eichberg DG, Ivan ME, et al. Letter: Surgical Management of Brain Tumor Patients in the COVID-19 Era. Neurosurgery. 2020.
3. Buttrick SS, Eichberg D, Ali SC, Komotar RJ. Intradermal Scalp Closure Using Barbed Suture in Cranial Tumor Surgeries: A Technical Note. Oper Neurosurg (Hagerstown). 2018;15(1):E5-E8.
4. Luther E, Berry K, McCarthy D, et al. Hair-sparing technique using absorbable intradermal barbed suture versus traditional closure methods in supratentorial craniotomies for tumor. Acta Neurochir (Wien). 2020;162(4):719-727.
5. Eichberg DG, Basil GW, Di L, et al. Telemedicine in Neurosurgery: Lessons Learned from a Systematic Review of the Literature for the COVID-19 Era and Beyond. Neurosurgery. 2020;In Press.
6. Basil GW, Eichberg DG, Perez-Dickens M, et al. Letter: Implementation of a Neurosurgery Telehealth Program Amid the COVID-19 Crisis-Challenges, Lessons Learned, and a Way Forward. Neurosurgery. 2020.
7. Eichberg DG, Di L, Shah AH, et al. Brain Tumor Surgery is Safe in Octogenarians and Nonagenarians: A Single-Surgeon 741 Patient Series. World Neurosurg. 2019;132:e185-e192.
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