Neurosurgery Practices During the COVID-19 Pandemic: Report from the Largest Neurosurgery Department in the Central Epidemic Area, Wuhan
Huaqiu Zhang1, Kai Shu1, Junwen Wang1, Juan Chen1, Kai Zhao1, Liang Zeng2, Chunlin Li1, Hongquan Niu1, Ting Lei1* 1Department of Neurosurgery, Tongji Hospital, Tongji Medical College 2Huazhong University of Science and Technology, Wuhan 430030.China *Corresponding author: Ting Lei, Email: tlei@tjh.tjmu.edu.cn
Over the past five months, as the largest medical center in central epidemic area (Tongji Hospital, Wuhan), we have witnessed and participated in the fight against the epidemic of COVID-19. This pandemic has disrupted all aspects of society, especially the regular clinical work in the hospital[1]. To date, almost half of our colleagues in our Neurosurgery Department have been enrolled in the COVID-19 units in designated hospitals. It became extremely challenging to guarantee the necessary treatment for patients with central nervous system (CNS) diseases with limited resources. Fortunately, the epidemic is under control right now in China. Here we focus on the neurosurgical practice and the reorganization strategies executed in the Neurosurgery department, Tongji Hospital, Wuhan. These experiences helped to maintain ‘zero infection’ of doctors and nurses in our department through the pandemic.
The Neurosurgical Department is located in three different hospitals (one main and two branch hospitals). It has a total of 300 beds divided into 7 wards, with 255 faculty members (including 62 doctors and 154 nurses). Most colleagues have received clinical skill training in German and American neurosurgery centers. In 2019, the Department performed 5,402 surgical procedures, classifying it as the biggest neurosurgical Department in Wuhan.
Our practices during the pandemic can be divided into 3 stages according to the development of the epidemic. The first stage is the period when the COVID-19 epidemic first started and spread quickly. During the second stage, the COVID-19 epidemic went from the exponentially increasing outbreak to the period with few newly-diagnosed patients. We are coming to stage 3, which started when there was no new COVID-19 patient in the city for over 28 days.
From early January 2020 to January 23rd, Wuhan city was under mixed messages. Early on there was caution about the unknown coronal virus attack and the possibility of outbreak. Integration and redistribution of the available medical resources were initiated. First, all elective operations were postponed, including shutting down 2 neurosurgical wards in two branch hospitals and suspending all non-emergent out-patient activities, in addition to merging neurosurgical wards in the main hospital district. Second, it was crucial to raise the protection level of medical workers such as by wearing surgical or even N-95 masks and in wards, increasing the frequency of hand washing, and adjusting hospitalization procedures for nosocomial infection control. The neurosurgical units were rearranged into the “3 zones and 2 passages” model as previously described[2]. The 3 zones include a clean zone (for medical staff desk work and to change clothes), a buffer zone (for disinfecting and sterilizing when the staff come out from a potentially contaminated zone), and a potentially contaminated zone (patient activity areas). One passage is for patients entering the unit exclusively and is treated as having the risk of contamination, and the other is a clean passage for medical staff coming from the clean zone. Daily sterilization was carried out for every room in the whole unit. Doctors and nurses took second level protection before entering a potentially contaminated zone.
From 23rd January to 8th April 2020 was the city lock-down period during the pandemic. The number of COVID-19 patients was booming. Most of our colleagues in Neurosurgery Department were reassigned to COVID-19 wards. To avoid the risk of in-hospital procedures for uninfected patients and neurosurgeons, non-emergent procedures had to be postponed. A close follow-up by phone call was recommended for those with a relatively stable condition. Surgical treatment was rigorously preserved for patients with an emergent condition. The main hospital was designated for emergent/urgent operations for uninfected patients, and the Sino-French New District branch hospital was designated for only COVID-19 patients. Due to the restriction of protective equipment, only uncomplicated operations such as brain trauma, hydrocephalus and intracerebral hemorrhage were performed. Microscopy was almost impossible to use by neurosurgeons unless wearing the powered air-purifying respirator.
From mid-April to the end of May, Wuhan city was restarted, based on no newly-diagnosed COVID-19 patients emerging. Our regular surgical practices also began returning to normal step by step. With sufficient COVID-19 test kits, patients with CNS diseases could be hospitalized after screening, and receive surgical treatment after 3-7 days quarantine observation period. The neurosurgical wards were separated into two categories, clean wards and observation wards. Observation wards were for newly-admitted patients, which had to be screened negative for COVID-19. The screening test includes RNA test, antibodies test and lung CT scan. The observation wards still employed the “3 zones and 2 passages” model and strictly restricted one room for each patient. All medical workers wear level 2 PPE (Personal Protective Equipment). After 7 days observation and the second screen test negative, the patients could be transmitted to the clean wards and enter to the common OR for operations. After 2 weeks practice experience, we cut down the observation time to 72 hours. Regular preoperative neuroimaging and laboratory examinations were performed after hospitalization in clean ward zones. All the other in-hospital units not contaminated by COVID-19 were considered as the clean and safe district, which should be strict monitored. If the patients could not pass the screen test, e.g. CT scan showing signs of pneumonia or RNA positive, the patients should receive the operation in a designated negative pressure OR and surgical team wore level 3 PPE. Under this flow management, we have safely finished over 100 elective operations in April. Recently, with the improvement of the epidemic prevention situation, the neurosurgery department in two branches of our hospital has been fully opened. The level of protection and isolation time also continue to decline.
To end this report, we would like to share a standardized procedure for neurosurgical emergency during the pandemic. Briefly, patients with emergent CNS diseases were first directed to the special fever clinic in urgent out-patient department. A careful history query (especially fever and cough manifestations in the last 2 weeks) and physical examination should be performed by two independent doctors from both emergency and neurosurgery departments under strict second level protection. Nucleic acid sequencing of throat swab, fast pulmonary, as well chest CT scan were carried out for preliminary diagnosis and screening, since COVID-19 patients could be asymptomatic and highly contagious during the incubation period. Positive screening results were identified to be confirmed cases with positive virus RNA or with negative RNA test but highly suspected viral pneumonia signs on CT images. However, these examinations should be skipped and a direct emergent surgery should be performed for patients with life-threating conditions. Patients without immediate life-threating conditions were transferred to the neurosurgery wards through a special lane to avoid cross infection.
With the shadow of COVID-19 fading away in China, hopefully Wuhan is reviving. The personal protection level is gradually lowered in our hospital. However, as these words were written, many other countries are still facing the challenge of the pandemic. To care for the massive numbers of COVID patients, a wider international collaboration is critically needed. We expect the experience described above can help other medical staff to be equipped to smoothly come through the pandemic. Not only neurosurgeons but also other specialist physicians should be the backbone in this battle. With all these efforts, we do have faith that working hand-in-hand will help more patients survive from this catastrophe, and become even stronger as a community of common health for humankind.
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