COVID-19 USA



An Update on Neurosurgery from the New York COVID-19 Hotspot

Chirag D Gandhi
Professor and Chair of Neurosurgery
Westchester Medical Center / New York Medical College
Valhalla, New York

It has been over 90 days since the first reported case of COVID-19 in New York City on March 1, 2020. Since then, within New York State there have been nearly 360,000 diagnosed cases, 90,000 hospitalizations, and 24,000 reported deaths related to the virus, with another approximately 15,000 deaths in the two surrounding states [1]. These staggering numbers, which reports suggest may be an underestimation, have unfortunately designated the New York metropolitan area as the largest hotspot in the world [2]. The implications for regional neurosurgery have been profound in terms of the delivery of emergency and elective clinical care, as well as the educational and research missions of our specialty. More recently, as the number of new admissions and deaths finally decrease (Figure 1), the region has entered a period of phased reopening. With what we hope was the worst of the regional pandemic behind us, reflection on the experience and appreciation of the durable lessons is undoubtedly the key to a successful transition to a “new normal”.

THE INITIAL RESPONSE:

In the early days of the New York pandemic, as the rapid spread of the virus became increasingly clear, regional health centers, following state mandates, discontinued all elective surgery and inperson outpatient office visits. Simultaneously, non-essential hospital administrative staff were instructed to work from home and medical students were transitioned to remote learning with cessation of all clinical rotations. Additionally, all teaching hospitals with residency programs requested Stage 3 Pandemic Emergency Status from the Accreditation Council for Graduate Medical Education (ACGME) allowing for the redeployment of residents to pandemic-related care and temporary suspension of specialty-specific training requirements.

At our institution, in addition to the dissemination of personal protective equipment (PPE), a multi-tiered COVID-19 polymerase chain reaction (PCR) testing regime was established for all admissions to the hospital, with the subsequent addition of drive-through testing capabilities for both healthcare workers and patients scheduled for urgent surgery. This triage system also allowed for the creation of physically distinct intensive care unit (ICU) and non-ICU beds, operating and interventional rooms, and designated radiology scanners based on a patient’s COVID-19 status. Within a few days of initiating this process, we were gratified to see very few patients developing COVID-19 after admission. This trend has been durable with nearly 1300 COVID-19 patient discharges as of June 1, 2020. These testing capabilities have expanded significantly over the past few weeks in anticipation of the restart of elective surgery. Overall, based on a systematic “surge plan” our hospital was able to increase ICU bed capacity by nearly 80%, and worked closely with the Federal Emergency Management Agency (FEMA) to help staff a large local field hospital to accommodate the potentially massive number of cases initially projected (Figure 2). Fortunately, the worst-case scenario numbers have not yet materialized but regionally we now have the ability to ramp up more rapidly in the event of a second wave of infections; the new field tents are now being utilized to offer antibody testing to the residents of the county.

The changes with our department were of course largely in parallel with those at the institutional level, and are representative of regional neurosurgery. With the cessation of elective procedures, the call schedules were modified so as to ensure appropriate staffing for neurosurgical emergencies, while building redundancy because of the concerns for rapid spread of the virus through the entire department. The faculty were placed on a rotating one week on-call, one week at home schedule. Similarly, smaller resident teams were created, allowing for a staggered schedule. With the re-deployment of our critical care colleagues to the newly established COVID-19 ICUs, neurosurgical faculty and residents were in-turn reassigned to frontline care of all ICU-level neurosurgical patients. Additionally, socially distant workspace away from COVID-19 designated regions of the hospital had to be created for our staff. These areas had clear protocols outlining appropriate attire, hand washing, and PPE precautions for entry and exit. All previously scheduled outpatient surgeries were initially stopped but as time passed selective case were allowed to proceed based on urgency; office visits were moved to HIPPAcompliant virtual health systems.

From an educational perspective, all our regularly scheduled weekly conferences were also transitioned to video conferencing platforms. With the drastic reduction in surgical volume, we collectively emphasized filling that time with increased clinical research productivity. Our group naturally studied and published our COVID-19-related experiences as well as continuing our peer-reviewed manuscript and abstract submissions, just at a much higher pace. Unfortunately, our departmental basic science laboratories continue to be shuttered but this has allowed for more focused time dedicated to grant funding submissions. Additionally, longstanding traditions such as the chief-resident graduation dinner and honorary professorship lectures have also been cancelled with the hopes for prioritizing their return next year.

LESSONS LEARNED AND THE FUTURE:

With the rapid spread of the pandemic, New York’s healthcare system has been pushed frighteningly close to the breaking point. But, for the moment at least, it appears that across our region there is a sustained decrease in new COVID-19 admissions, allowing for reallocation of hospital resources towards more traditional operations. For many of us who have lived through these events, this is the time to reflect on the lessons learned and create a new sustainable workflow. From a neurosurgical perspective, we have certainly seen various unique clinical manifestations of the COVID-19 virus that are relevant to our specialty. There have also been meaningful changes in how we can, and will be, delivering neurosurgical care as well as continuing education.

The medical community is only now starting to understand the widespread clinical manifestations of the COVID-19 virus outside of what was initially thought to be a very severe respiratory illness. The diffuse inflammatory cascade seen in the disease has been attributed to various clinical manifestations we have seen in our neurosurgical practice [4]. For example, there have been recent troubling reports of two pediatric deaths and many delayed post-infectious hospitalizations of children in region [5]. One of these tragic deaths occurred at our hospital in what may be the first brain-biopsy proven COVID-19-related isolated encephalopathy. The pathological specimens are still being closely reviewed prior to publication but neurosurgeons will undoubtedly be called on to help further characterize this pediatric illness. This inflammatory cascade may also be responsible for a greater propensity in younger patients to develop both dural sinus thrombosis and large vessel occlusions (LVO) [6,7]. While the true incidence remains very poorly understood, our own neurointerventional section has been distressed to note that the total number of patients presenting with ischemic stroke has decreased by nearly 40%, but a much large number of these patients have LVO and are candidates for thrombectomy. This reflects the growing number of reports suggesting that patients, because of fears of the pandemic, are not seeking even emergency care for time-sensitive diseases such as stroke and myocardial infarction [8]. As both a department and an institution, we have initiated a regional public health campaign to educate patients about these diseases and equally importantly, reassure them about the numerous safety measures in place within the hospital to ensure their safety. This is a major challenge that neurosurgery will continue to face as we work to restart our elective practices.

In the clinic practice, we quickly transitioned to the seeing patients using a web-based platform and initially, as would be expected, the learning curve of the new technology and workflow was frustrating. The advantages were quickly evident though in allowing patients living many hours away to easily access care and in situations where the doctor-patient relationship has been previously established. However, we have not found this to be an adequate substitute for the initial in-person consultation where the critical trust between the surgeon and a patient is commonly created. The increasing ease this method provides patients seeking non-urgent neurosurgical care cannot be denied and it will continue to be a permanent offering in our practice. As patients return to the office, new safety protocols for PPE use, appropriate physical distancing in our waiting rooms, and greater time between appointments are early initiatives that have been implemented. With the phased resumption of elective surgery just last week, COVID19 PCR testing three days prior to the procedure is now part of the mandatory pre-operative labs required. Additionally, as the ICU spaces previously dedicated to COVID-19 are now being consolidated, more complex neurosurgical procedures are also being scheduled. Patients with progressive neurological compromise, cancer, and unremitting pain are being prioritized but the expectation is to complete the significant back log of all elective surgery by summer’s end.

The other aspect of neurosurgery that has changed dramatically is in the delivery of educational content and potentially the resident recruitment process. While the pandemic forced both institutional and national-level neurosurgical education to move on-line, there are applications of the technology that will endure. At a departmental level, attendance of all faculty and trainees for weekly conferences was always a scheduling challenge. During the pandemic, the on-line attendance has been remarkable and the intellectual engagement of participants seems much greater. Some types of academic activities better lend themselves to the virtual conference format – these typically are the working conferences such as neuroradiology conference, journal clubs, and quality improvement conference. While this new modality cannot replace face-to-face meetings, we have helped to create new inter-institutional neurosurgery web-based conferences that allow more frequent interactions with colleagues. These were particularly helpful in the early days of the pandemic for disseminating ideas between departments struggling with similar COVD-19-specific challenges. Additionally, we have successfully completed recent fellowship interviews virtually, and as many readers may know, the 2020 resident match will be conducted entirely on-line. While the specifics of how this can be effectively and equitably conducted is still being finalized by leaders of the ACGME and Senior Society of Neurosurgery, the wellknown cost and logistical challenges of the traditional interview process may provide the impetus for meaningful long-term improvements.

The COVID-19 pandemic has permanently altered many aspects of how we will practice neurosurgery in the future. As we collectively face this change, it remains important that we quickly integrate new methods for the delivery of neurosurgical care and education, while maintaining our cornerstone traditions. This approach will ensure that our specialty will emerge from these unprecedented times even stronger.

REFERENCES:

  1. https://coronavirus.jhu.edu/map.html
  2. https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm
  3. https://www.acgme.org/COVID-19/Three-Stages-of-GME-During-the-COVID-19Pandemic/Stage-3-Pandemic-Emergency-Status-Guidance
  4. https://www.nature.com/articles/s41577-020-0331-4
  5. https://www.cbsnews.com/news/coronavirus-5-year-old-dies-new-york-severe-illness-linkedto-covid-19/
  6. https://www.nejm.org/doi/full/10.1056/NEJMc2009787
  7. https://pubmed.ncbi.nlm.nih.gov/32399457/
  8. https://www.medscape.com/viewarticle/928722

FIGURES:

Figure 1: Source: https://covid19.healthdata.org/united-states-of-america/new-york. Graph detailing previous daily deaths related to the COVID-19 pandemic within New York State as well as future projections.

Figure 2: Westchester County Center and FEMA field tents (in the foreground).

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