Getting Neurosurgery Services Back on Its Feet: "Learning to Live" with COVID-19

Abstract

Background: Cancellation/postponement of "non-emergent" surgeries during coronavirus disease of 2019 (COVID-19) pandemic has created a huge backlog of patients waiting for surgery and has put them at risk of disease progression. We share our institute's policy and our department's attempt to resume "non-emergent" surgeries.

Materials and methods: We collected details of all patients operated under department of neurosurgery since the onset of COVID-19 pandemic in India and categorized them into "lockdown" and "unlock" groups for comparison. COVID-19 tests done in these patients were also analyzed. We also compared our surgical volume with the number of COVID-19 cases in the state.

Results: One hundred and forty-eight patients (97 males, 51 females) with mean age of 37.8 years (range-2 months-82 years) underwent surgery in our department during the study period. The operative volume per week increased by 37% during the "unlock" period as compared to "lockdown" period. The proportion of elective/"non-emergent" surgeries increased from 11.3% during "lockdown" to 34.7% during the "unlock" period (P = 0.0037). During "lockdown" period, number of surgeries declined steadily as the number of COVID-19 cases rose in the state (rs(8) = -0.914, P = 0.000). Whereas there was a trend toward increased number of cases done per week despite increase in the number of cases in the state during the "unlock" period. During the "unlocking" process, in-patient department admissions and surgeries performed per month increased (P = 0.0000) and this increase was uniform across all specialties. COVID-19 test was done (preoperatively or postoperatively) for all surgeries during "unlock" period compared to 12 (22.6%) surgeries during "lockdown" period. Three neurosurgery patients who underwent surgery during the "unlock" period tested positive for COVID-19.

Conclusions: Our experience shows that proper evidence-based protocols, setting up of adequate COVID-19 testing facilities and provision of ample personal protective equipments are instrumental in re-starting "nonemergent" surgeries.

Keywords: Coronavirus disease of 2019 (COVID-19); coronavirus disease of 2019 testing; elective surgeries; emergency surgeries; nonemergent surgeries; pandemic; routine surgeries.

Figure 1

Frequency polygon depicting the number of surgeries performed per week in relation to the rising trend of COVID-19 cases in Uttarakhand during the pandemic. During the lockdown period, there was a strongly negative correlation between the number of surgeries performed and the number of COVID-19 cases in the state and this result was statistically significant (rs (8) = −0.914, P = 0.000). While in the unlock phase, there was a weak correlation between the number of surgeries performed and the number of COVID-19 cases in the state. This result was not significant (rs (11) = 0.307, P = 0.307)

Figure 2

Horizontal stacked bar graph depicting the number of elective and emergency surgeries performed in each month since the onset of pandemic in the country. No elective cases were done during the month of May (lockdown period). The number of elective cases increased from 0 in May to 5 in June and 14 each in July and August. The proportion of nonemergent/elective surgeries increased from 11.3% during the “lockdown” period to 34.7% during the “unlock” period and this result was statistically significant (P = 0.0037)

Figure 3

Vertical bar graph depicting number of surgeries performed from April to August in 2019 and 2020. During the ”lockdown” period of April and May, 44.9% surgeries were performed as compared to same months in 2019, whereas in the “unlock” period of June, July and August, this proportion increased to 63.6% compared to the same months in 2019 (P = 0.1889). However, when the same data for the 3 months of ”unlock” period was compared with month of May alone (17.3% surgeries in 2020 compared to last year), this difference was statistically significant (P = 0.0009)

Figure 4

Vertical bar graph depicting the number of in-patient department admissions from April to August in 2019 and 2020. During the ”lockdown” period of April and May, there were only 33.9% hospital admissions as compared to same months in the previous year, whereas in the ”unlock” period of June, July and August, this proportion increased to 94.9% compared to the same months in the previous year. This change was found to be statistically significant (P < 0.00001)

Figure 5

Clustered bar graph depicting the speciality-wise distribution of surgeries performed between lockdown period (March 25 to May 31, 2020) and 'unlock' period (June 1 to August 31, 2020). An increase in surgeries of all specialties is observed. No surgeries for congenital conditions and degenerative spinal conditions were performed during the lockdown period

Figure 6

Protocol for triaging and COVID-19 testing at our institute during the COVID-19 pandemic