The COVID-19 (SARS-CoV-2, nCoV, novel coronavirus) outbreak represents the worst pandemic experienced by nearly all people currently living and has had severe medical, social, and economic tolls worldwide. World Health Organization data demonstrate an exponential rise in the numbers of cases and deaths, with over 1.5 million people confirmed infected worldwide and a mortality rate of approximately 6% at the time of this writing in early April 2020.1 As the number of cases continues to climb, hospitals and health systems are being strained to a point of crisis, with the worst yet to come in many parts of the world.
In responding to this crisis, our usual systems of operation must be altered to contend with and adapt to a rapidly changing situation. Medical and surgical specialties must not only answer the call to assist in the management of COVID-19 patients, but also work to ensure personal safety, patient safety, and the provision of specialty care necessary in urgent and emergent situations. In this Invited Commentary, we share lessons we have learned regarding triage of cases, staff safety, workforce management, and the psychological impact as we have adapted to this new reality in the Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hot spot in New York City.
Triage of Cases and Patient Management
After the COVID-19 pandemic was declared a national emergency, the federal government began declaring states, including New York, as major disaster areas. In addition, state-level executive orders were issued to assist in preparation for the crisis, ranging from community social distancing to specific mandates for the health care community. In New York, hospitals rapidly phased out elective surgeries, allowing for emergent cases only, and were mandated to increase their bed capacity, emphasizing ICU-level care.2,3
The specialist’s role in achieving these goals, however, is not clear. Triage of cases into elective, urgent, and emergent is not straightforward, and it must balance the best care for each patient as an individual with the greater good in this public health crisis. As many specialists will attest, there is rarely an adequate algorithmic approach, despite guidance from the literature.4–10 A unified departmental protocol for such decision making can help in times of uncertainty.
At our institution, the stratification of neurosurgical cases is performed within each subspecialty (spine, vascular, tumor/skull base, pediatrics, trauma). Younger patients are prioritized, and there is an attempt to keep patients over 65 years old, particularly those with multiple comorbidities, out of the hospital (both to limit their exposure to COVID-19 and as a factor in resource sparing). This stratification limits our department’s case load to spinal pathologies with acute neurological deficit, intracranial vascular pathologies, infections, and trauma. Surgery for malignant intracranial neoplasms is reserved for cases where timely resection is essential to conserve neurological function or improve prognosis, with a thorough consideration of the risks to the patient in the hospital, as well as the patient’s age, comorbidities, and overall prognosis.
Symptomatology is also considered, with neurological signs and symptoms, rather than mere operative pathology, dictating management when appropriate. For instance, early in this pandemic, a female patient in her 80s with a medical history of type 2 diabetes presented with 1 month of confusion and word-finding difficulty after several falls. She was found to have bilateral subdural hematomas with significant mass effect. Before the pandemic, we would have admitted this patient for operative management without debate; in this case, due to the pervasiveness of COVID-19 in our hospital and the patient’s medical history, we extensively discussed following her as an outpatient until the cases of COVID-19 decreased or her neurological condition deteriorated. She was ultimately admitted for surgery because her neurological status deteriorated while she was at the hospital. She recovered and did contract COVID-19 in the hospital, but did not develop severe symptoms.
When consenting patients for surgery—in no small part due to the aforementioned patient experience—we have altered our usual process to include a discussion of the increased risk of COVID-19 infection in the hospital, prolonged intubation, and possibility of ventilator redistribution in a crisis scenario. (Fortunately, we have not had to make such a decision on our patients yet.) As an added measure, all booked cases are rapidly screened by an objective third party within our department as well as by an institutional panel for confirmation of urgent or emergent need, with the added consideration of public health and resource management. Finally, as a department, we recognize and are preparing for the possibility that our definition of “emergent” may need to change in the face of increasingly scarce resources.
The limited supply of personal protective equipment (PPE) is a major source of anxiety and frustration for health care workers. Those on the front lines caring for COVID-19 patients bear the brunt of the risk, including emergency, ICU, internal medicine, and infectious disease services. Specialty services are in a unique position: Despite decreased risk of known exposure, their mobile nature throughout the hospital may increase risk of unknown exposure and/or transmission. Additionally, with small staff pools, any staff member infected, and thus unable to perform their duties, may have a high impact on the service’s ability to function. Consequently, it is of paramount importance to lay out proper protocols for protection and to be both conscientious about the safety of and cognizant of transmission by specialists throughout the hospital.
At our institution, specialty team members practice social distancing and have been instructed to wear, at minimum, surgical masks (standard 3-ply) for all patient encounters throughout the hospital, regardless of patients’ known COVID-19 status. Our department staff, especially on-call neurosurgical residents, try to limit movement around the hospital. For example, we attempt to batch emergency department (ED) consults into one visit when possible, thus decreasing our frequency of entering and leaving the ED. During rounds, we limit the number of residents entering the rooms of COVID-19-positive patients.
For surgical specialties, aerosolizing procedures provide an added risk of transmission.11 Our institutional policy is for full PPE—including N-95 mask, visor, and gown—to be donned during such procedures (e.g., bronchoscopy, laparoscopy, intubation) when performed on COVID-19 symptomatic patients. To further reduce risk, only essential staff are permitted in the room during procedures. During intubation, for example, only the anesthesiologist/intensivist is in the room, with the rest of the staff in substerile and available if needed.
General safety protocols may be broadly effective, but just as with the general population, certain health care workers are at increased risk of infection and serious complications due to preexisting conditions. Staff members with advanced age, with medical comorbidities, who have at-risk family members at home, or who are pregnant are positioned in the office or in support roles (e.g., telehealth) and away from patient contact as much as possible.
Running the Specialty Service: Workforce Management
With the changes in case load and in consideration of patient and staff safety, adjustments have been made in the day-to-day running of our neurosurgical service. Given the rapidly changing situation, we have gone through multiple iterations of our service provision with the goal of limiting the number of providers in the hospital, close contact between providers, and interactions with patients, while also being mindful to not compromise patient care.
With the initial decrease in our service’s case load, our contingent of 10 residents was reduced to a skeleton crew of 1 junior resident on in-house call and 1 senior resident on backup and case coverage. This rotation decreased the number of residents in the hospital at any time and the total amount of time each resident had to spend in the hospital, limiting exposure. The neurosurgical interns (first-year residents) had the most significant change in their typical work experience. They no longer were required to work in nonneurosurgical units because of the need for every resident to be involved in the neurosurgical service. Interns were placed into the junior call pool or stroke call pool. There was always a more senior resident available to offer guidance to the interns during these difficult times.
Contact between residents on a 24-hour cycle shared between multiple junior and senior residents, however, resulted in overexposure of the entire pool of residents. Thus, the call schedule was modified to 3 teams of 3 residents each (2 junior residents and 1 senior resident), with a day/night float schedule on a 6-day cycle. Handoffs between teams were performed via videoconference, with each team isolated from the others to contain transmission. The added benefit of this schedule was that each team was off for 12 days between calls, so an approximate 2-week “quarantine” would be practiced—which was of particular importance given the lengthy incubation period of COVID-19.12
This iteration required the full resident contingent and was, consequently, short-lived, as our hospital and New York State Department of Health required health care workers to be reassigned to the care of the increasing number of COVID-19 patients. Thus, the majority of our residents have been slated for the ICU. Our current iteration consists of 3 in-house call residents who rotate every 24 hours.
The other members of our staff include our team of 3 nurse practitioners who normally care for the patients on the neurosurgical floor and previously alternated 12-hour shifts. They have adjusted their schedule multiple times, with 1 team member pregnant and another who was quarantined at home after community exposure. Attending physician coverage has been limited to those who are at high risk; the rest of the attendings have been reassigned to ICU and ED coverage.
Finally, we are taking steps to limit exposure of staff and patients. We are minimizing redundant patient examinations and cross over between patient rooms by attempting to assign individuals to specific patients for a shift or multiple shifts when relevant, as in the case of nurse practitioners. When possible, the nurse practitioners provide routine care for the patients on the neurosurgical floor during the day, separate from the rest of the hospital, which the resident team covers. Additionally, we are working with the staff involved in discharge planning to discharge patients as rapidly as is safe, both to minimize the risk of infection and to make available as many beds as possible.
The key takeaway from our experience with workforce management is that no iteration is perfect. Each service would be well-advised to maximize isolation of its staff from one another and the hospital at-large when they are not clinically active to maintain the health of team members for as long as the virus permits, as it is unclear how long the crisis will last.
Research focusing on the psychological impact of natural disasters on health care workers may be relevant to our current paradigm. In certain studies, such as Brooks et al,13 participants have demonstrated a boost in their morale if they believe their work had a positive impact on the community. Similarly, bonds can be strengthened between colleagues due to a mutual understanding of their experiences during the crisis. Conversely, and unfortunately more frequently, medical providers report negative emotional responses in these situations, including feelings of shock, concern for colleagues, and helplessness. Everyday life stressors also tend to contribute to emotional distress.
Our neurosurgical department has experienced a similar mix of psychological effects in response to the COVID-19 pandemic, including an apparent increase in general anxiety. However, there has been an increase in team bonding during this difficult situation. Our department holds daily videoconference meetings to provide departmental news as well as to check on the general well-being of all residents and attendings. In addition, the residents hold daily informal videoconference meetings to allow for a social outlet while still practicing safe social distancing. These meetings help raise morale and create a feeling of community. Our small department has also been very charitable, offering child care to one another and allowing for flexible work schedules whenever possible and appropriate. Furthermore, staff have been encouraged to avail themselves of mental health support provided by our institution.
An interesting and important variable in the psychological impact of the COVID-19 pandemic relates to patient visitation restrictions. The majority of hospitals in the New York City area, including our own, have adopted a policy allowing a single visitor as a compassionate consideration in pediatric, severe neurologically deteriorated, and terminal cases. Consequently, we as a team are serving as emotional intermediaries for our patients and their families, including facilitating video calls and passing personal messages of support. While it is an honor and privilege to be entrusted with our patients’ confidences, the nature of the content exacts an emotional toll.
Recommendations and Conclusions
In the response to the COVID-19 pandemic, adaptability is key, as specialty services are tasked with assisting with the care of COVID-19 patients while also maintaining appropriate care of their own patients with urgent and emergent pathologies. We recommend following the general guidelines in List 1 to help ensure patient and practitioner safety. However, every situation is unique and requires constant reevaluation of best practices. We hope sharing our experiences in a rapidly changing COVID-19 epicenter can help provide guidance for others in how to prepare for and manage specialty care during this evolving crisis.
General Guidelines for Patient and Health Care Worker Safety on Specialty Services During the COVID-19 Pandemic
- 1) Be adaptable and prepare contingency plans for the unexpected.
- a. Have “jeopardy” staff available.
- b. Consider reliance on attendings in lieu of senior residents.
- c. Consider a senior resident as sole in-house call, if necessary.
- 2) Limit admitted patients to urgent/emergent cases, with stratification by pathology, age, comorbidities, type of care required, and availability of resources.
- 3) Adjust informed consent process to include discussion of the risks of COVID-19 infection.
- 4) Remember that staff safety is just as important as patient safety.
- 5) Limit staff exposure and transmission to one another and to patients by implementing protective measures.
- a. Practice social distancing.
- b. Wear proper personal protective equipment.
- c. Limit the number of staff who interact with patients to essential staff only.
- d. Separate staff into groups and limit interaction between groups, if possible.
- e. Limit movement around the hospital as much as possible to limit transmission between units.
- 6) Be mindful of staff mental health in addition to physical health.
- a. Use institutional mental health resources, or provide them if they are not available.
- b. Communicate frequently on multiple department levels; this is essential.
1. World Health Organization. Coronavirus (COVID-19).https://who.sprinklr.com
. Published 2020. Accessed April 10, 2020.
2. Cuomo A. Executive order no. 202.10: Continuing temporary suspension and modification of laws relating to the disaster emergency.New York State. https://www.governor.ny.gov/news/no-20210-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency
. Published March 23, 2020. Accessed April 9, 2020.
3. Cuomo A. Executive order no. 202.14: Continuing temporary suspension and modification of laws relating to the disaster emergency.New York State. https://www.governor.ny.gov/news/no-20214-continuing-temporary-suspension-and-modification-laws-relating-disaster-emergency
. Published April, 7, 2020. Accessed April 13, 2020.
4. Atzema C, Mower WR, Hoffman JR, et al.; National Emergency X-Radiography Utilization Study (NEXUS) II Group. Defining “therapeutically inconsequential” head computed tomographic findings in patients with blunt head trauma. Ann Emerg Med. 2004;44:47–56.
5. Quigley MR, Salary M. Defining survivorship after high-grade aneurysmal subarachnoid hemorrhage. Surg Neurol. 2008;69:261–265.
6. Tuchman A, Pham M, Hsieh PC. The indications and timing for operative management of spinal epidural abscess: Literature review and treatment algorithm. Neurosurg Focus. 2014;37:E8.
7. Pacheco MG Jr, Pessoa BL, Landeiro JA, de Abreu Macedo PH, Leite MAA. Spontaneous resolution of chronic subdural hematoma: Does only the size matter? Surg Neurol Int. 2019;10:194.
8. Kayahara T, Kikkawa Y, Komine H, et al. Predictors of subacute hematoma expansion requiring surgical evacuation after initial conservative treatment in patients with acute subdural hematoma. Acta Neurochir (Wien). 2020;162:357–363.
9. Sufaro Y, Avraham E, Alguyn F, Azriel A, Melamed I. Unfavorable functional outcome is expected for elderly patients suffering from acute subdural hematoma even when presenting with preserved level of consciousness. J Clin Neurosci. 2019;67:167–171.
10. Zekaj E, Saleh C, Minichiello M, Perazzo P, Servello D. How to treat repeated subdural hematomas after lumbar puncture? Asian J Neurosurg. 2019;14:249–252.
11. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One. 2012;7:e35797.
12. Lauer SA, Grantz KH, Bi Q, et al. The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: Estimation and application. Ann Intern Med. 2020. doi:10.7326/M20-0504.
13. Brooks SK, Dunn R, Amlôt R, Rubin GJ, Greenberg N. Protecting the psychological wellbeing of staff exposed to disaster or emergency at work: A qualitative study. BMC Psychol. 2019;7:78.