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Reviews: Review Article

Response to the Coronavirus Disease 2019 Pandemic by the Spine Division at a Level-I Academic Referral Center

DeKeyser, Graham J. MD; Brodke, Darrel S. MD; Saltzman, Charles L. MD; Lawrence, Brandon D. MD

Author Information
Journal of the American Academy of Orthopaedic Surgeons: December 15, 2020 - Volume 28 - Issue 24 - p 1003-1008
doi: 10.5435/JAAOS-D-20-00493
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  • COVID-19

Abstract

The novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) was first identified in patients in the People's Republic of China in late December 2019.1-3 As of April 10, 2010, this viral infection had been diagnosed in more than 1.5 million individuals worldwide and accounted for nearly 100,000 deaths. The World Health Organization has appropriately labeled this outbreak as a global health emergency, and this has led our society and global healthcare system into unprecedented territory. The public health focus has been on the suppression of disease transmission, preservation of valuable healthcare resources, and mitigation of the disease.4-6

The impact of this pandemic on spine surgery has forced practices to balance the urgency of clinical care against the conservation of healthcare resources and the suppression of diseases transmission. The orthopaedic spine division at our institution is a tertiary referral center serving a wide geographic area. The division consists of four fellowship-trained, subspecialized faculty with busy clinical practices, three physician assistants, two nurses, six medical assistants (MAs), two residents, and two fellows. The entire division has made rapid and dramatic adjustments to clinical practice and patient care in the midst of this healthcare crisis.

The spine division in concert with the department and our hospital system has rapidly pivoted in the face of coronavirus disease 2019 (COVID-19). These changes include halting all elective surgeries, creating a committee to appropriately triage urgent and emergent spine cases, changing operating room policies to protect surgical personnel, “platooning” residents in small groups to evaluate and round on patients, focusing on education through virtual platforms, delaying nonessential clinic visits, transitioning most clinic visits to a virtual platform, and participating in department and institutional leadership committees to communicate and adapt in the face of rapid changes and obstacles.

The purpose of this review is to describe the changes implemented by the spine division at an academic, tertiary care center in response to the COVID-19 pandemic.

Implementation of Changes

Halting All Elective Surgeries

On March 16, the orthopaedic spine division along with the entire Department of Orthopaedics at the University of Utah chose to indefinitely delay all elective surgeries. This was a decision that was made to preserve critical resources, reduce exposure, and protect against a potential surge of affected patients. This action was in line with the actions of other healthcare systems around the world and lessons learned from previous pandemics.7-9 On March 23, the State of Utah and the Department of Health followed suit and issued a state public health order to halt all elective and nonurgent surgeries through at least April 25.

Predictably, the surgical volume of the orthopaedic spine division has decreased dramatically since elective surgical cases have been placed on an indefinite hold. From March 16, 2020, to April 10, 2020, the orthopaedic spine division has performed 10 total surgeries including 3 cases for traumatic spinal injuries and 7 urgent/emergent cases. During this same period over the previous 5 years, our division had performed an average of 60.4 spine surgeries, a stark contrast to the COVID-19 pandemic (Table 1). Clearly, this pandemic has marked affected the surgical productivity of the department.

Table 1 - Surgical Case Volume Between March 16 and April 10 (by Year)
2020 2019 2018 2017 2016 2015 Avg 2019-2015
Elective/urgent surgery 7 62 58 54 50 47 54.2
Trauma surgery 3 6 4 7 7 7 6.2
Total 10 68 62 61 57 54 60.4

Committee to Determine/Review Urgent and Elective Spine Cases

The care of spine patients presents unique challenges, distinguishing elective from nonelective surgical treatment. A number of conditions related to the spine are time-sensitive; notable surgical delay can result in progression of weakness, worsening neurologic function, and potentially irreversible patient harm. Some diagnoses with clear and progressive potential for permanent nerve injury, such as cauda equina syndrome, spinal cord injury, myelopathy, and compressive tumors, clearly require urgent or emergent treatment. However, still more clinical situations fall into a gray area of urgency.7 In the face of a pandemic, with medical personnel putting themselves at risk and the supply of healthcare workers, drugs, hospital and intensive care unit beds, ventilators, and personal protective equipment (PPE) constantly fluxing, determining what is an absolutely necessary urgent spinal surgery treatment presented unusual challenges.

To standardize the definition of nonurgent spine cases and make executive decisions about operating room resource management, a spine surgical review committee was created. This committee consists of the Division Chiefs from Orthopaedics, Neurosurgery, and Anesthesia. This group has collectively created a classification of spine pathology that groups diagnosis into (1) urgent/emergent cases, (2) time-sensitive cases, and (3) nonurgent cases (Table 2). The classification system is consistent with the guidelines for triaging surgeries during COVID-19 outlined by the American Academy of Orthopaedic Surgeons and the American College of Surgeons.10,11 This committee reviews all spine cases that are proposed to determine appropriateness during this pandemic, and recommendations are presented back to the treating spine surgeon on the appropriateness of care. This organized system ensures that spine cases of appropriate urgency are allowed to proceed, and definitions of nonurgent cases are agreed upon in a multidisciplinary setting.

Table 2 - Classification of Spine Case Urgency
Urgent/Emergent Time-sensitive Elective (>6 wk)
• Spine trauma w/instability or cord injury • Tumor, pending instability w/stable neuro deficit • Degenerative disease w/stable neuro deficit
• Rapidly progressive myelopathy • Fracture or implant failure w/stable neuro deficit or impending deficit • Nonunion
• Wound infection • Moderate/severe myelopathy or preventing ADLs • Mild myelopathy w/stable neuro deficit
• Tumor w/neuro compromise • Infection, failed antibiotics • Spinal deformity
• Infection w/instability or neuro compromise • Cervical/lumbar disk herniation w/progressive weakness, or failed 6 wk non-op • Disk herniation w/stable neuro deficit, no CES
• CES • Cervical/lumbar stenosis w/progressive weakness • Stenosis preventing ADLs
• Fracture or implant failure w/myelopathy • Progressively worsening radiculopathy
ADL = activity of daily living, CES = cauda equina syndrome

Some controversy exists regarding the time sensitivity of spine cases, and the committee has helped to create standard protocols. In particular, defining a progressively worsening radiculopathy has been controversial. Our group has defined this as a “progressively worsening radiculopathy that has failed conservative treatment and continuously impairs activities of daily living” and has placed this diagnosis in the “time-sensitive” category.

When a case is approved by the committee, this decision is communicated back to the treating surgeon, and the intervention is scheduled with the operating room in a timely manner. The classification of the time sensitivity of the case determines the priority of scheduling. Before any surgical interventions, a negative COVID-19 test is required or the patient must proceed with strict COVID-19 precautions if the case is deemed emergent before a negative COVID-19 test being available.

Operating Room Procedural Protocols for Surgeons

A notable exposure to SARS-CoV-2 occurs through occupational environments, particularly in the hospital setting.12 A survey of orthopaedic surgeons in Wuhan, China, the early epicenter of the disease, estimated that approximately 12.5% of surgeons who tested positive were exposed in the operating room.2,13 The suspected mode of greatest exposure and transmission of the disease is through aerosolization, presumably around the time of intubation or extubation.2,13-15

The Orthopaedic Department at our institution instituted policies to protect surgeons in the operating room setting. First, all nonessential personnel should be outside of the operating room during aerosolization procedures (intubation, extubation, airway suctioning, etc.). Second, the surgeon and nonessential individuals should remain outside of the operating room for 14 minutes after intubation and extubation to allow for adequate air filtration and potential viral load drop in the operating rooms. This period was chosen because it corresponds to approximately two periods of 7 minutes, which is the estimated period of time for one turnover of aerosolized particles in our operating rooms. Third, only essential surgical personnel should be present in the operating room during surgery (one faculty and one trainee per case) to preserve PPE and limit exposure of healthcare workers as much as possible. Finally, COVID-19 testing is mandated for all surgical patients and is used to clarify surgical timing, method of anesthesia, and perioperative care of the patient.

Beginning in early April, COVID-19 testing was mandated for all surgical cases. Urgent and emergent cases received a “rapid” COVID-19 test which was processed by our laboratory in 30 minutes to 2 hours. If the case was too time-sensitive to wait for a rapid COVID-19 test, then the patient proceeded to the operating room with full COVID-19 precautions. In the case of “time-sensitive” and “elective” cases, a negative COVID-19 test was required within 7 days of the surgical intervention. Ideally, this testing was performed within 48 to 72 hours of the planned surgical intervention. This testing was performed with a nonrapid polymerase chain reaction COVID-19 test, which generally results within 8 to 12 hours after testing.

Resident “Platooning” to Decrease Exposure

The orthopaedic department quickly restructured the inpatient workforce to decrease exposure and risk of disease contraction. Resident “platoons” were created based on the location of work rather than the classic model of learners rotating based on subspecialty. Two residents were assigned to cover all consults, rounding, and urgent surgical cases for all subspecialties including spine at the main hospital. A separate resident was assigned to the veteran's hospital, the pediatrics hospital, and the cancer hospital. These resident platoons work on-site for 1 week and then are assigned 2 weeks of working remotely. This weekly rotating schedule would allow 2 weeks of isolation for the novel coronavirus incubation period to show symptoms if the disease is contracted. Other academic centers have enacted similar tactics.16

This system of resident platooning has drastically decreased the amount of resident and patient exposure and PPE usage. Previously, an average emergency department (ED) spine consult would be evaluated by an ED resident, an ED attending, two junior level residents, a senior level resident, and potentially a fellow or attending. Under our current system, a single ED provider evaluates the patient, followed by evaluation by a single orthopaedic resident, and the resident directly calls the appropriate faculty. This process has markedly decreased the exposure for patients and providers in this situation. Still, we continue to provide continuous orthopaedic coverage of the ED and inpatient setting at multiple hospitals while minimizing patient interactions and protecting resources. To this point, no confirmed COVID-19 illnesses exists within our residency or our spine division.

Educating Through Virtual Platforms

The spine division at our institution is heavily involved in training and educating, and we have turned to creative measures during this pandemic to continue to educate. Our team consists of two fellows and two residents on service. During this pandemic, their exposure to surgical spine procedures has dramatically decreased (Table 1). To fill this void, we have expanded the resident and fellow didactic sessions through virtual platforms. Multiple videoconferencing platforms are free for download and allow efficient learning platforms while maintaining appropriate “social distancing.”

On a weekly basis, the spine division performs 4.5 hours of education sessions within the institution through a videoconference platform. This includes 1 hour of fellow-led orthopaedic in-training examination and board prep, 1 hour of faculty-led didactics, 30 minutes of resident-led presentation, 1 hour “journal club,” and 1 hour of indications conference reviewing trauma or urgent/emergent cases in great detail. Furthermore, the residency has taken this opportunity to create surgical technique guides that describe common spine procedures and technical tips for their own education and the benefit of future trainees on service.

The nationwide decrease in clinical duties has also allowed unique opportunities. As our fellows prepare to enter into their own independent practice, we have taken this opportunity to help them prepare for their board examinations. Over the course of this pandemic, the fellows have performed “mock” oral board examinations with faculty acting as reviewers. Furthermore, interinstitutional online learning opportunities have been created over virtual platforms that highlight important educational topics including case-based discussions, pertinent literature review, and high-quality lectures from national leaders in the field.

Delay Nonessential Clinic Evaluations and Transition to Virtual Clinic Setting

The guiding principle in changes to the spine clinic evaluation was to eliminate unnecessary patient and healthcare worker interaction. Beginning March 16, the spine division transitioned to delaying nonurgent visits and triaging most visits to the virtual setting. In-person visits were reserved for select circumstances to include worsening neurologic condition, post-op suture removal that cannot be performed at home or locally and wound/infection concern.

Logistically, this process begins with patient phone calls performed by MAs on the day before clinic visit to inform patients of the policy change and confirm their participation in the virtual visit. Most patients have agreed to participate and are appreciative of efforts to decrease in-person interactions. The clinic is virtually staffed by an attending, MA, physical therapist, physician assistant, and resident or fellow. A secure, real-time, shared document was created to communicate between this team regarding patient updates, plans, imaging, physical therapy, and follow-up (Figure 1). Patients are contacted through telephone calls or video calls in compliance with the Health Insurance Portability and Accountability Act of 1996 and the recent legislative modifications in the setting of COVID-19.17 The following website provides a number of commercially available vendors approved by the Health & Human Services with Health Insurance Portability and Accountability Act compliant video communication platforms: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html. Coding for telehealth patient interactions has also changed in the setting of this pandemic, and our office has followed the coding recommendations put forth by the American Academy of Orthopaedic Surgeons and American Medical Association during these times.18,19 After telehealth phone calls or video calls are completed, the MA and physical therapist enact patient plans including making follow-up appointments, imaging, orders, and sending patients home exercise programs to continue rehabilitation and nonoperative therapies while maintaining social distancing.

Figure 1
Figure 1:
Illustration showing the example of secure, editable document to organize telehealth clinic. MA = medical assistant, PSF = posterior spinal fusion, PT = physical therapy

These clinic policies went into effect on March 16. Since that time, the spine division has clinically evaluated 65 new patients and 257 return patients for a total of 322 patient evaluations. This is compared with an average of 117 new patient visits and 300.4 return patients over the same period, averaged for the previous 5 years (Table 3). This corresponds to 77.1% total clinic volume during COVID-19 compared with the average of 5 years previously. The patient mix has shifted from an average 28.0% new patient visits to 20.2% new patient visits during COVID-19. In line with the guiding principles during this pandemic, 98.8% (318 of 322) of visits were performed via telehealth, and only 4 of 322 visits were performed in person. The transition to telehealth clinic care has been surprisingly seamless without sacrificing quality patient care.

Table 3 - Clinic Visits to See Spine Faculty Between March 16 and April 10 (by Year)
2020 2019 2018 2017 2016 2015 Avg 2019-2015
Return patient (virtual visit) 257 (253) 392 378 293 193 246 300.4
New patient (virtual visit) 65 (65) 149 155 128 85 68 117
Total (virtual visit) 322 (318) 541 533 421 278 314 417.4

The physical examination performed via virtual visits has allowed appropriate and timely care with some creativity required in administration. Multiple resources exist regarding appropriate neurologic testing in the virtual setting.20,21 However, there is inevitably some loss of quality in the examination that cannot substitute for the in-person examination. In cases where the examination is critical to diagnosis and treatment and a virtual examination are insufficient, the patient is encouraged to present for an in-person evaluation.

Participation in Department Coronavirus Disease 2019 Task Force

In early March 2020, the Orthopaedics department at the University of Utah created a faculty leadership COVID-19 task force to help guide the department throughout this unprecedented situation. The task force involves department-level leadership from administration and education and, importantly, clinical leadership from each of the six hospitals we cover; this task meets frequently in a virtual setting. The spine division has a representation on this group, as do nearly all divisions. Communication between the task force and all members of the department is frequent and clear. No other source of information on the response to the COVID-19 pandemic is communicated to the department, helping to maintain certainty of information in this time of quickly changing protocols.

The COVID-19 task force is collectively responsible for making protocol decisions regarding triaging patient care, PPE usage, and department policies surrounding the changing landscape surrounding the pandemic.

Planning for the Future

The global response to the COVID-19 pandemic has been born out of necessity. We are in the midst of this worldwide battle against a highly contagious and potentially lethal virus; the terrain is constantly shifting. As our orthopaedic spine division continues to focus on protecting patients and healthcare workers, and being cognizant and respectful of rationing critical resources, we are beginning to look forward to a recovery phase. Certainly, difficult questions lay ahead about when to recommence elective surgical cases and which patients and conditions to prioritize. How will we ease back in to normalcy? Will it be punctuated by recurrent surges in prevalence and new discoveries for testing, treatment, or immunization? Do we allow younger, healthier patients to return to the elective surgical schedule earlier or do we prioritize more time-sensitive cases? How do we define time-sensitive cases? Should we enact policies to allow longer surgical cases to conserve PPE or should shorter cases with likely shorter inpatient stays be the focus? In addition, are there aspects of our pandemic required approach to patient care that may serve the delivery of patient care and education better in the future? Can we effectively treat patients via telehealth and save costly trips to our office? Can we provide effective education via teleconferences with other institutions more regularly?

Summary

The COVID-19 pandemic has forced our orthopaedic spine division to rapidly enact a number of changes in protocol and patient care. We present the many substantial changes that have been made to face the challenges of physical distancing, keeping patients and healthcare workers safe, preserving critical resources, and still being sure we are providing urgent and emergent care along with the rationale for such changes. We now must continue to weather the storm while also planning for recovery. We hope that unique opportunities learned from this experience such as interinstitution didactics, increased familiarity with telehealth modalities, and a heightened sense of community allow us to come out of this experience more cohesive, caring, and efficient. Perhaps this is the silver lining associated with the COVID-19 pandemic.

References

References printed in bold type are those published within the past 5 years.

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Copyright 2020 by the American Academy of Orthopaedic Surgeons.