Letter:
On March 11, 2020, the World Health Organization declared the coronavirus 2019 (COVID-19)
infection a pandemic, where more than 110 countries reported around 120,000 confirmed
cases.
1
The numbers in the Unites States were relatively low (≈1100 confirmed cases and 40
deaths) around that time
1
; the curve, however, demonstrated an exponential trend in the following week, instigating
an emergency response at the local, national, and international levels.2, 3, 4
Hospitals in some states and counties were especially overwhelmed with large numbers
of severely affected patients with COVID-19, mandating an urgent modification of treatment
protocols for patients with other conditions to meet emergency care needs.
5
,
6
A neurosurgical treatment algorithm was recently published,
7
and neurosurgical departments are sharing their response models during the COVID-19
pandemic.
8
To maintain optimal care for patients with neurosurgical conditions and mitigate the
risk of COVID-19 transmission to residents, nurse practitioners, staff and attendings,
the department of neurosurgery at the University of South Florida devised a crisis
plan, the “Battle Plan,” which was put into effect on March 23, 2020.
The “Battle Plan” Teams
The idea behind the battle plan is to divide the pool of attending physicians and
residents into 3 teams, where each team provides comprehensive coverage of the neurosurgical
service for 1 week, followed by a 2-week self-quarantine at home in accordance with
the United States Centers for Disease Control and Prevention recommendations for exposed
individuals.
9
Each team is composed of 3 attendings of different subspecialties, i.e., cranial,
spine, and endovascular, 2 junior residents, and 1 senior resident (Table 1
).
Table 1
Composition of the 3 Battle Plan Teams
Team 1
Team 2
Team 3
Cranial/open vascular attending 1
Cranial/open vascular attending 2
Cranial/open vascular attending 3
Spinal attending 1
Spinal attending 2
Spinal attending 3
Endovascular attending 1
Endovascular attending 2
Endovascular attending 3
Chief resident 1
Chief resident 2
PGY 6 (acting as chief resident)
PGY 2 (night coverage all week)
PGY 2 (night coverage all week)
PGY 1 (night coverage all week)
PGY 3 (alternate day/night with PGY 5)
PGY 3 (alternate day/night with PGY 4)
PGY 4 (alternate day/night with PGY 5)
PGY 5 (alternate day/night with PGY 3)
PGY 4 (alternate day/night with PGY 3)
PGY 5 (alternate day/night with PGY 4)
Contingent back-up coverage
2 residents (PGY 1, PGY 6), 1 fellow, and 3 attendings (>65 years of age)
PGY, postgraduate year.
Being in a facility that has known and also possibly unidentified patients infected
with COVID-19, our personnel on the neurosurgery service are potentially exposed and
subsequently quarantined for 2 weeks after 1 week of service coverage (Table 2
). Members of any one team are prohibited from physically meeting with members from
the other 2 teams, whether inside or outside of the hospital premises, to prevent
disease spread among service personnel. COVID-19 testing is reserved for individuals
displaying disease signs/symptoms (fever, cough, dyspnea, etc.); if positive, all
other members of the same team are tested and thoroughly screened over several days
for early COVID-19 manifestations.
Table 2
Coverage-Quarantine Schedule for the Battle Plan Teams
Complete Service Coverage by:
Week 1
Team 1
2 weeks quarantine for Team 1
Week 2
Team 2
2 weeks quarantine for Team 2
Week 3
Team 3
2 weeks quarantine for Team 3
Repeat schedule starting with Team 1
While the battle plan allows residents and attendings to provide neurosurgical care
for all admitted patients, safety remains of utmost importance; thus, proper personal
protective equipment is provided to personnel examining new patients in the emergency
department (ED) as well as consults who are either COVID-19 positive or of indeterminate
status. All hospital personnel wear masks to avoid contributing to in-hospital community
spread.
Transfer of care between 2 teams occurs in 2 phases. On Sunday afternoon, the covering
team is in-house and presents all cases and imaging in great detail to the in-coming
team through videoconferencing. At 6 am on Monday, the new team is in-house and reviews
all cases again, including overnight admissions, but this time the outgoing team participates
through videoconference so that the 2 teams are never in-house at the same time. Continuity
of care is established by the night call resident. The in-coming team's night call
resident assumes control of the house at 6 pm on Sunday so that he/she is knowledgeable
of all patients transferred to the new team, as well as with any new patients admitted
overnight, again without having any physical contact with the previous team.
To exemplify the efficiency of the battle plan, we will describe a real-life encounter.
On April 3, 2020, a patient presented to the ED with a large intraparenchymal hemorrhage.
She was rushed to the operating room from the trauma bay for emergent evacuation of
the hematoma, but she was not tested for COVID-19. Postoperatively, her respiratory
status declined, and the intensive care unit team could not wean her off the ventilator.
Subsequently, her COVID-19 testing returned positive. In the neurosurgery department,
3 residents and 1 attending from Team 2 were exposed to that patient. Their exposure,
however, did not alter the dynamics of the battle plan since, all members of Team
2 were subsequently quarantined for the next 2 weeks per protocol. They all tested
negative for COVID-19 and were followed up closely for the emergence of any disease
signs, until they returned for service coverage on week 3 postexposure.
Surgical Staffing
Since the implementation of the battle plan, all elective neurosurgical cases have
been cancelled to allocate hospital resources and, most importantly, neuro-intensive
care unit beds, to patients with COVID-19. Inpatient neurosurgical cases are discussed
by the covering team in a daily 6 am meeting conducted in a conference room properly
cleaned, and all attendees wearing masks and maintaining 6-foot social distancing.
New patients with conditions requiring urgent attention (brain tumors with mass effect,
progressive spinal cord myelopathy, etc.) are also presented during the daily meeting
to rank the urgency for surgical intervention and are scheduled accordingly. Per the
judgment of attendings on call, emergent cases (head/spinal cord trauma, cauda equina
syndrome, acute hydrocephalus, etc.) are admitted through the ED and staffed for surgery
without delay in management.
Special considerations to protect the teams as well as all other operative room staff
include universal COVID-19 testing for all scheduled patients; this preemptive strategy
allows for catching asymptomatic carriers. In addition, a negative-pressure operating
room is designated for intubating and extubating the patients by a dedicated anesthesia
team in full personal protective equipment, given the high risk of COVID-19 transmission
during these procedures.
Teleclinic
All new and follow-up patient clinic visits are conducted through telemedicine. These
telemedicine visits are conducted by faculty from home during their 2-week quarantine
period. Before setting up an appointment, new patients are screened for urgent and
emergent conditions. Urgent cases are scheduled within the same week, whereas emergent
cases are directed to the ED for immediate evaluation by the covering team. If the
telemedicine visits identify a patient who requires urgent but not emergent in-person
evaluation, they are referred to the Advanced Practice Providers clinic service (also
on rotation), evaluated, and then seen by the covering attendings for the week as
necessary. Postoperative visits also are performed through telemedicine, unless in-person
visits are deemed necessary (removal of sutures, new neurologic complaints requiring
examination, the need for urgent radiologic or laboratory studies, etc.). Only the
patient is allowed into the clinic during the in-person visit, although guests are
welcomed into a telemedicine format. The overall patient load decreased to around
25%, and all urgent/emergent patients seen at the clinic are admitted through the
ED. The PowerShare platform (Nuance Communications, Inc., Burlington, Massachusetts,
USA) capabilities had to be quickly upgraded to facilitate access to crucial imaging
studies performed at institutions/radiology centers that were not electronically linked
to our radiology applications. Gaps to this capability still exist.
Educational and Research Activities
Upholding all educational activities has remained at the core of the battle plan since
the first week of implementation. Grand rounds, journal clubs, and all other conferences
(morbidity and mortality, vascular meeting, spine meeting, tumor board, etc.) are
organized through videoconference applications, and attendance of all battle plan
teams members remains mandatory.
The battle plan offers the residents an excellent opportunity to resume and finalize
research activities that can be conducted remotely (chart reviews, manuscript write-up,
etc.), as well as extra time to read neurosurgical references and prepare for board
exams.
Conclusions
We present a crisis plan at the level of an academic neurosurgical service during
the COVID-19 pandemic. The implementation of this plan is feasible in most academic
neurosurgical departments and in our limited experience proved to be safe for the
providers and efficient in maintaining urgent/emergent patient care during a viral
pandemic.