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Abstract
Objective
To describe telemedicine utilization in neurosurgery at a single tertiary institution
to provide outpatient care during the coronavirus disease 2019 (COVID-19) pandemic,
with 315 telemedicine visits performed by the neurosurgery department.
Patients and Methods
In response to the COVID-19 pandemic national stay-at-home orders and postponed elective
surgeries, we converted upcoming clinic visits into telemedicine visits and rescheduled
other patients thought not to be markedly affected by surgical postponement. We reviewed
the charts of all patients who had telehealth visits from April 1 through April 30,
2020, and collected demographic information, diagnosis, type of visit, and whether
they received surgery; a satisfaction questionnaire was also administered.
Results
In March 2020, 94% (644 of 685) of the neurosurgery clinic visits were face-to-face,
whereas in April 2020, 55% (315 of 573) of the visits were telemedicine (
P<.001). In April, of the 315 telemedicine visits, 172 (55%) were phone consults and
143 (45%) video consults; 101 (32%) were new consults, 195 (62%) return visits, and
18 (6%) postoperative follow-up. New consults were more likely to be video with audio
than return visits and postoperative follow-up (
P<.001). Only 39 patients (12%) required surgery. Ninety-one percent of the questionnaire
respondents were very likely to recommend telemedicine.
Conclusion
Rapid implementation of telemedicine to evaluate neurosurgery patients became an effective
tool for preoperative consultation, postoperative and follow-up visits during the
COVID-19 pandemic, and decreased risks of exposure to severe acute respiratory syndrome
coronavirus 2 to patients and health care staff. Future larger studies should investigate
the cost-effectiveness of telemedicine used to triage surgical from nonsurgical patients,
potential cost-savings from reducing travel burdens and lost work time, improved access,
reduced wait times, and impact on patient satisfaction.
Summary In December 2019, a cluster of patients with pneumonia of unknown cause was linked to a seafood wholesale market in Wuhan, China. A previously unknown betacoronavirus was discovered through the use of unbiased sequencing in samples from patients with pneumonia. Human airway epithelial cells were used to isolate a novel coronavirus, named 2019-nCoV, which formed a clade within the subgenus sarbecovirus, Orthocoronavirinae subfamily. Different from both MERS-CoV and SARS-CoV, 2019-nCoV is the seventh member of the family of coronaviruses that infect humans. Enhanced surveillance and further investigation are ongoing. (Funded by the National Key Research and Development Program of China and the National Major Project for Control and Prevention of Infectious Disease in China.)
Since the outbreak of severe acute respiratory syndrome (SARS) 18 years ago, a large number of SARS-related coronaviruses (SARSr-CoVs) have been discovered in their natural reservoir host, bats 1–4 . Previous studies have shown that some bat SARSr-CoVs have the potential to infect humans 5–7 . Here we report the identification and characterization of a new coronavirus (2019-nCoV), which caused an epidemic of acute respiratory syndrome in humans in Wuhan, China. The epidemic, which started on 12 December 2019, had caused 2,794 laboratory-confirmed infections including 80 deaths by 26 January 2020. Full-length genome sequences were obtained from five patients at an early stage of the outbreak. The sequences are almost identical and share 79.6% sequence identity to SARS-CoV. Furthermore, we show that 2019-nCoV is 96% identical at the whole-genome level to a bat coronavirus. Pairwise protein sequence analysis of seven conserved non-structural proteins domains show that this virus belongs to the species of SARSr-CoV. In addition, 2019-nCoV virus isolated from the bronchoalveolar lavage fluid of a critically ill patient could be neutralized by sera from several patients. Notably, we confirmed that 2019-nCoV uses the same cell entry receptor—angiotensin converting enzyme II (ACE2)—as SARS-CoV.
On March 11, 2020, the World Health Organization (WHO) declared the novel coronavirus disease 2019 (COVID-19) a global pandemic, which classifies the outbreak as an international emergency [1]. At the time of drafting this editorial, COVID-19 has swept through more than 115 countries and infected over 200,000 people around the globe [2–4]. More than 7000 individuals have died during the early phase of the pandemic, implying a high estimated case-fatality rate of 3.5% [2–4]. The rapidly spreading outbreak imposes an unprecedented burden on the effectiveness and sustainability of our healthcare system. Acute challenges include the exponential increase in emergency department (ED) visits and inpatient admission volumes, in conjunction with the impending risk of health care workforce shortage due to viral exposure, respiratory illness, and logistical issues due to the widespread closure of school systems [5]. Subsequent to the WHO declaration, the United States Surgeon General proclaimed a formal advisory to cancel elective surgeries at hospitals due to the concern that elective procedures may contribute to the spreading of the coronavirus within facilities and use up medical resources needed to manage a potential surge of coronavirus cases [6]. The announcement escalated to a nationwide debate regarding the safety and feasibility of continuing to perform elective surgical procedures during the COVID-19 pandemic [7, 8]. Many health care professionals erroneously interpreted the Surgeon General’s recommendation as a “blanket directive” to cancel all elective procedures in the Country [9]. This notion was vehemently challenged in an open letter to the Surgeon General on behalf of United States hospitals [10]. The letter outlined a significant concern that the recommendation could be “interpreted as recommending that hospitals immediately stop performing elective surgeries without clear agreement on how we classify various levels of necessary care “[10]. Notably, the Surgeon General’s recommendation was based on a preceding statement by the American College of Surgeons (ACS) with a call to prioritize appropriate resource allocation during the coronavirus pandemic as it relates to elective invasive procedures. The ACS bulletin stated the following specific recommendations [11]: Each hospital, health system, and surgeon should thoughtfully review all scheduled elective procedures with a plan to minimize, postpone, or cancel electively scheduled operations, endoscopies, or other invasive procedures until we have passed the predicted inflection point in the exposure graph and can be confident that our health care infrastructure can support a potentially rapid and overwhelming uptick in critical patient care needs. Immediately minimize use of essential items needed to care for patients, including but not limited to, ICU beds, personal protective equipment, terminal cleaning supplies, and ventilators. There are many asymptomatic patients who are, nevertheless, shedding virus and are unwittingly exposing other inpatients, outpatients, and health care providers to the risk of contracting COVID-19. Importantly, the notion to “thoughtfully review all scheduled elective procedures “does not reflect on a presumed imperative to cancel all elective surgical cases across the United States [11]. The uncertainty on the predicted time course of COVID-19 beyond a critical inflection point implies that patients may be deprived of access to timely surgical care likely for many months to come. Arguably, the potential fallout from inconsiderate elective surgery cancellations may have a more dramatic and immeasurable impact on the health of our communities than the morbidity and mortality inflicted by the novel coronavirus disease. For the sake of this discussion, it is imperative to understand that the term “elective “surgery does not mean optional surgery, and rather implies that a procedure is not immediately indicated in response to a limb- or life-threatening emergency. A current estimate suggests that more than 50% of all elective surgical cases have a potential to inflict significant harm on patients if cancelled or delayed [12]. The physiological condition of a vulnerable cohort of patients may rapidly worsen in absence of appropriate surgical care, and the resulting decline in patients‘health will likely make them more vulnerable to a coronavirus infection [12]. A recent publication from the Naval Medical University in Shanghai reported on the inherent risks of delaying surgery for colorectal cancer during the COVID-19 outbreak in China [13]. In addition, impressive anecdotal reports of individual patient stories illustrate the unintended consequences imposed by cancelling scheduled surgery, as exemplified by a woman who stated that she felt like there was a “time bomb” inside her after surgery for early stage cervical cancer had been cancelled and indefinitely postponed [14]. Unequivocally, many elective non-urgent surgeries will become urgent at some point in time, depending on how long the COVID-19 outbreak will prevail. Dr. David Hoyt, a trauma surgeon and executive director of the ACS, recently stated:” Right now, most people are planning for a time period of 4–6 weeks for the peak to hit, but nobody really knows. We’re using our best judgment on the fly.” [11]. In light of all the underlying assumptions and uncertainties, it appears imperative to design and implement clinically relevant and patient safety-driven algorithms to guide the decision-making for appropriate surgical care. Elective procedures can pragmatically be stratified into “essential“, which implies that there is an increased risk of adverse outcomes by delaying surgical care for an undetermined period of time, versus “non-essential “or “discretionary“, which alludes to purely elective procedures that are not time-sensitive for medical reasons. Table 1 provides a suggested stratification by urgency of surgical indications for considering appropriate elective case cancellation. Equivocal surgical cases – which do not fall into either “essential “or “non-essential “categories – appear to have shown an effective self-regulating mechanism in the early phase of the COVID-19 outbreak, driven by patients voluntarily cancelling their scheduled elective procedures and surgeons evaluating appropriate indications on a case-by-case basis [15]. Table 1 Examples of surgical case types stratified by indication and urgency Indication Urgency Case examples Emergent 3 months • Cosmetic surgery • Bariatric surgery • Joint replacement • Sports surgery • Vasectomy / tubal ligation • Infertility procedures In essence, during the current time of widespread anxiety around the COVID-19 pandemic [16], a pragmatic guide based on underlying risk stratification and resource utilization will help support our ethical duty of assuring access to timely and appropriate surgical care to our patients, while maintaining an unwavering stewardship for scarce resources and emergency preparedness. Figure 1 provides a tentative decision-making algorithm based on elective surgical indications and predicted perioperative utilization of critical resources, including the consideration for intra−/postoperative blood product transfusions, estimated postoperative hospital length of stay, and the expected requirement for prolonged ventilation and need for postoperative ICU admission. Fig. 1 Proposed decision-making algorithm for risk-stratification of elective surgical procedures based on the underlying surgical indication and predicted resource utilization during the current COVID-19 pandemic. Abbreviations: ASA, American Society of Anesthesiologists; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; COVID, corona virus disease; ICU, intensive care unit; IP, inpatient; PACU, post-anesthesia care unit; PRBC, packed red blood cells; SNF, skilled nursing facility; SOB, shortness of breath Ultimately, if rationing of healthcare resources in terms of limiting access to surgical care in the United States will never be needed, then these ongoing crucial discussions will have served as an important exercise in nationwide disaster preparedness.
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