key: cord-0880645-42zltpx3
authors: Antony, Joyce; James, William Thomas; Neriamparambil, Anna Jolly; Barot, Dwarkesh Dharmendra; Withers, Teresa
title: An Australian Response to the COVID-19 Pandemic and its Implications on the Practice of Neurosurgery.
date: 2020-05-22
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.05.136
sha: b1264feb7d60810550d087244f4b0cb0bb72f351
doc_id: 880645
cord_uid: 42zltpx3

Abstract Objective This study was designed to assess the impact of public health policy in Australia in response to the Coronavirus disease 2019 (COVID-19) pandemic on the delivery of neurosurgical services. Being essential services, we postulated that there would not be a decrease in elective and emergency neurosurgical presentations and surgeries. Methods This is a prospective, observational, epidemiological study in strict adherence to the STROBE guidelines. It is a cross-sectional, multicentric study involving five tertiary neurosurgical centres to capture all public neurosurgical admissions in Queensland during the last three months (Feb-April, 2020) of significant public health policy changes to combat COVID-19. Results An analysis of the 1,298 admissions for the Queensland population of 5.07 million Australians demonstrated a decrease in the number of elective and emergency admissions. The decline in elective admissions, particularly degenerative spine, benign neoplasms and vascular pathologies, was a direct response of government strategy to curb activity to urgent surgical interventions only. Moreover, a trend towards decline in emergency admissions was also noted, partly explained by fewer trauma, but partly attributed to a decline in vascular pathologies including subarachnoid haemorrhage. Conclusions In comparison to Europe and North America, this study demonstrates the impact of proactive public health measures in Australia that successfully flattened the COVID-19 curve, whilst facilitating ongoing care of the acutely unwell neurosurgical patients.

COVID-19 was first reported as a pneumonia of uncertain aetiology in 44 patients from Wuhan City, Hubei province, China on the 8 th of Jan, 2020 1 . It swept through the province and further outbreaks were reported in Europe and North America quickly bringing the health care sector to its knees 2, 3 . On the 30 th of Jan, the World Health Organization (WHO) declared the COVID-19 outbreak a public health emergency of international concern. In the next three months, COVID-19 rapidly spread to the rest of the world facilitated by international commercial travel and was officially deemed a pandemic by WHO on the 11 th of Mar, 2020 2 . Hospitals became overcrowded, personal protective equipment and essential medical resources became sparse and, in some instances, crippling an already overwhelmed system 2, 3 .

On the contrary, the narrative in Australia was very different with swift, stringent public health policies that quickly flattened the curve. In this prospective epidemiological study, we wish to document the Australian response to COVID-19 and the impact of public health policy on the delivery of neurosurgical services.

Being essential services, we postulate that there would not be a decrease in elective and emergency presentations as a result of the public health policies in response to COVID-19. We also postulate that neurosurgical interventions would also remain constant during this period.

Study Design: This is a prospective, observational, multicentric, epidemiological study of the impact of COVID-19 on neurosurgical practice. This cross-sectional study was undertaken in strict adherence to the STROBE guidelines. A multicentric study, all neurosurgical admissions across five tertiary neurosurgical centres over the three months from February, 2020 to April, 2020 were collected.

Data was prospectively collected by five neurosurgical trainees, one from each centre, and cross examined by a senior neurosurgeon to ensure there was no error in interpretation. The data collected pertaining to the neurosurgical admission included institution, month of admission, age, gender, type of admission (Elective or Emergency), region of interest (Cranial, Spine or Peripheral), aetiology (Congenital, CSF flow, Degenerative, Functional, Infection, Oncology, Trauma and Vascular) and surgery (Yes or No). Depending on institutional practices, some minor procedures were performed in theatre or by the bedside. Therefore, cranial procedures such as external ventricular drain insertion, wound washouts and intracranial pressure monitoring although documented, were recorded as not being a surgical procedure. Similarly, image guided injections were inconsistently performed by neurosurgeons at some centres and interventional radiologists at others and were therefore not recorded as surgical procedures. An MRI under general anaesthetic and diagnostic digital subtraction angiograms were also not recorded as surgical procedures. Data was also collected for the number of COVID-19 positive patients during the same time period.

In order to account for bias from sampling error, the study incorporated all neurosurgical admissions across all five tertiary neurosurgical centres in Queensland. Moreover, to account for bias from confounders, demographic data including age and gender was collected. Descriptive analysis was performed using histograms, point-plots and bar-plots to study trends. Inferential analysis was performed using Welch two sample t test to examine difference in means of continuous variables and Pearson's chi-squared test for categorical variables to determine if the observed distribution was due to chance. The Pearson's chi-squared test demonstrated a p-value <0.05, therefore rejecting the null hypothesis that urgency of presentation (X-squared=14.9, df=2), site (X-squared=17.3, df=4) and aetiology (X-squared=38.0, df=14) are independent of the timing of admission. Although the decrease in elective presentations was planned and therefore anticipated, there was also a decrease in the number of emergency presentations as demonstrated in Fig 5 and Fig 6. The Pearson's chi-squared test demonstrated a p-value <0.05, therefore rejecting the null hypothesis that site (X-squared=13.0, df=4) and aetiology (X-squared=25.0, df=14) were independent of the timing of elective admissions. Whilst the decline in emergency presentations (X-squared=21.3, df=14, p-value 0.09) could be attributed to the decrease in trauma presentations, there was also a decrease in the number of vascular presentations that could be clinically significant.

Moreover, in patients who underwent surgical intervention, the Pearson's chi-squared test demonstrated a p-value <0.05, therefore rejecting the null hypothesis that site (X-squared=13.0, df=4) and aetiology (X-squared=25.0, df=14) were independent of the timing of admission as demonstrated in Fig 7 and Fig 8. DISCUSSION:

The first confirmed case of COVID-19 in Queensland, presented on the 28 th of Jan, a day after the group of nine tourists flew in from Wuhan. Despite attempting strict individual isolation and daily testing, five of the nine individuals were subsequently tested positive with varying severity of symptomology. On the 29 th of Jan, the Queensland government declared a public health emergency. The Federal Government banned gatherings of more than 500 people and advised against non-essential overseas travel on the 12 th of Mar, 2020 with the first reported death in the state the day after. All individuals returning from overseas travel were imposed a 14-day isolation period. The testing criteria was sequentially broadened from a positive travel history to Wuhan, to any overseas travel history, to health care workers with respiratory symptoms and eventually anyone with respiratory symptoms. Contact tracing became a pivotal tool in the armamentarium of the Public Health Unit to understand how the virus was spreading in the community. The COVID SAFE App, approved by the Australian government with contact information being deleted on a 21-day rolling cycle, was rolled out on the 26 th of April to fast track contact tracing.

In response to the increasing number of cases, towards the end of March, the federal government introduced a series of lock down measures beginning with an Australian ban of arrivals by non-citizens and non-residents and a shutdown of all non-essential services including pubs, clubs and restaurants. This was followed by a state government response to shut down state borders and to transition schools to an electronic mode of curriculum delivery with the exception of children of essential service personnel. On the 30 th of March, the Queensland government further tightened social distancing restrictions with ban to travel outside the home except for essential reasons and strict policing to ensure compliance. From initial modelling that suggested 30,000 Queenslanders would die from COVID-19 if not contained, these drastic measures produced a significant flattening of the curve within a month. Towards the end of April, with a growth factor of 0.88, the government commenced a gradual relaxation of the stringent travel restrictions whilst encouraging social distancing. Emergence of a second wave would likely see the re-establishment of more stringent restrictions.

As part of Queensland Health's response to increase capacity and manage the impact of COVID-19, from the 23 rd of Mar, 2020, all hospitals were mandated to perform urgent operations only. This was anticipated to increase capacity of emergency care and limit non-essential physical contact to manage the risk to patients and staff 4 . Endoscopic endonasal skull base procedures were postponed if patients were clinically stable, given the high likelihood of aerosolizing virions within the nasal sinuses and infecting the entire operating room staff despite laminar flow 3 . In the setting of clinical deterioration, the general practice was then to consider a craniotomy. COVID-19 theatres were also established for confirmed or suspected COVID-19 patients to minimize cross-contamination. While staff received training in the use of COVID-19 specific personnel protective equipment and workflow, this did not require implementation as no COVID-19 positive or suspected patients warranted a neurosurgical procedure. If deemed clinically appropriate, the anaesthetic and pre-admission reviews were conducted via videoconference by appropriately qualified clinicians using the Queensland Health Telehealth Portal.

Similarly, outpatient reviews were converted to telehealth reviews when medically safe to do so, with only new referrals and urgent reviews potentially requiring surgical intervention being reviewed physically in clinics. All departmental meetings, multi-disciplinary meetings and educational sessions were also continued using video conferencing that facilitated remote and thus safe participation. Interhospital transfer of neurosurgical patients presenting to peripheral hospital had to be endorsed by hospital's senior staff management. Visitations were strictly limited to one per person per day and for patients in isolation, visitors were discouraged from attending at all. Neurosurgical staff were split into two teams, two weeks on clinical duties and two weeks on administrative duties, to ensure continued safe provision of neurosurgical service. Given the successful flattening of the curve, neurosurgical staff members did not require redeployment to COVID-19 wards or fever clinics. Administrative staff members were encouraged to work from home when possible. Towards the end of April, with the relaxation of travel restrictions, the government has proposed a staged reintroduction of semi-urgent and non-urgent elective surgery.

An examination of the bar-plots, demonstrate an obvious reduction in the number of presentations during the COVID-19 response. As mandated by government policy, there was a planned reduction in the number of elective admissions and surgeries, particular degenerative spine, benign neoplastic lesions and vascular pathologies. However, a surprising trend that was not statistically significant, demonstrating a decrease in emergency presentations was also noted. Although, this could be explained by the reduction in trauma from the strict travel restrictions imposed by the government, there was an obvious reduction in the number of emergency vascular presentations, particularly subarachnoid haemorrhage. Despite the decreased emergency presentations of SAH, those that did present were higher grades with higher mortality. Whilst contrary to current literature demonstrating the increased incidence of SAH during cold temperatures and influenza epidemics, the noted trend could be explained by the general public's fear of presenting to the emergency department during the COVID-19 pandemic 5 . However, fear alone might not fully explain this trend as there were similar if not slightly increased emergency presentations for shunt dysfunction and oncology during the same period. Another postulation might be the stringent social distancing laws and travel bans that meant a vulnerable segment of the population may not have received timely attention from a good Samaritan. Therefore, larger, multicentre studies across the globe are required to fully comprehend the impact of the numerous, varying public health policies on COVID-19 and health care delivery This study has several limitations. First, the study could be subject to a sampling bias as other states such as Victoria and New South Wales have a larger migrant population compared to Queensland. Moreover, the data collected does not incorporate a minority of the population who sought private neurosurgical care and some spinal presentations managed by the orthopaedic service. However, it is worth noting that the Queensland data was comparable to the national averages. Second, the study could be subject to confounders. As this study was designed to examine the epidemiological trends in neurosurgical presentations during the COVID-19 rather than specifically subarachnoid haemorrhage, known confounders such as ethnicity, history of subarachnoid haemorrhage or hypertension and aneurysmal characteristics such as site and size, were not documented 6 . For these reasons, the external validity of the study needs to be cautiously interpreted. Larger studies examining the impact of the various public health policies implemented around the globe on health outcomes would shed further light on those that made the most difference. Moreover, larger studies examining emergency vascular presentations including subarachnoid haemorrhage during a viral pandemic could shed further light on a causal rather than an associational inference, if one exists.

Proactive public health measures in Australia has ensured successful flattening of the curve and conservation of PPE and essential medical resources whilst facilitating care of the acutely unwell neurosurgical patients. While stringent public health strategies and its implementation such as limiting elective surgery to urgent surgeries only might help combat a pandemic, it may also have an impact on health care delivery. Lessons learnt from this pandemic should guide future health care bureaucrats and politicians to minimize disruption in the delivery of essential medical services. 

Pneumonia of unknown aetiology in Wuhan, China: potential for international spread via commercial air travel

COVID-19 outbreak: single center experience in neurosurgical and neuroradiological emergency network tailoring

On pandemics: the impact of COVID-19 on the practice of neurosurgery

COVID-19 and neurosurgical practice: an interim report

Increased incidence of subarachnoid hemorrhage during cold temperatures and influenza epidemics

Development of the PHASES score for prediction of risk of rupture of intracranial aneurysms: a pooled analysis of six prospective cohort studies

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. The contents of this manuscript or part thereof has never been presented nor published at another forum