J Korean Med Sci.  2021 Jan;36(2):e16. 10.3346/jkms.2021.36.e16.

Clinical Pathway for Emergency Brain Surgery during COVID-19 Pandemic and Its Impact on Clinical Outcomes

• Lee Sh
• Jang Js
• Chung JW
• Kwon Jt
• Park Ys

• KMID: 2510589
• DOI: http://doi.org/10.3346/jkms.2021.36.e16

Abstract

Background
One of the challenges neurosurgeons are facing in the global public health crisis caused by the coronavirus disease 2019 (COVID-19) pandemic is to balance COVID-19 screening with timely surgery. We described a clinical pathway for patients who needed emergency brain surgery and determined whether differences in the surgery preparation process caused by COVID-19 screening affected clinical outcomes.
Methods
During the COVID-19 period, patients in need of emergency brain surgery in our institution were managed using a novel standardized pathway designed for COVID-19 screening. We conducted a retrospective review of patients who were hospitalized through the emergency room and underwent emergency brain surgery. A total of 32 patients who underwent emergency brain surgery from February 1 to June 30, 2020 were included in the COVID-19 group, and 65 patients who underwent surgery from February 1 to June 30, 2019 were included in the pre-COVID-19 group. The baseline characteristics, disease severity indicators, time intervals of emergency processes, and clinical outcomes of the two groups were compared. Subgroup analysis was performed between the immediate surgery group and the semi-elective surgery group during the COVID-19 period.
Results
There were no significant differences in baseline characteristics and severity indicators between the pre-COVID-19 group and COVID-19 group. The time interval to skin incision was significantly increased in the COVID-19 group (P = 0.027). However, there were no significant differences in the clinical outcomes between the two groups. In subgroup comparison, the time interval to skin incision was shorter in the immediate surgery group during the COVID-19 period compared with the pre-COVID-19 group (P = 0.040). The screening process did not significantly increase the time interval to classification and admission for immediate surgery. The time interval to surgery initiation was longer in the COVID-19 period due to the increased time interval in the semi-elective surgery group (P < 0.001).
Conclusion
We proposed a clinical pathway for the preoperative screening of COVID-19 in patients requiring emergency brain surgery. No significant differences were observed in the clinical outcomes before and after the COVID-19 pandemic. The protocol we described showed acceptable results during this pandemic.

Keyword

Coronavirus; Pandemic; Critical Pathways; Algorithms; Emergencies; Neurosurgery

Figure

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  Fig. 1 Clinical pathway for emergency brain surgery during the COVID-19 pandemic.In the case of COVID-19 RT-PCR result (+) in a patient who underwent emergency surgery, the patient was reported to local public health authorities and transferred to a 1-person room in an isolated ward. In the case of COVID-19 RT-PCR result (+) in a patient requiring semi-elective surgery, the patient was reported to local public health authorities. The location of containment and time of neurosurgical treatment were decided according to the severity and risk.COVID-19 = coronavirus disease 2019, RT-PCR = reverse transcription-polymerase chain reaction, PPE = personal protective equipment, ICU = intensive care unit.

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  Fig. 2 Preparation for emergency brain surgery in PUI or suspected cases.(A) Level D PPE (coveralls, safety boots, goggles, double gloves, N95 or KF94/99 respirator) (B) Preparation of the operating room.PUI = patients under investigation, PPE = personal protective equipment, KF = Korea filter.

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  Fig. 3 Comparison of the time intervals of emergency processes among the pre-COVID-19 group and COVID-19 subgroups.(A) The time interval from ER arrival to severity classification was significantly longer in the semi-elective surgery group during the COVID-19 period compared with the pre-COVID-19 group (P = 0.017) and immediate surgery group during the COVID-19 period (P = 0.035). (B) The time interval from ER arrival to admission was significantly longer in the semi-elective surgery group compared with the immediate surgery group during the COVID-19 period (P = 0.038). (C) The time interval from ER arrival to skin incision was significantly longer in the semi-elective surgery group during the COVID-19 period compared with the pre-COVID-19 group (P < 0.001) and immediate surgery group during the COVID-19 period (P < 0.001). In comparison with the pre-COVID-19 group, the immediate surgery group during the COVID-19 period rather showed a shorter time interval from ER arrival to skin incision (P = 0.040).COVID-19 = coronavirus disease 2019, COVID-19 (IM) = immediate surgery group during COVID-19 period, COVID-19 (SE) = semi-elective surgery group during COVID-19 period, ER = emergency room.*P < 0.05; ***P < 0.001.

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