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Impact of the COVID-19 Pandemic on Neurosurgical Practice in India: Results of an Anonymized National Survey
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.289004
Keywords: COVID-19 (coronavirus disease of 2019), India, neurosurgical practice, personal protective equipment
The latest medical crisis caused due to coronavirus disease of 2019 (COVID-19), currently gripping the world, is probably the first such experience for most of medical practitioners. Though some countries have been affected more than others, most of us have been impacted by the COVID-19 pandemic. At the time of writing this article, the number of COVID-19 positive patients in India has touched 1,65,799 with a death toll of 4706.[1] According to a study by Indian Council of Medical Research (ICMR), healthcare workers (HCWs) constitute about 5% of the total infected cases in India [2] and are 33 times more vulnerable to contract COVID-19 as compared to common public.[3] The challenge today is to keep the healthcare system intact and to prevent hospitals from becoming 'super-spreaders.' Healthcare professionals including neurosurgeons have been forced to adapt to the current medical scenario. It is also important to create “COVID-free” spaces to allow restarting of elective neurosurgery to tackle the huge backlog of the waiting patients. The objective of this survey was to analyze the change in neurosurgical practices in India following the COVID-19 outbreak and assess its impact on practising neurosurgeons.
Designing and validating the survey questionnaire A cross-sectional study was conducted using an online survey questionnaire circulated from May 7th and 23rd, 2020. For this purpose, a well-constructed questionnaire was designed by the authors on www.googleforms.com. Face validity was done by two medical professionals. For content validity, the questionnaire was sent via an e-mail to four subject experts and they were asked to rate each question individually on the basis of relevance on a scale of 1–4 [Supplementary Material 1]. Using their feedback, the item content validity index (I-CVI) and S-CVI/Avg (scale-level content validity index based on average method) were calculated,[4] both of which met a satisfactory value of 1 [Supplementary Material 2]. Further, any feedback of the experts was discussed by the authors and necessary changes to the questionnaire were made. Questionnaire for practising neurosurgeons The final questionnaire comprised of seven sections with 45 questions [Supplementary Material 3]. After briefly explaining the purpose of the survey, consent was taken from each respondent regarding their inclusion in the study. The first section comprised of the respondent's demographic details. The second section contained questions related to impact of COVID-19 pandemic on neurosurgical practice. This included questions regarding their departments' functioning, manner of conducting outpatient department (OPD) and compared the number and nature of patients before and after COVID-19 pandemic. The third section dealt with how interaction with patients has changed due to COVID-19 pandemic. It contained questions dealing with patient examination and neurosurgeons' perception of elective and emergency surgery. The fourth section compared surgical practice before and during the pandemic including questions regarding preoperative COVID-19 testing. The fifth section had questions pertaining to academics and research. The sixth section covered the impact of COVID-19 pandemic on the respondents' personal life including work-related stress and financial burden. The last supplementary section was added at a later stage and dealt with adaptations made in respondents' wards, operation rooms (ORs) and intensive care units (ICUs) during the pandemic. The survey questionnaire was then circulated online to neurosurgeons across the country by social media and e-mails. All of them were completely anonymized to ensure a frank response. They were asked to forward the questionnaire to their colleagues, thus using the “snowballing technique” for survey recruitment.
Of the 207 responses received, one was excluded due to denial of consent and five responses from outside India were excluded. Subsequently, 201 responses were included for final data analysis. Section 1: Demographic profile There were 201 eligible respondents (196 males, 4 females, 1 other), with good representation from all over India including 22 states/union territories [Figure 1]. In total, 95 respondents were less than 40 years old and 106 were 40 years of age or above. In terms of post-training neurosurgical experience, 76 respondents (37.81%) had less than 5 years' experience, 51 (25.37%) had 6–10 years' experience, 26 (12.93%) had 11–15 years' experience while 48 respondents (23.88%) had more than 15 years of experience. In total, 79 (39.30%) respondents worked in government hospitals, while 116 (57.71%) worked in private hospitals. Six (2.98%) respondents had multiple affiliations (i.e., both government and private). The number of respondents in teaching positions was 124 (61.69%), and the rest (77, 38.30%) were in non teaching positions. Majority of respondents (112, 55.72%) worked at hospitals treating both COVID-19 and non-COVID-19 patients; 84 (41.79%) worked at hospitals treating only non-COVID-19 patients, while five (2.48%) worked at hospitals that treat COVID-19 patients exclusively [Table 1]. Most (161, 80.09%) felt that as neurosurgeons, they had a role to play in battling COVID-19 pandemic.
Section 2: Impact on practice Departments of most respondents (154, 76.61%) worked with reduced staffing. In total, 20 respondents (9.95%) had completely stopped their OPD, 39 (19.40%) had completely switched over to telemedicine, while 70 (34.82%) were running physical OPD exclusively. A total of 72 (35.82%) were conducting both physical OPD and telemedicine [Table 2]. The survey demonstrated that before the pandemic, the respondents used to attend to an average 50.9 patients per OPD (range 2–300, median: 30) which had dropped to an average of 9.15 patients (range 0–150, median: 5) representing a mean drop of 76.25% ± 22.64. This finding was statistically significant (P-value = 0.000) [Figure 2].
During the pandemic, most respondents noticed a significant increase in proportion of their patients being emergencies. Before the pandemic, 28.50% ± 20.21 of all cases were emergencies, while during the pandemic, this figure increased to 57.91% ± 38.11. This increase in proportion of emergencies was higher for government practitioners (42.21% ± 40.22) as compared to private practitioners (21.16% ± 31.74) and those with multiple affiliations (20.33 ± 41.67). This observation was statistically significant (P = 0.000) [Figure 3].
Section 3: Impact on patient examination While examining patients, most respondents (140, 69.65%) wore N-95 masks, 77 (38.30%) wore surgical masks, 83 (41.29%) wore surgical caps, 74 (36.81%) wore face-shield/goggles, 44 (21.89%) a surgical gown, and a full personal protective equipment (PPE) was used by only 9 (4.47%) neurosurgeons. Most respondents (184, 91.54%) reported that they ask for travel history and COVID-19-related symptoms while attending to neurosurgical patients. A total of 146 respondents (72.63%) did not assess their patients in as much detail during the pandemic as before. When specifically asked if during the pandemic, they would perform tests such as gag-reflex when indicated; only 31 (15.42%) responded in the affirmative. Most neurosurgeons (135, 67.16%) concurred that patients planned for elective surgeries should not be operated upon during COVID-19 pandemic. In total, 104 (51.74%) said their perspective on what constitutes a neurosurgical emergency had changed after the onset of the pandemic [Table 2]. When asked about their opinion regarding which neurosurgical patients should be tested for COVID-19, 24 (11.94%) said all patients visiting OPD, 136 (67.66%) respondents wanted testing for all patients getting admitted, 53 (26.36%) wanted it for all patients planned for elective surgery only, 42 (20.89%) wanted it for all patients planned for emergency surgery only, and 137 (68.15%) wanted testing for patients at high risk for COVID-19. Two (0.99%) respondents felt that testing was not needed for any patient [Table 2]. Section 4: Impact on surgery In their practice before an elective surgery, most participants (130, 64.67%) reported the requirement of one negative COVID-19 test, while 47 (23.38%) required two negative COVID-19 tests. Three respondents (1.49%) require more than two reports, while 21 respondents (10.44%) were still operating without any COVID-19 testing prior to elective surgery. In comparison to this, prior to an emergency surgery, most participants (127, 63.18%) do not perform any COVID-19 testing, while 70 (34.82%) and 4 (1.99%) performed 1 and 2, respectively [Table 3]. Before the pandemic, the respondents used to perform/assist an average number of 32.28 ± 30.91 surgeries in a month, while during the pandemic, this number reduced to 8.29 ± 8.50. This represents a 70.59% ± 22.46 decrease in surgeries performed, which is statistically significant (P-value = 0.000) [Figure 2].
In total, 109 respondents (54.22%) said they would operate with PPE on patients with negative COVID-19 test and having no high-risk features of COVID-19. When asked the same question with a negative COVID-19 test but with high-risk features of COVID-19, 188 (93.53%) would want to operate with PPE.A total of69 respondents (34.32%) have not operated wearing PPE, 85 (42.28%) reported that wearing PPE affected their surgical performance adversely, while 37 (18.40%) felt that it made no difference. Ten respondents (4.97%) reported that wearing PPE improved their surgical performance [Table 3]. When specifically asked, 157 (78.10%) respondents said that they would not do a transnasal-trans-sphenoidal excision for pituitary adenoma during COVID-19 pandemic. Section 5: Impact on academics In total, 107 respondents (53.23%) felt that the pandemic has adversely impacted research work they were pursuing. This difference was more pronounced in those in teaching jobs (88, 70.96%) as compared to the ones in non teaching jobs (19, 24.67%) and this observation was statistically significant (P-value = 0.000) [Table 4]. Total of 180 respondents (89.55%) had planned to attend a conference which got cancelled due to the current situation. A third-party webinar had been attended by 165 respondents (82.08%). Most respondents (185, 92.03%) felt that the pandemic would adversely affect training of neurosurgical residents.
When asked how they were spending their extra time academically during the lockdown while not on duty, 156 (77.61%) said they were studying themselves, 108 (53.73%) responded they were attending classes/webinars, 49 (24.37%) replied that they were conducting classes/webinars, and 93 (46.26%) indulging themselves in scientific writing/publications [Table 4]. Section 6: Impact on personal life During the lockdown, 165 respondents (82.08%) were spending quality time with family, 110 (54.72%) were pursuing hobbies/passions, 109 (54.22%) were learning new skills, 107 (53.23%) were spending time on physical fitness, and 77 (38.30%) were involved in spiritual activities. The pandemic had an adverse effect on 164 respondents (81.59%) financially. When asked to quantify the financial burden, 29 (14.42%) responded “less than 25%,” 58 (28.85%) responded “25 to 50%,” 36 (17.91%) responded “51 to 75%,” and 34 (16.91%) responded “more than 75%.” Seven respondents (3.48%) could not quantify the financial burden. The financial burden due to pandemic affected the private practitioners and those with multiple affiliations more than those in government jobs (P = 0.000) [Figure 4].
A total of 120 respondents (59.70%) participated in philanthropic activities. A majority of the respondents reported increased work-related stress (n = 100; 49.75%). Section 7: Supplementary section (regarding modifications done in ward, ICU, and OR) It was observed that wards and ORs of respondents had been modified in various ways to make them COVID-19 safe [Table 5]. When asked specifically about adaptations made while making a craniotomy, 30.55% did not use drills and 22.22% wore two gowns to remove the outer one at 20 min after doing craniotomy. Craniotomy was avoided by 13.88% respondents, while 47.22% respondents had made no adaptations. In total, 58.33% respondents had a separate ICU for their COVID-19- suspect patients. There was a lot of variation in the protective gear used by ICU staff of the respondents. The ICU staff of 47.22% respondents were given PPE [Table 5].
Presently, the medical fraternity is faced with the unique challenge of protecting ourselves from the very patients we are trying to protect. The highly infective nature of COVID-19 and high proportion of asymptomatic carriers put HCWs at a high risk. The challenge is to keep the elective healthcare system intact and to prevent hospitals from becoming 'super-spreaders.' This has forced healthcare professionals including neurosurgeons change their practices according to changing times. Our data show varied practices among neurosurgeons across the country, indicating a lack of implementation of uniform policies. Strong, effective, and evidence-based policies are required to protect our medical professionals. Our survey revealed that almost all neurosurgeons (91.54%) ask their patients for travel history and COVID-19-related symptoms. However, this alone is unreliable as it is estimated that the proportion of pre-symptomatic transmission is 44% (25–69%).[5] With regard to neurologists and neurosurgeons of the country, Gupta et al. recently recommended thermal screening and rapid COVID-19 diagnostic tests for patient screening.[6] Our survey revealed that 32.33% of our respondents did not get COVID-19 testing done for all neurosurgical patients getting admitted and 79.10% proceed for an emergency surgery without prior testing for COVID-19, which puts them at a risk. As was observed in our survey, there was no consensus among neurosurgeons regarding the number of negative COVID-19 tests required preoperatively [Table 3]. With a sensitivity of 71% for the available antigen RT-PCR tests,[7] the false-negative rate of the test is 29%. If two and three tests are done consecutively, the false-negative rate still stands at 8.41% and 2.44%, respectively. Given the highly infectious nature of COVID-19,[5] even these apparently low figures of false-negative results pose a threat to the HCWs. Though the typical symptoms of COVID-19 are fever, cough, and dyspnea, several patients present with vomiting, headache, dizziness, and delirium.[8],[9] This makes widespread testing among patients all the more important. Even though the facilities in OR have undergone various amendments to make them COVID-19 safe, most neurosurgeons are worried about themselves getting infected while operating during the COVID-19 pandemic. Most neurosurgeons in our survey felt that elective surgeries should not be performed during the pandemic. The same is reflected in their practice, as around 60% of patients seen by our respondents are in emergency during the pandemic compared to around 30% earlier. This is supported by evidence from a seminal article where it was shown that in patients with perioperative COVID-2019 infection, the 30-day mortality of elective surgery was 23.8% and pulmonary complications were seen in 51.2%.[10],[11] Most neurosurgeons' perception of a neurosurgical emergency has changed during the pandemic (51.74%). An estimated 28,404,603 operations would be cancelled or postponed globally during the peak 12 weeks of disruption due to the COVID-19 pandemic, accounting for 72.3% cancellation rates overall. It would take a median of 45 weeks to clear the backlog of operations resulting from this disruption if the normal surgical volume was increased by 20% postpandemic.[12] Though not specific to neurosurgery, the American College of Surgeons has prescribed guidelines for the triaging of surgical patients.[13] Most hospitals in the USA have restricted all nonessential elective surgeries and procedures in accordance with recommendations from the American College of Surgeons and Centres for Medicare and Medicaid Services.[14],[15],[16] The postponement of surgeries considered 'elective' is likely to result in the progression of the disease, hence rendering patients more difficult to manage. Due to highly contagious nature of COVID-19, the extent of clinical examination by most neurosurgeons has reduced significantly. This reluctance is even higher in performing tests like gag-reflex and in performing trans-sphenoidal surgeries as is evident from our study. Our survey shows wide variation in the protective-gear used by various neurosurgeons and their ICU staff in their practice. Gupta et al. advised the use of protective gear such as N95 masks, face shields, hospital scrubs, hair covers and gloves in the OPD during the ongoing pandemic. Ensuring a glass barrier between the patient and doctor can protect both doctor and patient.[6] Moreover, our survey suggested that despite having one negative COVID-19 report, a significant number of surgeons wanted to operate with PPE, especially if the patient had COVID-19-related symptoms. This may be attributed to the poor sensitivity of the currently available COVID-19 tests as discussed above. Our survey also revealed that almost 34.32% of the neurosurgeons had not operated in PPE and of those who had, most (42.28%) felt that wearing PPE adversely affected their surgical performance. Thus, neurosurgeons are faced with the difficult situation of either exposing themselves to the risk of getting infected with COVID 19 or have the poor quality PPE affect their surgical performance. In medical fields such as neurosurgery where the surgeon's finesse and concentration are crucial to the surgical outcome, comfortable PPE is need of the hour. Procurement of positive air powered respirators (PAPR) may be a solution to create greater comfort for neurosurgeons while operating. This is especially important as most neurosurgical procedures are of long duration. The high chances of getting infected with COVID-19 virus requires making at least three teams in the department, with each team working for two weeks alternatively, while the other team can be kept in isolation. This is based upon the incubation period of the coronavirus which is 6.4 days, ranging from 2.1 to 11.1 days (2.5th to 97.5th percentile).[17] In our survey, almost three-fourth of the neurosurgeons were working with reduced staffing. There has been a drastic fall in the number of patients being seen in OPDs and patients being operated upon as seen in our survey. This has also been observed across the world.[12],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29] The number of patients in OPD and those getting operated have decreased significantly for all neurosurgeons across public and private sectors as has been shown in our study. This can be largely attributed to the nation-wide lockdown resulting in decreased movement of patients. To deal with decrease in patients in the OPD, many have adapted to telemedicine to attend to their out-patients.[12],[16],[19],[22],[23],[26],[28] Telemedicine has its own legal challenges, for which guidelines have been put forth by Ministry of Health and Family Welfare, Government of India.[30] The reduction in case load has financially impacted neurosurgeons, especially those in the private sector. Decreased patient load with resulting financial burden effects on research work and risk of themselves getting infected while discharging their duties has probably resulted in increased work-related stress as reported by most of our respondents. The pandemic has had an adverse effect on academics as well including research work,[31] resident training and conferences. Many have taken to attending/arranging webinars or self-study in order to make up for the time lost. In addition, the extra time is being spent by most neurosurgeons by spending quality family-time, pursuing hobbies/interests, physical fitness and spiritual activities. This can be considered a silver lining in the lives of one of the most workaholic medical professionals.
To conclude, the authors feel that there is need for evidence-based protocols, rotation at work, proper screening, universal testing, tests with better sensitivity and specificity, better availability of user-friendly PPE and switch to tele-medicine and webinars. To deal with increased work-related stress in the HCWs, psychiatric counseling should be available at the hospital. An alternative to postpone elective surgeries should be found, otherwise there is a big risk of all these patients worsening while waiting for surgery. The best way forward would be to resume work with necessary precautions and universal effective COVID-19 testing. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Acknowledgments The authors wish to acknowledge the role of Dr Saquib Azad Siddiqui, Dr Gaurang Vaghani, Dr Aditya Patil, and Dr Punit Kumar in the process of content validation of the survey questionnaire. We acknowledge the role of Dr Yamini Kansal and Dr Mandara Muralidhar Harikar in the process of face validation of the survey questionnaire. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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