Impact of COVID-19 Pandemic on Neurosurgical Practice in India: A Survey on Personal Protective Equipment Usage, Testing, and Perceptions on Disease Transmission
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.299173
Source of Support: None, Conflict of Interest: None
Keywords: Asymptomatic screening, COVID-19 pandemic, neurosurgery, personal protective equipment, SARS-CoV-2 testing
The first case of SARS-CoV-2 in India was reported from Kerala on January 30, 2020. The World Health Organization declared COVID-19 disease due to SARS-CoV-2 infection as a pandemic on March 11, 2020. Following the rapid spread of infection due to SARS-CoV-2, the Indian government enforced a lockdown on the country as part of infection control measures and to mobilize the resources for the health care system to deal with the pandemic as the cases rise.,, Synchronously, there was an advisory to all hospitals to stop elective surgeries in order to divert and mobilize all available resources towards management of patients with SARS-CoV-2 infections.
Neurosurgical procedures are unique in that a large proportion of them can be classified as semiemergencies that cannot be deferred for long and frequently surgeries last for several hours, which can expose the neurosurgeon to the patient's aerosol for long periods. Neurological Society of India published a consensus statement that provides guidelines on the appropriate PPE usage for different neurosurgical procedures and other measures to reduce risk of infection among health care workers (HCWs). In spite of such guidelines, HCWs and neurosurgeons in particular are concerned about acquiring the infection in hospital due to the poor quality or lack of appropriate personal protective equipment (PPE).,, There has also been a concern about operating on SARS-CoV-2 infected but asymptomatic patients because of the risk of acquiring the infection and the poor surgical outcomes in such patients.,,,,,
There is tremendous variation in the practice of neurosurgery in different parts of the country and in different practice settings that has been exacerbated during this pandemic. In order to document these practice variations and make public health authorities and hospitals aware of the perception of neurosurgeons with respect to adequacy of PPE and utility of testing of asymptomatic patients, we performed this survey. The survey was performed through an electronically dispatched questionnaire among neurosurgeons in India. This survey was conducted in the last 2 weeks of May 2020, by which time most health care facilities had established protocols towards reopening of services in the “new normal” situation, PPE availability had improved, and RT-PCR testing for SARS-CoV-2 had become more permissive.
A survey questionnaire was framed and entered into Google Forms (Google LLC, CA) to collect data regarding the change in neurosurgical practice in the first 6 weeks of the COVID-19 pandemic, use of PPE, and policies regarding preoperative and routine screening for SARS-COV-2 infection among neurosurgeons in India from the level of trainee onwards. In addition, perceptions among neurosurgeons regarding PPE usage as well as screening and risk of disease transmission were also queried. The questionnaire is detailed in [Figure 1]. While most of the questions were single-response type, multiple responses were allowed for questions addressing type of PPE used for various surgical procedures. Participation was voluntary and the anonymity of the responder was ensured and protected with no questions identifying the responder or their institution being included in the questionnaire.
The questionnaire was administered electronically through a link send via e-mail as well as social media (WhatsApp Messenger) to a list of neurosurgeons who were members of the Neurological Society of India, between May 12, 2020 and May 31, 2020. In order to improve the response rate, the questionnaire was recirculated three times over this time period. This time period coincided with that of gradual withdrawal of complete lockdown measures in most areas of the country and at a time were hospitals were gearing towards resuming normal quantum of work.
Data were imported into a spreadsheet and frequencies of the responses calculated and expressed as percentages. Comparisons between the responses from different places of work were made with respect to PPE usage and perceptions regarding preoperative screening for SARS-CoV2.
There were 244 respondents (237 males), and their median age being 42 years (IQR, 35–52 years; range, 26–72 years). Thirty (12.3%) respondents were 60 years or older. Ninety-one (37.3%) of 244 respondents had 10–30 year experience as a neurosurgeon after completion of training. In total, 84.3% of 244 respondents were performing semiemergency or emergency procedures only. Seventy-four (30.3%) of the respondents were performing only emergency surgeries, 135 (55.3%) reported performing semiemergency and emergency surgeries, and 21 (8.6%) were performing all surgeries. Fourteen (5.7%) of the respondents were not performing any surgical procedures. The details are summarized in [Table 1].
Data regarding PPE usage were obtained from 230 of the 244 respondents, who had performed at least one surgical procedure in the 6 weeks prior to the date of response. N95 masks were utilized by only 83% of the respondents while performing surgical procedures. In total, 2.1% of the respondents were using only a triple layer surgical mask and 2.6% were using only a standard surgical gown while performing surgical procedures. Only 67.8% of respondents were using appropriate shoe covers while performing surgical procedures.
While performing nonaerosol generating procedures such as external ventricular drain placement or lumbar puncture, adequate PPE was utilized by almost 80% of the respondents. Utilization of shoe covers was limited to 39.1% of respondents while performing nonaerosol generating procedures. The data are summarized in [Table 2].
Over 85% of respondents estimated that the tolerance period for the PPE appropriate for surgical procedures ranged from 1 to 4 h at most. Only 40.9% of the respondents were satisfied with the adequacy of PPE that was available to them.
SARS-COV-2 testing protocols
In total, 67.2% of the respondents stated that the preoperative testing of asymptomatic individuals was permitted in their institutions. The practice setting (government hospitals versus others) had no influence on whether preoperative testing was being performed or not.
Testing of asymptomatic individuals for SARS-CoV-2 infection prior to their admission into the ward/intensive care unit (ICU) was being performed in 53.7% of the respondents' institutions. The data are summarized in [Table 3].
SARS-CoV-2 testing and risk of infection
More than 85% of the 244 respondents believed that preoperative testing for SARS-CoV2 as well as screening of all asymptomatic individuals prior to admission into ward/ICU would be beneficial in reducing the risk of in-hospital transmission of the virus among HCWs. More than 90% of the respondents felt that HCWs including neurosurgeons were at risk of acquiring infection through an outpatient consultation from an asymptomatic individual. The data are summarized in [Table 4].
Rationale for the survey
The COVID-19 pandemic secondary to SARS-Cov2 infection has changed the way we live in less than 6 months of the first case being reported. Social distancing, masking in public, and hand hygiene measures have been adopted world over in order to contain its spread.,,, Major changes in practice of medicine as well as neurosurgery have been adopted during the pandemic, with marked restriction or cessation of elective surgical procedures being the one having maximal impact on neurosurgeons.[5–7] Mortality rates and rates of pulmonary complications among COVID-19 positive cases were unacceptably high, necessitating modification of management guidelines among these patients for elective surgery., A previous survey found knowledge and perception among HCWs regarding COVID-19 was poor and a large majority of HCWs sourced their information from social media. Another survey among undergraduate medical students and HCWs from Mumbai reported deficiencies in knowledge with regards to hand hygiene practices and mask application. Jean et al. surveyed the impact of COVID-19 on the global neurosurgical community among 494 respondents from 60 countries. There were only 21 participants from India who completed this survey. This survey reported a significant reduction in the load of elective cases and suggested a scoring system that might help in triaging of nonemergent cases during the pandemic.
Our survey is the first one that has been conducted exclusively among neurosurgeons in India in the background of reduction in the elective case load, coupled with a stringent lockdown. Since one of the objectives of the lockdown was to prepare the country's health system to face the imminent peak of COVID-19 cases in the coming months, we aimed to study the experience of neurosurgeons in India during the lockdown with respect to use of PPE and their perceptions on preoperative testing for SARS-CoV2 in asymptomatic individuals as a means of reducing transmission. The results of this survey will help neurosurgeons as well as health care administrators to modify their policies towards ensuring safety of HCWs of the neurosurgical team without compromising on timely care that several neurosurgical patients require.
Surgical practice and PPE usage
Our finding that more than 80% of the respondents were performing surgeries on emergencies or semiemergent cases only was not surprising as this had been recommended by the central government. Moreover, stringent lockdown measures resulted in patients with nonemergent neurosurgical problems choosing not to visit a hospital. A global survey of neurosurgical practice during the pandemic revealed similar findings.
Use of PPE has been associated with significant reduction in the risk of acquiring infection when HCWs are exposed to confirmed cases during a pandemic. The association was the strongest with use of masks, followed by gloves, eye protection, gowns, and hand hygiene measures. In a recent study conducted by ICMR, HCWs who were in close contact with a confirmed case without PPE were found to have higher rate of infection. In this case-control study, 18% of the infected HCWs did not use masks compared to 7.2% in the control group of HCWs. Typically, 2–2.6% of the respondents were still using a triple layer surgical mask and standard surgical gown while performing surgical procedures, reflecting inadequate PPE usage. Our survey results showed that N95 masks were not being used by 19% of respondents while performing surgical procedures. This suggests lack of availability or awareness regarding PPE among one-fifth of the neurosurgeons, which needs to be addressed by hospitals as well as individuals.
Most respondents indicated that PPE cannot be tolerated for more than 2–4 h due to excessive perspiration and difficulty in breathing. While advanced PPEs with inbuilt respirators are available, these cannot be universally applied due to cost considerations. With guidelines mandating the use of appropriate PPE during this pandemic and in the “new normal” situation that would evolve in the coming months, it would be difficult to envisage neurosurgeons being able to perform procedures that require donning the PPE for more than 4 h. Inability to work under the PPE environment might result in long-duration surgeries being staged or broken down into sequential phases performed by two teams of surgeons.
Nearly 40% of the respondents perceived that the PPE used by them was not adequately protective. This could be a reflection of their own anxiety and fear regarding contracting the infection and being a vector of transmission despite PPE usage. Such anxieties have been documented during the time of pandemic., A number of respondents had also raised concern regarding the quality of PPE that was provided to them. It will be a challenging task for administrators to ensure quality control of PPEs being supplied by various commercial sources.
Our survey has brought out difficulties that the neurosurgical community and hospital administrators face in ensuring adequate number and quality of PPE. While guidelines are strict on the use of appropriate PPE, ensuring universal PPE usage will be a difficult task for reasons mentioned above. Therefore, alongside the use of PPE, universal preoperative screening (if necessary, repeated more than once) and isolation of SARS-CoV-2 negative patients into a separate treatment area may be a more practical solution.
Policy of preoperative screening and perceptions
Results of our survey show that nearly 30% of hospitals have not employed preoperative SARS-CoV-2 testing as part of their protocol. Sixty percent of hospitals allow preoperative test to be done once prior to surgery. The policy of testing a patient for SARS-CoV-2 infection prior to admission into a ward/ICU of the hospital is being followed in only 50% of the hospitals. The reasons mentioned for the same included added costs, poor accessibility to testing facilities, long turnover time for the test result when the sample is sent to an external laboratory, and restrictions imposed by the governmental agencies for testing.
Studies have shown that a proportion (range, 1.6–51.7%) of infected individuals are asymptomatic.,,,, Those who acquire the infection and are in the presymptomatic phase also shed the virus and are hence potential sources of transmission.,, The risk of transmission of SARS-CoV-2 from an asymptomatic individual is similar to that from a symptomatic individual., It has been suggested that patients with confirmed SARS-CoV-2 infection, patients confirmed with no infection, and those who are suspected to have infection be managed in three separate areas of the hospital. To implement this protocol, all patients admitted to a hospital must undergo testing. However, there is the issue of false negative tests that needs to be addressed through various strategies including repeated tests, high-resolution chest CT, and other means.,, The benefit of preoperative and preadmission testing not only aids in protecting HCWs but also other patients visiting the hospital as well as in reducing operative mortality by deferring surgery in a positive individual whenever possible. More than 90% of the survey respondents felt that there is benefit for preoperative or preadmission testing for SARS-CoV-2. A similar number were also concerned about transmission of the disease in the outpatient setting, suggesting that asymptomatic patients should probably be tested prior to this interaction. Testing of all outpatients for SARS-CoV2 becomes very relevant once elective neurosurgical practice and outpatient clinics resume even as the COVID pandemic is ongoing.
Our survey highlights the need for improved access to optimal quality PPE among neurosurgeons and HCWs as lack of confidence in the available PPE was reported by 40% of the participants. Majority of the neurosurgeons perceived risk of infection transmission from their patients indicating the need for mandatory preoperative and inpatient screening for SARS-CoV-2 infection among asymptomatic patients.
The authors would like to acknowledge Ms. Vijayalakshmi Kovardhan, Programmer, Department of Neurological Sciences, Christian Medical College, for helping in preparing and formatting the form for mailing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4]