The Impact of COVID-19 on the Functioning of a Neurosurgical Service at a Tertiary Institute in a Low-Resource Setting

Objective During the COVID-19 pandemic, certain precautionary measures were implemented to limit its effect, including the cancellation of clinics and elective surgical lists. To determine the impact, if any, of the pandemic on the running of a neurosurgical service, an audit was performed on the volume of referrals, admissions and type of surgeries performed at a tertiary institute in a low-resource setting. Methods An audit of the neurosurgical department’s database was performed on the number of referrals, admissions, surgical procedures, and types of procedures done at the San Fernando General Hospital. This was divided into two 15-month periods, pre-pandemic (January 1, 2019 to March 31, 2020) and intra-pandemic (April 1, 2020 - June 30, 2021). Results During the pre-pandemic period (January 1, 2019 - March 31, 2020), 2,597 patients were referred to the service and 309 major procedures were performed. Two thousand and forty-two patients were referred during the intra-pandemic (April 4, 2020 - June 30, 2021) period, with 354 surgeries performed. More external ventricular drains (29 vs 50), craniotomies for trauma (73 vs 98), anterior cervical fusion (42 vs 47), lumbar fusions (9 vs 12), ventriculo-peritoneal shunts (16 vs 19) and aneurysm clipping (10 vs 13) were done during the intra-pandemic period. Conclusion Although elective surgical procedures and clinics were reduced, the number of patients seen and total procedures performed did not vary significantly. The neurosurgical pathology encountered remained constant during the pandemic. This shows the importance of maintaining a fully functional neurosurgical service, as we continue to adapt to the COVID-19 pandemic.


Introduction
The COVID-19 pandemic in Trinidad and Tobago created certain challenges in managing the on-call referrals and admissions, surgical procedures and clinics for the neurosurgical department of San Fernando General Hospital (SFGH). While there were periodical shutdowns of the clinics and elective surgeries due to surges in COVID-19 positive patients, the number of neurosurgical referrals and procedures are done appeared unchanged.
Our aim was to audit and analyse the numbers pre-pandemic and intra-pandemic, to ascertain if there was any impact on the care and service provided. If there was a change in the operative volume and type of procedure performed, this would allow for better resource allocation and equipment ordering during this pandemic.

Materials And Methods
The neurosurgical department utilises a spreadsheet database, and all referrals and admissions are logged by 1, 2 1 1 1 the on-call officers. The surgical logbook housed in the operating theatre includes all neurosurgical procedures performed. These sources were examined to collate the numbers of emergency/ward referrals seen, ward admissions and surgical cases done. It was carried out during two timeframes -period A, January 1, 2019 -March 31, 2020 (pre-pandemic) and period B, April 1, 2020 -June 30, 2021 (intra-pandemic).

Results
In   Surgical volume for period A was 309 major procedures, whereas 354 were done during period B ( Table 3).
Comparing periods A to B, there were higher numbers for certain procedures during the pandemic. These

Discussion
Neurosurgical services have evolved and improved over the years, with more pathology being deemed treatable. Increases in both the numbers of emergency referrals and lowered thresholds for referrals have been documented [1]. The COVID-19 pandemic has affected the running of neurosurgical services worldwide, with varying effects seen. Some services have noted no change in their volume [2], or an increase in emergency procedures performed [3]. Other centres have seen a reduction in procedures and admissions [4][5][6].
In Trinidad and Tobago, this pandemic resulted in the creation of a parallel healthcare system to manage affected patients, in addition to the existing government-funded public healthcare model. This is under the purview of specific regional health authorities, of which the San Fernando General Hospital is the main tertiary institute for the South-West Regional Health Authority. Neurosurgical services for this region are only provided at this institution, and it caters to 600,000 paediatric and adult populations [7].
No data were previously collated to assess the volumes treated by our service, and during the pandemic we expected that volumes may have been altered. This was due to the intermittent reduction/cancelling of outpatient clinics and elective operating lists, reassignment of staff from the department to assist in COVID-19 hospitals and public health measures including a state of emergency. Neurosurgical emergencies cannot be deferred, as they tend to result in poorer outcomes [2], and we anticipated that the overall volume would remain the same. The auditing of two 15-month periods to assess the output of the department both established data and will allow future analyses.

The impact of COVID-19 on our neurosurgical service
There were 555 fewer total referrals to us during the intra-pandemic period; however, there were 509 more primary admissions to the service. This may indicate that more of the referrals required procedures and possibly a lower threshold for admission. There were significantly more craniotomies for trauma and EVDs performed during the pandemic. Spinal cases did not significantly vary in volume.
In Trinidad, overall shortages of healthcare workers, including those with particular skills and their subsequent distribution, contribute to challenges in the public healthcare system [8]. This resulted in staff burnout and may have led to delays in patient care.
At our institute, there are currently three consultant surgeons in the neurosurgical department -two neurosurgeons and an orthopaedic spine surgeon. The addition of a fellowship-trained vascular neurosurgeon in September 2018 has increased the overall volume of general neurosurgical and vascular procedures performed. In July 2020, the addition of a fellowship-trained spine surgeon further boosted the number of spinal surgeries that could be done weekly.
Another important factor is the availability of neurosurgical equipment for the performance of procedures. Neurosurgery is a heavily equipment-dependent speciality, and certain procedures are not possible without the required equipment. Difficulty in procuring this equipment as a result of delays in shipping and customs due to COVID-19 would have led to longer waiting times for surgeries.

Limitations
The databases used rely on individual input by the officers, and human error may result in some entries not being logged. This will affect the true number of referrals. Also, this data was collected from a single institution, and may not reflect the situation at other hospitals.
The lack of an electronic medical record system hinders data collection. Reliable and easy access to disease coding for every admission would facilitate a sub-group analysis of the types of referrals encountered (for example, hydrocephalus, chronic subdural haematomas, cauda equina syndrome, etc.).