Reallocation of Carotid Surgery Activity with the Support of Telemedicine in a COVID-Free Clinic during COVID-19 Pandemic

Abstract

The aim of this study is to report the reallocation of carotid surgery activity with the support of telemedicine in a COVID-free clinic during COVID-19 pandemic. Patients with symptomatic carotid stenosis or asymptomatic vulnerable plaques were reallocated to a COVID-free private clinic which began to cooperate with the National Health System during the emergency. Quick training of staff nurses was performed. Surgeons moved to the COVID-19 free clinic. Remote cerebral monitoring was performed with the support of telemedicine. Twenty-four patients underwent standard carotid endarterectomy with eversion technique. Five patients (20.8%) had recently symptomatic stenosis, and the remaining 19 patients (79.2%) had a risky asymptomatic carotid stenosis. No technical issue with remote cerebral monitoring was detected. In the early postoperative period, no neurological/systemic complication was observed. Three patients under dual antiplatelet therapy (12.5%) had neck hematoma. All patients were discharged the day after surgery. In our preliminary experience, reallocation in a COVID-free clinic allowed us to maintain a functioning carotid surgery activity during COVID-19 pandemic. A multidisciplinary approach and support of telemedicine were crucial. Training of unskilled nurse staff was necessary.

Introduction

Hospital administrations prepared plans for surgical services to offer an effective response to COVID-19 pandemic [1]. National and international societies issued guidelines about vascular surgery to share strategies regarding the identification and prioritization of vascular procedures during the worldwide COVID-19 pandemic [2, 3, 4].

Many vascular surgery departments experienced a worldwide great reorganization [5, 6, 7, 8]. Hub and spoke systems with network groups including all vascular surgery consultants from both public and private hospitals were established [9, 10]. According to recommendations, carotid surgery should be postponed for patients with asymptomatic carotid stenosis. However, carotid revascularization should be guaranteed in patients with symptoms. Alternatively, the Vascular Society of Great Britain and Ireland suggested aggressive best medical therapy for recently symptomatic carotids if there are severe resource limitations [3].

Technology and virtual visits have been advocated even for vascular surgery services to maintain high-quality care during the COVID-19 pandemic [11]. Remote monitoring of cerebral activity has been well-established [12]. The aim of this study was to report the reallocation of carotid surgery activity with the support of telemedicine (remote cerebral monitoring) in a COVID-free clinic during COVID-19 pandemic.

Materials and Methods

At the beginning of March 2020, during the initial spread of COVID-19 in Italy, a vascular surgical hub was created in the Unità Sanitaria Locale (USL) Toscana Centro, including 13 public hospitals serving >1.6 million people in an area of about 3 square mile. When the vascular surgical hub was created, patients with symptomatic carotid stenosis were centralized to one hospital, admitted in the stroke unit, and operated if necessary.

From October 2020, a cooperation was initiated between the public health system and a private clinic. The main field of interest of this private clinic was orthopedic surgery. The staff nurse had no expertise in arterial vascular surgery. Nevertheless, the clinic had surgery beds; in addition, 4 intensive care unit beds were available. The policy of this private clinic was to maintain a COVID-free environment.

Hospital administration of hub hospital planned to reallocate the carotid surgery activity to the private clinic. Patients with symptomatic carotid stenosis were transferred to the clinic from the surrounding hospitals. In addition, a careful review of the waiting list was made to find all asymptomatic carotid stenoses with vulnerable plaques (stenosis >80%, soft atheroma, hemorrhage, ulceration, ultrasound hypoechogenicity) and give them a priority of treatment.

The week before the beginning of the surgical activity, we created a web remote access between the private clinic and the hub hospital. Data for the admission, operative report, and discharge of the patients commonly used at the hub hospital were installed in the computers of the private clinic with a remote access (virtual private network, VPN). In addition, an intensive nurse staff training was conducted. Table 1 and Figure 1 resume the steps of reallocation.

Table 1.

Reallocation of carotid surgery activity (summary)

Who	What	When	How
Hospital administrators	Reallocation of surgical activity	Rapidly	Agreement with administrators of a private clinic
Healthcare informatics employees	Direct web link from hospital Hub to private clinic	One week before the surgical activity	Creation of a secure remote VPN access
Staff nurse − hub hospital	Education of other nurses without know-how in carotid endarterectomy	One week before the surgical activity	Intensive on-site training course
Staff nurse − private clinic	High level of perioperative assistance	One week before the surgical activity	Study and participation in the intensive training course
Neurophysiology technicians	On-site cerebral monitoring	Few days before the surgical activity	Availability to move to the private clinic for on-site cerebral monitoring
Neurologists	Remote cerebral monitoring at hub hospital	During the surgical activity	Web connection with VPN access
Anesthesiologists − hub hospital	Re-evaluation of patients' clinical documentation	Few days before the surgical activity	Web connection with VPN access
Vascular surgeons	Surgical activity	Operative time	Availability to move to the private clinic for carotid endarterectomy

VPN, virtual private network.

Fig. 1.

Flowchart: treatment of patients with carotid stenosis during COVID-19 pandemic.

Subjects have given their written informed consent to the procedure. The study is exempt from ethical committee approval because no change has been made in terms of standard operative technique and perioperative management.

Nurse Staff Training

The patients were admitted to the orthopedics department. The training started with the ward nurses being given a short intensive course on how to manage the patient in the immediate postoperative period. It was illustrated how to perform a basic neurological examination and how to manage bleeding by checking and changing, if necessary, the drainage that was routinely positioned at the surgical site during the operation. In addition, ward nurses were given the clinical pathway usually used in public hospitals where carotid endarterectomy is routinely performed. In the ward, the phone catalog of all vascular surgeons was provided with the indication to call the vascular surgeon “on call” in case of need. An intense course managed by the nurses of the hub hospital was performed to make the scrub nurses aware of the timing of the intervention and the potential critical moments of the procedure.

Operative Technique

Vascular surgeons moved to the COVID-19-free clinic together with the neurophysiology technicians. The anesthesiologists were those of the private clinic. Neurologists were in the hub hospital and connected to the VPN access. In all cases, a standard carotid endarterectomy with eversion technique was performed. A selective shunting policy was applied according to cerebral monitoring.

Remote Cerebral Monitoring

Simultaneous continuous monitoring of multichannel somatosensory evoked potentials (SEPs) and electroencephalogram (EEG) was performed to determine the need for selective shunting during carotid endarterectomy. Surgical and neurological staff shared a two-decade experience in the field of carotid endarterectomy with over 2,400 patients in the last 10 years. A skilled neurophysiology technician was present in the operating room, whereas a neurologist was online and observed EEG and SEP traces online on a remote desktop (shown in Fig. 2). Ten channels of raw EEG were continuously recorded using needle electrodes placed on the scalp (Fp1, Fp2, F3, F4, C3, C4, P3, P4, 01, O2 10–20 International system) with mastoid reference. Time constant was 0.1 s, and the low-pass filter was 30 Hz. To record SEPs, the median nerve contralateral to the carotid endarterectomy was stimulated at the wrist at motor threshold intensity. Stimulus frequency was 3 Hz. The same scalp electrodes and reference used for EEG were employed. In addition, peripheral and cervical responses were recorded at Erb's point and Cv6, respectively. Band-pass filtering was 5–5,000 Hz. For each trial, seventy trials were averaged. The alert for shunting was given by the neurologist if at least one of the following electrophysiological modifications was observed after clamping: (1) a decrease >50% in the amplitude and/or a 10% increase in latency of the early cortical components (N20, P25) of SEPs and (2) a decrease in EEG amplitude greater than 30% lasting at least 30 s in the hemisphere ipsilateral to carotid clamping [13, 14].

Fig. 2.

Screenshot of remote computer connected to virtual private network.

Results

From October 2020 to February 2021, 24 patients underwent carotid surgery in the COVID-free private clinic. Patients were predominantly male (14, 58.3%), with an average age of 76.7 years (range 63–86). All patients underwent nasopharyngeal swab for COVID-19 72 h prior to clinic admission. All tests were negative. On the day of the operation, all patients were admitted to the private clinic at least 2 h before the time surgery was scheduled. The patients with recent symptomatic carotid stenosis were transferred from the surrounding hospitals. The average time from symptoms and surgical operation was 4.7 (range 2–9) days. Patients with vulnerable plaques selected from the waiting list came to the private clinic directly from their own home. Five patients (20.8%) had recently symptomatic stenosis, and the remaining 19 patients (79.2%) had a risky asymptomatic carotid stenosis.

In the same period, 19 asymptomatic patients with high-grade stenosis were postponed. At the moment, none of these patients treated with best medical therapy had neurological impairments.

All patients received a standard carotid endarterectomy with eversion technique. No technical issue with remote cerebral monitoring was detected. No shunt was needed. The average operation time was 71 (range 55–83) min. No patient was admitted to intensive care unit. In the early postoperative period, no patient had neurological/systemic complications. Three patients under dual antiplatelet therapy (12.5%) had neck hematoma. Just in one case, the vascular surgeon “on call” received a call from the private clinic for a drug-resistant hypertension. On the first day, all patients were evaluated by a vascular surgeon already present during the operative time. All patients were discharged the day after surgery with a routine follow-up program.

Discussion

A novel coronavirus from patients with pneumonia in Wuhan, China, was found on December 2019 [15]. The World Health Organization declared a pandemic. Daily situation reports are continuously released [16]. The world rapidly changed. Health-care systems experienced a quick reorganization. Telemedicine was immediately worldwide considered a valid alternative to maintain adequate health assistance [11, 17].

Concerning vascular surgery, national and international guidelines recommended maintaining actively surgical sessions for life-threatening conditions (large aortic aneurysm, critical limb ischemia, dysfunctional hemodialysis access, symptomatic carotid stenosis). Some differences existed in terms of aneurysmal diameter or grade of carotid stenosis [2, 3, 4]. Usually, carotid surgery is a priority in vascular surgery services to reduce the number of potential strokes even in asymptomatic patients [18]. Postponing carotid surgery in high-risk patients with vulnerable plaques should result in an increase of neurological events. In some centers, a reduction of access in patients with minor strokes or transient ischemic attacks has been found [19]. In the near future, we should expect more neurological events.

Therefore, in our center, we considered carotid surgery activity a priority even during the COVID-19 pandemic. For this reason, we adopted a quick plan to obtain a good reallocation of our service; the aim was to maintain a high-quality surgical assistance in our patients affected by symptomatic carotid stenosis or with a vulnerable plaque. One of the purposes of our reallocation was to increase the possibility to preserve our patients' health and safety; for this reason, our hospital administration indicated a COVID-free private clinic to perform the carotid surgery activity [19]. Multidisciplinary approach, training, and telemedicine support were crucial.

The close and effective collaboration in our center between vascular surgeons, neurologists, and neurophysiology technicians allowed us to create a quick plan of action. The key point was the flexibility of the surgeons and technicians. The neurologists maintained their standard activities in the hub hospital and offered remote support.

Nurse training was necessary during COVID-19 pandemic [20]. In this article, we reported a different quick training: the scrub nurses of the hub hospital offered support to the staff nurses of the private clinic to obtain an immediate high-quality level of nurse assistance in the operative theater during carotid surgery (knowledge of surgical instruments, procedural steps, shunts, etc.) [21].

In our experience, the use of a VPN connection and “remote” desktop software allowed the neurologist to be able to take control of cerebral monitoring with the support of telemedicine. At the end of each surgical procedure, the neurologist provided a remote report with the help of modern electronic digital signature techniques. Privacy could have been an issue [22]. However, once disconnected from the customer's personal computer, there was no information left about the patient and the examination as the data were stored on the server piloted personal computer set up inside the operative theater and directly managed by the neurophysiology technician.

Regarding clinical outcomes, no patient had postoperative neurological symptoms, therefore demonstrating the good quality of our surgical pathway. Two patients experienced a cervical hematoma not requiring an extended hospital stay. In addition, the average time of surgery and the average hospital stay remained unchanged if compared with the standard surgical activity performed in the hub hospital.

Anyway, the study has 2 main limitations. First of all, we just reported perioperative outcomes. Second, the low number of patients enrolled in this study represents a limit to the firmness of the conclusions.

In our preliminary experience, the reallocation in a COVID-free clinic allowed us to maintain ongoing carotid surgery activity for symptomatic and patients at risk during COVID-19 pandemic. No neurological/systemic complications were detected in this small patient series. Support of telemedicine was crucial for cerebral monitoring. Intensive training of unskilled nurse staff was necessary to maintain a high-quality standard of care.

Statement of Ethics

Subjects have given their written informed consent to the procedure. The article is exempt from ethical committee approval because no change has been made in terms of standard operative technique and perioperative management.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Author Contributions

Nicola Troisi contributed to writing, data analysis, data interpretation, and final revision and final approval of the manuscript. Massimo Cincotta contributed to data interpretation, and final revision and final approval of the manuscript. Consuelo Cardinali contributed to data interpretation, and final revision and final approval. Donato Battista contributed to data interpretation, and final revision and final approval. Aldo Alberti contributed to data interpretation, and final revision and final approval. Luciana Tramacere contributed to data interpretation, and final revision and final approval. Stefano Michelagnoli contributed to data interpretation, and final revision and final approval. Emiliano Chisci contributed to data interpretation, and final revision and final approval.