The Case for Accelerated Discharge After Brain Tumor Surgery

As hospitals experienced an influx of COVID-19 patients beginning in March 2020, there was a significantly reduced capacity to perform surgical operations and a shortage of available beds. This prompted clinicians at Providence Saint John’s Health Center in Santa Monica, CA to create accelerated timelines and safety protocols from admission to discharge for brain tumor surgery patients.

In their 2021 case-control study, Mallari et al. examined the efficacy of earlier discharge by assessing the ICU and hospital length of stay (LOS), surgical complications and hospital readmission rates of brain tumor surgery patient cohorts before and during the pandemic.

Comparing Brain Surgery Recovery Time Before and During the Pandemic

The study authors included 295 patients in their analysis, and all patients had undergone brain tumor surgery for a primary or secondary brain tumor, skull base tumor or pituitary tumor.

The study period was divided into a pre-pandemic epoch with 163 patients (March 2019 to January 2020) and a pandemic epoch with 132 patients (March 2020 to January 2021). Tumor pathology subtypes were similar between the two epochs.

Here are some key takeaways:

• • Among both epochs, 179 patients underwent a craniotomy, and ICU utilization for brain surgery recovery decreased from 80% pre-pandemic to 33% during the pandemic.
  • Gross-total/near-total tumor resection was achieved in 68% of craniotomies pre-pandemic and in 80% of craniotomies during the pandemic.
  • The average ICU and hospital LOS for brain surgery recovery decreased for both epochs.
  • The percentage of patients discharged by post-op day 1 increased from 12% pre-pandemic to 41% during the pandemic.
  • Hospital readmission rates were low and similar between the two epochs.
  • No patients or members of the surgical team contracted COVID-19 during the pandemic epoch.

The study authors note that several factors can help facilitate safe and early discharge of brain tumor patients, thus reducing ICU usage. The pandemic encouraged them to place an emphasis on:

• • Having more stringent patient preparation and education:
    • • • Patients and families were directly told that they would be ready for discharge by post-op day 1 or 2 if they could ambulate well and post-operative imaging changed as expected. They were also informed that a quicker discharge would be beneficial for them as it would not only allow them to be home with family, but also free-up beds for COVID-19 or other critically ill patients.
        • This additional education process motivated patients to minimize their hospital length of stay when they would have previously been reluctant to do so prior to the pandemic.
        • Aligning the surgical team, anesthesiologists, recovery room staff, intensivists, ICU staff, step-down unit nursing staff, and hospital administration on the same goal was likely critical to the successful reduction of ICU utilization and LOS.
  • Implementing a more rigorous patient evaluation in the recovery room to assess the need for ICU monitoring and admission to a step-down unit bed
  • Focused care team engagement to encourage and facilitate early discharge
  • Earlier postoperative patient mobilization
  • Early patient follow-up post-discharge: Patients received a phone call one day after discharge and had their first follow-up appointment within seven days of surgery

To help avoid postoperative brain surgery risks and complications, they found that it is important for patients to have a CT immediately after surgery as this can serve as a warning system for early evolving complications or as a way to ensure that recovery in a non-ICU bed is safe for the patient.

Additionally, they note that total intravenous anesthesia has been shown to have lower rates of post-op nausea, vomiting and cognitive dysfunction, symptoms which could lead to longer hospital length of stay, and reduced narcotic use helps patients be more alert and physically active.

Having used these two methods for this patient population, there was only one case of deep vein thrombosis and no pulmonary emboli, myocardial infarctions, or 30-day surgical mortalities.

They note that while their brain tumor center mainly treats non-emergent patients and their findings are specific to patients with primary and secondary brain tumors, their pathology population is similar to that of national brain tumor demographic trends, and many of these measures taken are relevant and applicable to other specialties.

Are There Other Ways COVID-19 Has Impacted Brain Surgery Recovery Care?

While the impact of the pandemic on almost every patient population was suspected to be notable, it was suspected to worsen neuro-oncological patient outcomes in particular as neuro-oncology elective procedures are often time-sensitive.

In their retrospective review published in September 2021, Norman et al. analyzed alterations in care and outcomes during the pandemic among patients with a malignant brain tumor at a major academic center in New York City. They included 112 patients from 2020 and 166 from 2019, and while they did not find any significant differences in outcomes between these two cohorts, there was a significant difference in treatment delays and use of telehealth.

Between the pre-pandemic period, defined as January to April 2019 and January to February 2020, and the pandemic period, defined as March to April 2020, the average number of brain tumor consults per month decreased by half. Telehealth use increased from 0% to 82% between 2019 and 2020, and patients who had used telehealth had significantly higher rates of stable brain tumor control compared to patients who only had in-person visits.

The study authors note that physician-led delays in care and/or the use of telehealth did not cause any adverse outcomes or additional brain surgery risks and complications in their patient population. With this in mind, they urge patients to continue to seek cancer care regardless of any pandemic-related fears.