An editorial published in The Spine Journal details a series of strategies to mitigate the mental health impact of the provision of spine care during COVID-19. Authored by Victoria Williamson (King’s College London, London & University of Oxford, Oxford, UK) the paper outlines the impact of the COVID-19 pandemic on spine care to date, as well as discussing the potential mental health implications for clinicians and patients. Williamson then sets out a series of recommendations for preserving wellbeing in the two groups.
Williamson, a research fellow at the University of Oxford & King’s College London’s Psychological Medicine department, writes that the COVID-19 pandemic has placed substantial demand on already overstretched healthcare services. The added demand placed upon services, as well as the need to stem the spread of the virus has led to significant changes in clinical practice across a number of medical specialties, notably the postponement of many elective surgeries, including in spine care.
The paper notes that the decision as to postpone or perform a spine-related surgical procedure has become more complicated in light of the pandemic, as delaying surgery may cause clinical deterioration at a time when they may be less easily manageable. “The pathologic process may move beyond surgical intervention by the time the pandemic moves into a more controlled phase,” Williamson writes.
In cases where surgery is performed, there are concerns over what this may mean for the clinical team performing the procedure due to the potential risk of transmission of COVID-19. “There is concern yet little evidence whether aspects of surgical procedures may make surgical teams more vulnerable to the virus,” Williamson notes, adding that it remains unclear whether individual elements of an operation should be omitted to reduce the overall risk to the patient and surgical team, while perhaps reducing the effectiveness of the surgery itself.
Williamson acknowledges that caring for patients with spine difficulties is not without its complications at the best of times and adds that the pandemic adds a further layer of complexity, with spine clinical care teams now required to make extremely difficult decisions with very limited data and high levels of uncertainty. She goes on to write that healthcare providers may be particularly vulnerable to experiencing moral injury during this time—which is defined as “the profound psychological distress which results from actions, or the lack of them, which violates one’s moral or ethical code”.
She writes: “In the context of the COVID-19 pandemic, a lack of resources in healthcare systems, such as limited access to rapid triage facilities and theatres, may mean spine clinical care teams are unable to adequately care for those they are responsible for which may result in great patient suffering or loss of life. A lack of clear guidance or training, as well as personal protective equipment (PPE), may also mean clinical teams perceive that their own health is not being properly considered by their employers and they may feel at increased risk of disease exposure.”
Discussing the psychological bearing upon spine surgery patients felt at this time, Williamson writes that spine surgery has always been an area of anxiety and concern for patients mainly due to the potential risks of life-changing neurologic injury. But, she adds that the emergence of COVID-19 has “redefined assumptions regarding spinal surgical risk-benefit ratios”. She goes on to write: “Clinical care teams are now faced with the added burden of a highly contagious life-threatening condition totally unrelated to the surgical procedure that, as such, they cannot treat. Informed consent will need to include risk of COVID-19 transmission and yet clinicians cannot currently quantify that risk.”
From point of presentation through to hospital admission patients are also faced with the prospect of contracting COVID-19, and face isolation from friends and family at a time of need. Changes in practice including surgical thresholds and the reasoning behind those changes will need to be relayed to the patient, potentially heightening patient anxiety about quality of care and the potential for harm, she adds.
Turning to recommendations for spine clinicians to preserve patient wellbeing during this time, Williamson identifies adherence to social distancing measures at work and at home, as well as protecting the health system through streamlined working and virtual outpatient clinics where possible, as important strategies to maintain. Ensuring that appropriate personal protective equipment (PPE) is used at all times is a further key strand. “Healthcare workers who feel correctly that they have been placed in harm’s way without adequate protection will inevitably feel affected by that process whether they contract the virus or not,” she argues.
Furthermore, she writes, collaborative decision making and resource sharing between neurosurgery and orthopaedic spinal teams is vital, and patient and family expectations will need to be managed judiciously with a realistic outlook on treatment objectives and outcomes.
In terms of managing their own psychological wellbeing, the paper recommends further strategies for clinicians. These include keeping good documentation of the clinical decision making surrounding the decision to postpone or proceed with spine-related surgeries is recommended, which it argues, may help to mitigate any adverse psychological effects for staff should negative patient outcomes arise.
Spine clinical care teams should be prepared for the tasks they will be asked to carry out, the impact COVID-19 will have on standard operating procedures, as well as the thoughts, behaviours, and feelings that they may experience as a result, Williamson notes. “Frank and open discussions as a team, led by senior clinicians or management, may help encourage psychological preparedness among staff.”
Finally, Spine clinical care teams should be encouraged to seek social support from colleagues or alternatively access informal support from other organisational avenues, such as trained peer supporters, managers or chaplaincy services. Williamson concludes that encouraging healthcare professionals to work in small teams at this time may also promote a sense of unified purpose and may mean at risk members are identified earlier.