The Adjustment of Neurosurgery Practices during COVID-19 “Adapting to New Habits” Era in East Nusa Tenggara of Indonesia

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should be done correctly to coexist with the COVID-19 pandemic term "New Normal" is applied to recover economic growth while still maintaining the existing COVID-19 protocols to prevent further virus transmission.
Although the "New Normal" policy has been going for approximately one month, there are still many pros and cons to its application in the community. One of the disadvantages is that there is still a lot of citizens who do not fully understand the definition of "New Normal", especially those who are less literate. They are unfamiliar with the term "New Normal" as the "new way of living". As a result, the word "normal" is often misinterpreted as if the pandemic is over and the conditions have stabilized to the point where they can move as usual without having to stick to the health protocols. This is proven by the massively increasing number of positive cases per day after "New Normal" is applied. Indonesian government faced the situation by revising the term "New Normal" to "Adapting to New Habits", where the application and principles are the same as "New Normal". By changing the term or words into "Adapting to New Habits" the government expects the public to have a better understanding and awareness of the situation and as a result that there will be no more misconception and the health protocols can be implemented by the public.
When the term of Large-Scale Social Restriction or PSBB was applied by the regional government, the number of neurosurgical patients in East Nusa Tenggara has decreased significantly especially patients with traumatic brain injury (TBI). There were only 3 to 5 neurosurgical patients treated every month when the PSBB took place.
Before the COVID-19 pandemic hits, there are at least 1 or 2 patients who came with head injury or spinal trauma every day. This decrease is considered reasonable because during the Large-Scale Social Restriction the government was limiting the public to leave their house which reduced road accidents. However, only 2 weeks after the "New Normal" or "Adapting to New Habits" policy has occurred, traumatic patients increased dramatically to at least 3 to 8 patients per day. This is caused due to boredom and the desire in individuals to go out after PSBB which causing the accident rate to increase again.
The transition from travel limitation to "Adapting to New Habits" caused changes in the hospital service system. Our neurosurgery department also adapts and adjusts to existing changes.
Until now, there has been an official appeal from the Indonesian Neurosurgical Society (INS) regarding the practice of neurosurgery in the COVID-19 era and we followed the appeal by adding some modifications according to each case and conditions in our service. 2,3 There have not been many significant differences in neurosurgery services since "Adapting to New Habits" is occurred. Still, there are few things that we have added to our services so that we can handle the increasing number of patients in our hospital since we stand as the main center of neurosurgery services and main COVID-19 referral hospital in East Nusa Tenggara. Therefore, we would like to share our ways of coping with the neurosurgical patients in our hospital especially in the emergency room, outpatient room, operating room, and the policies towards practical medical students and interns.

Emergency Room Service for Neurosurgical
Patients Every single emergency patient who comes through the emergency room has done some screenings that lead to suspicion of COVID-19 infection, this is done to avoid accidental or unwanted transmission. Screenings such as temperature taking, questions about medical record and travel history, previous contact with an individual who is infected with COVID-19, also complaints of coughing, snoring disorder (anosmia), eye disorders, new skin rash or disorder, followed by a complete blood test, x-ray or CT scan of the thorax, and at least a rapid test or swab test to determine whether the patient is categorized as close contact, suspect, or positive cases with or without symptoms. Since the "Adapting to New Habits" era applied, we have implemented different outpatient service systems in our hospital.
Outpatient services that were initially held 6 times a week were reduced to 2 times a week. For now, we are accepting patients from 2 different hospitals: a regional hospital and a private hospital, both hospitals are the main neurosurgery centers in East Nusa Tenggara.
With the approval of both hospital management, we decided to only practice in one main hospital. We collected and moved the patients from the private hospital into the regional hospital to minimize contact and time effectiveness.

Operating Room Services
As we have mentioned before, according to our hospital standards every neurosurgical patient who is planned for receiving surgery must undergo COVID-19 tests. We divided the patients into 2 In elective cases that are not emergencies, surgery will still be planned with a maximum limit of 2 operations per week. Patients with a higher risk of worsening such as brain tumor cases will be prioritized. All plans or cases of elective surgery will be evaluated every week to determine its priorities. 7  should be completed within 2 hours and the use of a bone drill is reduced to prevent aerosolized. [7][8][9] Because the space in the ICU is fairly limited and out of balance with the number of patients that have increased, we also screen patients that will be placed in the ICU. For now, the ICU only provides 7 beds and one isolation room inside. We prioritize patients with good predict outcomes after the surgery to be placed in the ICU for 2 days at the maximum before moved into the regular room. For patients with worst predict outcomes, we suggest they be placed in the ICU room only if there is enough bed and for 1 day at the most before moved into the regular room. Patients categorized in good predict outcomes group are those who are: under 60 years old with GCS >8, bleeding due to trauma or stroke which can allow total evacuation, the time from incident to operation is under 12 hours, and patients without a severe medical history of illness such as heart failure and chronic kidney disease. Those with the worst predict outcomes are the opposite of the criteria for patients with good predict outcomes. All surgical inpatients will be discharged as soon as possible when the condition has improved.

Practical Medical Students (Clerkships) and
Interns In our neurosurgery center, we routinely hold the entrance of clerkships and internship doctors every year. Before the COVID-19 pandemic hits, we usually accept two clerkships and two internship doctors with a service period of 1 year. Currently in this "Adapting to New Habits" era we only accept one clerkship and one internship doctor at the most. Clerkships and internships should wear hair caps, face shields, surgical masks, scrub suits, boots, and raincoats as their daily PPE. Currently, clerkships are not allowed to enter the operating room and only internships are permitted, this is done to minimize the risk of exposure. Both clerkships and internships are not permitted to do a follow up on outpatients with COVID-19 risk, they were only allowed to follow up on patients with negative COVID-19 rapid test results. We changed the maximum working hours of clerkships and internships from 8 and 10 hours a day to 5 and 7 hours a day respectively.
In dealing with the "Adapting to New Habits" era we should still follow the developing COVID-19 guidance and protocols when carrying out practices and services in hospitals. After describing all the actions and adjustments we have implemented in the services at our hospital, especially in the neurosurgery department, we can say that the most important and effective way to reduce the number of COVID-19 positive cases is to adhere to the basic principles of COVID-19 health protocol such as physical distancing, and always wearing complete PPE whenever we are out meeting other people both fellow medical personnel and patients. We must have a high awareness of our surroundings and skeptical towards everyone we meet in the hospital.
Even though our facilities are still limited compared to other regions especially when it comes to personal protective equipment, by applying these methods and adjustments we can confirm that until now there is no medical personnel at our hospital who have been confirmed to have COVID-19 (based on the screening results that carried out every 2 weeks in the hospital).
By sharing the changes and modifications to the services in our hospital, we are hopeful that the ideas we have done can be useful and applied in other hospitals or neurosurgery centers during the "Adapting to New Habits" era. Although we are still at battle with the COVID-19 pandemic and the number of positive patients keeps