As hospitals resume elective surgeries during the COVID-19 pandemic, questions remain around how to safely engage in these surgeries from a clinical perspective. While the American Association of Orthopaedic Surgeons (AAOS) still recommends delaying elective surgeries if possible, a number of organizations and associations have begun to release their best practices and experiences in operating during the age of COVID-19 (https://www.aaos.org/about/covid-19-information-for-our-members/guidance-for-elective-surgery/). In an effort to assist in the dissemination of these best practices, we rounded up the most salient findings on how hospitals, both domestically and internationally, have addressed conducting elective surgeries (In Massachusetts, for example (where Avant-garde Health is headquartered), Governor Charlie Baker has released guidance that providers can perform elective surgeries on a case-by-case basis, based on their clinical judgements. Providers must “consider the preservation of the patient's life and health.” For more information on each state’s resumption of elective surgeries, see here: https://www.acr.org/-/media/ACR/Files/COVID19/States-With-Elective-Medical-Procedures-Guidance-in-Effect.pdf?la=en).

While there is a myriad of recommendations across the literature, one common finding is that health care providers must place a heavy emphasis on testing patients for COVID-19 to ensure that they are aware of their medical status prior to their entry into the hospital. Given that there are a number of types of COVID-19 tests (with varying accuracy rates), we first describe the testing landscape to ensure that you are engaging in the proper tests to protect yourself, your staff, and your patients.

Currently, there are three types of COVID-19 tests:

• Polymerise Chain Reaction or PCR - tests for viral RNA to determine if a patient is currently infected. The test, which uses a nasal swab, is highly accurate, but can take anywhere from less than one day to several days to get results.
• Antigen - tests for proteins specific to COVID-19 to determine if a patient is currently infected. The test, which uses a nasal swab, produces results much more quickly than the PCR test, but is far less accurate. A person testing positive for COVID-19 through an antigen test should be tested using a PCR test.
• Antibody - using a blood draw, tests for antibodies to determine if you have had COVID-19 in the past (though does not test for current infection).

Therefore, when providers state that a patient’s COVID-19 infection status must be determined prior to their entry into the health care facility, they are referring to the PCR test status. For further information, see the CDC’s recommendations here: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/testing.html.

Beyond testing, there are also several other best practices that clinicians around the world have suggested when resuming elective surgeries. First and foremost, clinicians recommend that patients only receive elective procedures if they test COVID-19 negative, with those testing positive be restricted to urgent surgeries. Guidelines recommend that patients and clinicians wear masks (ideally N95s for clinicians) and patients avoid congested areas as much as possible. Operating rooms should be frequently cleaned and sterilized and additional precautions such as more intensive airway management systems should be put in place. Visitors should be limited during the patient’s stay, and discharging a patient home should be the preferred route to avoid the added risk associated with a post-acute care facility. Telehealth follow-up appointments should be used where possible. Finally, every effort should be made to delay any surgeries that are not time sensitive.

We dive deeper into the key insights from a number of recent studies on resuming orthopaedic surgery during COVID-19 below:

Resuming Elective Orthopaedic Surgery During the COVID-19 Pandemic (The Journal of Bone and Joint Surgery, published May 14, 2020*)

*refer to Resources Digest section at the bottom for full details

In order to minimize the risk of the spread of COVID-19, the International Consensus Group (ICM) of the American Association of Hip and Knee Surgeons (AAHKS) issued a series of guidelines for how hospitals should safely resume elective orthopaedic surgeries.

Overall, delegates largely agreed on the following moderate-strong recommendations:

• Elective surgeries should be resumed when:

Lockdown has been lifted in the geographic area and authorities issue a mandate allowing for resumption of elective surgeries

The number of COVID-19 cases in a region has been declining consistently

Your organization has enough capacity to separate COVID-19 and non-COVID-19 patients

Your organization has personal protective equipment (PPE), can conduct the PCR test for the virus, and can perform surgeries with low risk of transmission

Your organization can maintain social distancing at all times

Your organization has adequate PPE to address a second wave

Your organization should educate patients on the protocols in place to minimize transmission of COVID-19.

Delegates agreed that pre-operatively, the following steps should be taken:

Test all patients for COVID-19 before surgery

Patients and providers must have have a surgical mask on during encounters

Reduce use of common spaces, including waiting rooms

Place limits on the number of family members and visitors a patient can have

Reduce surgeon interactions with relations of the patient, and patients should stay in a single room if possible

Retest patients for COVID-19 if they show symptoms but initially tested negative

Intra-operatively, the group made the following suggestions:

Limit the amount of equipment in the operating room

Use HEPA filters (or something similar) and ensure a ventilation system and positive-pressure system are in place

Limit the number of people in the operating room

Use appropriate PPE

Use localized anesthesia when possible to avoid interaction with airwaves

Conduct a thorough cleaning of the room after each case

Surgeons should also operate in multiple rooms to allow for cleaning time

Finally, postoperatively, the delegates recommended the following:

If a patient acquires COVID-19 after surgery, they should be quarantined

If not testing positive, patients should still be separated from one another by six feet

Require that medical staff wear appropriate masks

Avoid allowing visitors

If possible, bypass the PACU to avoid additional potential exposure

Patients should wear a mask postoperatively

Minimize patient length of stay as much as possible

Consider having physicians conduct rounds using telemedicine if possible

When possible, patients should be discharged directly home, and office visits limited to when they are truly necessary

The COVID-19 outbreak in Italy: perspectives from an orthopaedic hospital (Nature Public Health Emergency Collection, published May 22, 2020*)

*refer to Resources Digest section at the bottom for full details

Italy has experienced some of the worst rates of COVID-19 cases and deaths in the world. The Rizzoli Orthopaedic Institute, which is one of the largest orthopaedic surgery hospitals in the country with 90 surgeons performing over 12,000 procedures a year, was impacted by the current pandemic. In a conversation with four doctors from the hospital, a series of findings came to light on how the hospital most effectively handled the outbreak, including:

Learn how to properly identify patients suspected of COVID-19 and defining care pathways for those patients (separate from wards with non-COVID-19 patients)

Provide personal protective equipment (PPE) to each clinician

Eliminate elective surgeries while only allowing trauma surgeries

Designate “clean” and “dirty” spaces in which requirements for PPE differ (defining “clean” spaces as those that were not inhabited by suspected COVID-19 cases) and stage areas to allow for clinicians to dress and undress for procedures without risking exposure to COVID-19

Cancel in-person teaching instruction of clinicians to avoid gatherings by moving education online

Another important observation was that it was difficult to care for elderly trauma patients with comorbidities at this time, as they were at-risk both for developing COVID-19 while in the hospital and also for poor outcomes if discharged, creating a more complex environment. While clinicians did not have a foolproof plan for how to deal with these patients, it is important to note the following recommendation:

Thought needs to be given to how to manage patients who require beds in the ICU for long periods of time for reasons related to traumas other than COVID-19

An Orthopaedic Department’s Response to the COVID-19 Health-Care Crisis (The Journal of Bone and Joint Surgery, published May 4, 2020*)

*refer to Resources Digest section at the bottom for full details

As a result of the COVID-19 pandemic, the University of Washington‘s Department of Orthopaedics and Sports Medicine took a number of indirect (e.g. actions involving avoidance of clinical practices harmful during pandemic) and direct (e.g. actions involving adoption of additional clinical practices as a result of COVID-19) actions to safely practice medicine.

Examples of indirect action that should be taken:

Cancel elective cases (measured as those cases that could be delayed by 4 to 6 weeks without undue suffering)

Limit outpatient clinic visits

Adjust workforce to the reduced caseload

Examples of direct action that should be taken:

Increase telehealth capabilities

Provide more efficient consultative care to emergency departments (defined as orthopaedic surgeons providing more rapid clinical assessments in the emergency department, reducing potential need for inpatient admission)

Help by directing patients with traumatic injuries toward hospitals not overwhelmed with COVID-19 patients

By taking these actions, clinicians were able to reduce interaction between themselves and patients (allowing for increased social distancing and lower probability of transmission), preserve PPE for other areas of the hospital that needed it more urgently, and redeploy to clinical departments in need (or serve as a reserve clinical force in case other front-line staff became sick). Additionally, hospital leadership recognized that ultimately, the direct communication of decisions made was imperative for improved morale and planning.

Post COVID-19: Planning strategies to resume orthopaedic surgery challenges and considerations (Journal of Clinical Orthopaedics and Trauma, published May 4, 2020*)

*refer to Resources Digest section at the bottom for full details

As hospitals begin to resume elective orthopaedic surgeries across the world, the authors examined potential ways to overcome challenges of reintroducing these surgeries in the Indian context.

Planning in particular will become increasingly important when guiding a patient through care:

Develop guidelines for considerations regarding whether a patient is asymptomatic or symptomatic (only treating those testing positive for critical acute traumas)

Conduct consistent COVID-19 testing for all patients entering for surgeries

Delay the primary fixation of fractures, as the delay does not cause negative outcomes to healing, and also reduces the patient’s risk of contracting COVID-19 by entering the hospital

Government involvement in making these determinations is also paramount--if explicit orders and planning is generated at the top, clinicians and hospital systems will have an easier time determining how to safely move forward with care. The role of orthopaedic associations is also important; as the authors note, it will be imperative for the Indian Orthopaedic Association to issue guidelines for safely resuming surgeries.

When it comes to the setting of care, researchers recommended the following:

Develop non COVID-19 care (NCC) zones and COVID-19 care zones to ensure that there is division between the two, shielding non at-risk patients from developing the disease

Designate a COVID-specific operating theatre in which surgeons can move from “dirty” to “sterile” settings without exposing themselves or others for too long a period

Limit length of postoperative stay, leading to this care being performed increasingly at home

Prepare for a second wave

Interested in learning how the American College of Surgeons, Penn Medicine and Trinity Health of New England think about and are successfully resuming surgeries during the COVID-19 pandemic? Click here to view a webinar replay.

RESOURCES DIGEST

Study Name: Resuming Elective Orthopaedic Surgery During the COVID-19 Pandemic

Published: May 14, 2020

Authors: Parvizi, J. MD, FRCS (Rothman Institute); Gehrke, T. MD (Helios ENDO-Klinik, Hamburg, Germany); Krueger, C.A. MD (Rothman Institute); et al.

Link: https://journals.lww.com/jbjsjournal/Abstract/9000/Resuming_Elective_Orthopaedic_Surgery_During_the.99717.aspx

Study Name: The COVID-19 outbreak in Italy: perspectives from an orthopaedic hospital

Published: May 22, 2020

Authors: Alberto Grassi (II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli), Nicola Pizza (II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli), Dario Tedesco (Medical Affairs Department, IRCCS Istituto Ortopedico Rizzoli), and Stefano Zaffagnini (II Clinica Ortopedica e Traumatologica, IRCCS Istituto Ortopedico Rizzoli)

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7242018/

Study Name: An Orthopaedic Department’s Response to the COVID-19 Health-Care Crisis

Published: May 4, 2020

Authors: Iannuzzi, Nicholas P. MD (Department of Orthopaedics and Sports Medicine, University of Washington), Lack, William D. MD (Department of Orthopaedics and Sports Medicine, University of Washington), Gee, Albert O. MD (Department of Orthopaedics and Sports Medicine, University of Washington), Chansky, Howard A. MD (Department of Orthopaedics and Sports Medicine, University of Washington)

Link: https://journals.lww.com/jbjsjournal/Citation/9000/An_Orthopaedic_Department_s_Response_to_the.99728.aspx

Study Name: Post COVID-19: Planning strategies to resume orthopaedic surgery challenges and considerations

Published: May 4, 2020

Authors: Karthikeyan P. Iyengar (Southport and Ormskirk NHS Trust), Vijay K. Jain (Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital), Abhishek Vaish (Indraprastha Apollo Hospital), Raju Vaishya (Indraprastha Apollo Hospital), Lalit Maini (Maulana Azad Medical College), and Hitesh Lalf (Sports Injury Centre, Safdarjung Hospital)

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7196552/

May Webinar: Successfully Resuming Surgeries During the COVID-19 Pandemic

Link: https://www.avantgardehealth.com/recordings

April Webinar: Managing Through COVID-19 for Health Care Leaders

Link: https://www.avantgardehealth.com/recordings