Infection prevention measures for orthopaedic departments during the COVID-2019 pandemic: a review of current evidence

Spinal fusion is an aerosol generating procedure

BACKGROUND

Transmission of severe acute respiratory syndrome coronavirus 2 can occur during aerosol generating procedures. Several steps in spinal fusion may aerosolize blood but little data exists to quantify the risk this may confer upon surgeons. Aerosolized particles containing infectious coronavirus are typically 0.5-8.0 μm.

AIM

To measure the generation of aerosols during spinal fusion using a handheld optical particle sizer (OPS).

METHODS

We quantified airborne particle counts during five posterior spinal instrumentation and fusions (9/22/2020-10/15/2020) using an OPS near the surgical field. Data were analyzed by 3 particle size groups: 0.3-0.5 μm/m³, 1.0-5.0 μm/m³, and 10.0 μm/m³. We used hierarchical logistic regression to model the odds of a spike in aerosolized particle counts based on the step in progress. A spike was defined as a > 3 standard deviation increase from average baseline levels.

RESULTS

Upon univariate analysis, bovie (P < 0.0001), high speed pneumatic burring (P = 0.009), and ultrasonic bone scalpel (P = 0.002) were associated with increased 0.3-0.5 μm/m³ particle counts relative to baseline. Bovie (P < 0.0001) and burring (P < 0.0001) were also associated with increased 1-5 μm/m³ and 10 μm/m³ particle counts. Pedicle drilling was not associated with increased particle counts in any of the size ranges measured. Our logistic regression model demonstrated that bovie (OR = 10.2, P < 0.001), burring (OR = 10.9, P < 0.001), and bone scalpel (OR = 5.9, P < 0.001) had higher odds of a spike in 0.3-0.5 μm/m³ particle counts. Bovie (OR = 2.6, P < 0.001), burring (OR = 5.8, P < 0.001), and bone scalpel (OR = 4.3, P = 0.005) had higher odds of a spike in 1-5 μm/m³ particle counts. Bovie (OR = 0.3, P < 0.001) and drilling (OR = 0.2, P = 0.011) had significantly lower odds of a spike in 10 μm/m³ particle counts relative to baseline.

CONCLUSION

Several steps in spinal fusion are associated with increased airborne particle counts in the aerosol size range. Further research is warranted to determine if such particles have the potential to contain infectious viruses. Previous research has shown that electrocautery smoke may be an inhalation hazard for surgeons but here we show that usage of the bone scalpel and high-speed burr also have the potential to aerosolize blood.

Does the COVID-19 personal protective equipment impair the surgeon's performance?

INTRODUCTION

Despite increasing vaccination rates, new viral variants of SARS-CoV-2 (severe acute respiratory syndrome coronavirus type 2) are advancing the COVID 19 (coronavirus disease 2019) pandemic and continue to challenge the entire world. Surgical care of SARS-CoV-2 positive patients requires special protective measures. We hypothesized that "COVID-19" personal protective equipment (PPE) during surgery of SARS-CoV-2 positive or potentially positive patients would negatively affect the surgeon and thus the surgical outcome.

MATERIALS AND METHODS

Ten experienced trauma surgeons participated in the study. Each surgeon performed two simulated surgeries of a distal tibial fracture on a Sawbone® under standardized conditions either wearing regular PPE or special COVID-19 PPE. Baseline values at rest were acquired for heart rate, blood pressure, saturation of peripheral oxygen (SpO₂), respiratory rate and capillary blood gas (CBG) analysis including capillary partial pressure of oxygen (pO₂) and carbon dioxide (pCO₂), followed by four different standardized tests of attentional performance (TAP). Subsequently, the surgeon performed the first surgery according to a randomly determined order, with regular or COVID-19 PPE conditions in an operation theatre. After each surgery vital signs were acquired and CBG and TAP were performed again.

RESULTS

In our simulated surgical procedure heart rate, respiratory rate, systolic and diastolic blood pressure did not show relevant differences. Percutaneously measured SpO₂ decreased with additional layers of PPE, while CBG parameters were not affected. TAP tests showed a significant impairment of attention if PPEs were compared to the baseline, but both PPEs had similar results and no meaningful differences could be measured.

CONCLUSIONS

According to our results, for surgical procedures additional PPE required during COVID-19 pandemic does not relevant affect the surgeon's mental and physical performance. Surgeries under COVID-19 PPE conditions appear safe and do not increase patient risk.

LEVEL OF EVIDENCE

Level I.

Rapid review and meta-analysis of the effectiveness of personal protective equipment for healthcare workers during the COVID-19 pandemic

Objectives

Healthcare workers (HCWs) worldwide have and are using personal protective equipment (PPE) as COVID-19 prevention measures, including gloves, gowns, goggles, masks and hand hygiene. Although several reviews have been published on the effectiveness of PPE, these often include studies on other inflectional diseases. This is problematic, because these diseases differ with regard to, e.g. the transmissibility and viral loads in the days after infection. Therefore, we assessed the effectiveness of PPE to protect HCWs from COVID-19 infections.

Design

Rapid review of literature.

Methods

We followed a practical guide to conduct the rapid review based on a protocol established by the Cochrane Rapid Reviews Methods Group. Meta-analyses have been conducted to synthesize the results. The confidence in the evidence was determined using the GRADE method.

Results

We found 461 reviews and 208 primary studies, of which 16 systematic reviews included 11 observational studies of interest. Wearing PPE conferred significant protection against infection with COVID-19 as opposed to not wearing adequate PPE. Overall, the review results show that wearing face masks can significantly protect HCWs from infection. We found no effects for wearing gloves and gowns. Practicing thorough hand hygiene and having proper PPE, as compared to lacking proper PPE, showed a protective but not statistically significant effect. No studies reported the side effects of wearing PPE or acceptance rates.

Conclusion

This evidence supports PPE use by HCW, and especially N95 masks, to reduce the risk of a COVID-19 infection.

Impact of COVID-19 pandemic on hip fractures: the central London experience COVID-related urgent geriatric hip trauma (COUGH) study COVERT ( COVid Emergency-Related Trauma and orthopaedics) collaborative

Introduction

COVID-19 has been recognized as the unprecedented global health crisis in modern times. The purpose of this study was to assess the impact of COVID-19 on treatment of neck of femur fractures (NOFF) against the current guidelines and meeting best practice key performance indicators (KPIs) according to the National Hip Fracture Database (NHFD) in two large central London hospitals.

Materials and methods

A multi-center, longitudinal, retrospective, observational study of NOFF patients was performed for the first ‘golden’ month following the lockdown measures introduced in mid-March 2020. This was compared to the same time period in 2019.

Results

A total of 78 cases were observed. NOFFs accounted for 11% more of all acute referrals during the COVID era. There were fewer overall breaches in KPIs in time to theatre in 2020 and also for those awaiting an orthogeriatric review. Time to discharge from the trust during the pandemic was improved by 54% (p < 0.00001) but patients were 51% less likely to return to their usual residence (p = 0.007). The odds ratio was significantly higher for consultant surgeon-led operations and consultant orthogeriatric-led review in the post-COVID era. There was no significant difference in using aerosol-generating anaesthetic procedures or immortality rates between both years.

Conclusion

The impact of COVID-19 pandemic has not adversely affected the KPIs for the treatment of NOFF patients with significant improvement in numerous care domains. These findings may represent the efforts to ensure that these vulnerable patients are treated promptly to minimize their risks from the coronavirus.

Bioaerosols in orthopedic surgical procedures and implications for clinical practice in the times of COVID-19: A systematic review and meta-analysis

INTRODUCTION

Orthopedic surgical procedures (OSPs) are known to generate bioaerosols, which could result in transmission of infectious diseases. Hence, this review was undertaken to analyse the available evidence on bioaerosols in OSPs, and their significance in COVID-19 transmission.

METHODS

A systematic review was conducted by searching the PubMed, EMBASE, Scopus, Cochrane Library, medRxiv, bioRxiv and Lancet preprint databases for studies on bioaerosols in OSPs. Random-effects metanalysis was conducted to determine pooled estimates of key bioaerosol characteristics. Risk of bias was assessed by the RoB-SPEO tool; overall strength of evidence was assessed by the GRADE approach.

RESULTS

17 studies were included in the systematic review, and 6 in different sets of meta-analyses. The pooled estimate of particle density was 390.74 μg/m3, Total Particle Count, 6.08 × 106/m3, and Microbial Air Contamination, 8.08 CFU/m3. Small sized particles (

CONCLUSION

Whereas there is evidence to suggest that OSPs generate large amounts of bioaerosols, their potential to transmit infectious diseases like COVID-19 is questionable. High-quality research, as well as consensus minimum reporting guidelines for bioaerosol research in OSPs is the need of the hour.

Collapse

Key Words

• Aerosol
• Aerosol generating procedure (AGP)
• COVID19
• Coronavirus
• Guideline
• Orthopaedics surgical procedures
• Personal protective equipment (PPE)
• Review
• SARS

Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s) Collapse

SARS-CoV-2, surgeons and surgical masks

The exact risk association of coronavirus disease 2019 (COVID-19) for surgeons is not quantified which may be affected by their risk of exposure and individual factors. The objective of this review is to quantify the risk of COVID-19 among surgeons, and explore whether facemask can minimise the risk of COVID-19 among surgeons. A systematised review was carried out by searching MEDLINE to locate items on severe acute respiratory syndrome coronavirus 2 or COVID-19 in relation to health care workers (HCWs) especially those work in surgical specialities including surgical nurses and intensivists. Additionally, systematic reviews that assessed the effectiveness of facemask against viral respiratory infections, including COVID-19, among HCWs were identified. Data from identified articles were abstracted, synthesised and summarised. Fourteen primary studies that provided data on severe acute respiratory syndrome coronavirus 2 infection or experience among surgeons and 11 systematic reviews that provided evidence of the effectiveness of facemask (and other personal protective equipment) were summarised. Although the risk of COVID-19 could not be quantified precisely among surgeons, about 14% of HCWs including surgeons had COVID-19, there could be variations depending on settings. Facemask was found to be somewhat protective against COVID-19, but the HCWs’ compliance was highly variable ranging from zero to 100%. Echoing surgical societies’ guidelines we continue to recommend facemask use among surgeons to prevent COVID-19.

Operation theatre protocol for COVID-19 cases requiring orthopaedic surgery: A workflow without altering the existing infrastructure

INTRODUCTION

The surge in the number of trauma cases following relaxation of lockdowns in the backdrop of COVID-19 pandemic, has strained the existing infrastructure to cater to these patients and also prevent the spread of infection. Moreover, with the rise of newer strains, the period ahead has to be tread carefully to prevent resurgence of infections. There have been recommendations regarding the ideal setup to operate orthopaedic cases in this pandemic scenario. However, many of the hospitals in India with financial and logistic constraints are unable to implement these structural changes into their existing setup. We propose a model which can be used in an existing operation theatre which has a single entry and exit corridor, which is the layout in many hospitals.

METHODOLOGY

A protocol with the consultation of a panel of health care professionals was designed on the basis of WHO guidelines in a way so as to remain dynamic. Prior to its implementation, online classes were conducted and a dry run of the protocol was done with the whole team involved. The theatre layout is one with a single entry and exit and had predesignated rooms. The personnel were divided into 3 teams, each with a fixed set of people and preset workflow, to be followed during entry and exit. Five COVID positive cases have been operated since then using the protocol and has been used as a pilot study to further amend the protocol.

CONCLUSION

This model can be used as a guideline by hospitals having a limited infrastructure, to develop their own protocol to operate on COVID positive cases, in the present situation of increasing trauma cases post the relaxation of lockdown and also in any subsequent waves of infection with newer strains. Simulation and periodic stringent audits with the entire team would prove successful in rectifying errors and avoiding any possible contamination.

Orthopaedic Practices and Surgeries during COVID-19 in Pakistan - A Survey Based Study

Introduction:

The study aimed to target the current practices of the orthopaedic community in outpatient (OPD), emergency (ER) and surgical services (OT) during COVID-19.

Material and method:

This study surveyed 303 orthopaedic surgeons from all over Pakistan. The survey had 30 questions targeting the setup of outpatient, emergency and operation services in orthopaedic departments of different hospitals in Pakistan.

Result:

A total of 302 surgeons were included from 53 cities all over Pakistan. Between 35-48% of the respondents reported lack of availability of standard operating procedures in OPD, ER and in OT. Majority of the respondents noted that their OPD and surgical practice had been affected to some degree and 69% of the surgeons were only doing trauma surgery. This trend was higher in younger consultants of less than 45 years of age (p<0.001). Almost two-third of the surgeons, mostly senior (p=0.03) were using surgical masks as the only protective measure during various practices of OPD, ER and OT, while most of the setups were not assessing patients even for signs and symptoms of COVID. Almost 89% of the orthopaedic community is facing definite to mild stress during this pandemic and this has significantly affected the senior surgeons (p=0.01).

Conclusion:

Our study highlighted that COVID-19 has resulted in marked changes to the practices of the majority of Pakistani orthopaedic surgeons. Despite a sharp upsurge in the number of cases and mortality due to COVID-19, guidelines were still lacking at most of the settings and a substantial percentage of the orthopaedic community were not following adequate safety measures while attending to patients.

Evidence-based review of safe theatre practice during the COVID-19 pandemic beyond personal protective equipment

INTRODUCTION

COVID-19 remains a threat for a fear of a second pandemic. Emergency orthopaedic operations are still among the most commonly performed procedures with increased risk of transmission of SARS CoV-2 to the patients and the healthcare workers. The aim of this study was to present the evidence available into best practices limiting the spread of COVID-19 in healthcare setting during current and future pandemics.

METHODS

A review of the literature was performed in multiple databases (PubMed, the Cochrane Library, Google Scholar, World Health Organization and Centers for Disease Control), using 'COVID-19' with other relevant keywords in different combinations. Owing to the limited and heterogenous evidence available, data were presented in a narrative manner.

FINDINGS

From the evidence gathered it was noted that a multimodal approach to minimising pathogen transmission is required. This primarily comprises the wider engineering and administrative controls to reduce the concentration of the pathogen and to separate staff and patients from it. Theatre isolation and traffic control bundling, theatre flow and logistics, ventilation and waste management form a pivotal role in the environmental/engineering controls. Administrative measures include policies for both patients and staff. For patients, isolation and preoperative screening are of utmost value. For staff, testing for COVID-19, risk assessment, redeployment and provision of persona; protective equipment, together with the necessary training are important administrative controls.

CONCLUSION

We believe these measures are likely to improve the sustainability of resources and can be carried to elective settings in order to return to some form of normality and help to mitigate the effects of future pandemics.

A comparative study looking at trauma and orthopaedic operating efficiency in the COVID-19 era

Backgroud

COVID-19 has led to a reduction in operating efficiency. We aim to identify these inefficiencies and possible solutions as we begin to pursue a move to planned surgical care.

Methods

All trauma and orthopaedic emergency surgery were analysed for May 2019 and May 2020. Timing data was collated to look at the following: anaesthetic preparation time, anaesthetic time, surgical preparation time, surgical time, transfer to recovery time and turnaround time. Data for 2019 was collected retrospectively and data for 2020 was collected prospectively.

Results

A total of 222 patients underwent emergency orthopaedic surgery in May 2019 and 161 in May 2020. A statistically significant increase in all timings was demonstrated in 2020 apart from anaesthetic time which demonstrated a significant decrease. A subgroup analysis for hip fractures demonstrated a similar result. No increase in surgical time was observed in hand and wrist surgery or for debridement and washouts.Although the decrease in anaesthetic time is difficult to explain, this could be attributed to a reduction in combined anaesthetic techniques and possibly the effect of fear. The other increases in time demonstrated can largely be attributed to the PPE required for aerosol generating procedures and other measures taken to reduce spread of the virus. These procedures currently form a large amount of the orthopaedic case load.

Conclusion

COVID-19 has led to significant reductions in operating room efficiency. This will have significant impact on waiting times. Increasing frequency of regional anaesthesia concurrently with non-aerosol generating surgeries may improve efficiency.

The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures

AIMS

During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery.

METHODS

This multicentre cohort study included 340 COVID-19-negative patients versus 82 COVID-19-positive patients undergoing surgical treatment for hip fractures across nine NHS hospitals in Greater London, UK. Patients in both treatment groups were comparable for age, sex, body mass index, fracture configuration, and type of surgery performed. Predefined perioperative outcomes were recorded within a 30-day postoperative period. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality.

RESULTS

COVID-19-positive patients had increased postoperative mortality rates (30.5% (25/82) vs 10.3% (35/340) respectively, p < 0.001) compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status (hazard ratio (HR) 15.4 (95% confidence interval (CI) 4.55 to 52.2; p < 0.001) and greater than three comorbidities (HR 13.5 (95% CI 2.82 to 66.0, p < 0.001). COVID-19-positive patients had increased risk of postoperative complications (89.0% (73/82) vs 35.0% (119/340) respectively; p < 0.001), more critical care unit admissions (61.0% (50/82) vs 18.2% (62/340) respectively; p < 0.001), and increased length of hospital stay (mean 13.8 days (SD 4.6) vs 6.7 days (SD 2.5) respectively; p < 0.001), compared to COVID-19-negative patients.

CONCLUSION

Hip fracture surgery in COVID-19-positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications, and increased mortality rates compared to COVID-19-negative patients. Risk factors for increased mortality in patients with COVID-19 undergoing surgery included positive smoking status and multiple (greater than three) comorbidities. Cite this article: Bone Joint J 2020;102-B(9):1136-1145.

From "business continuity" to "back to business" for orthopaedic surgeons during the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period.

Cite this article: Bone Joint Open 2020;1-6:222–228.

COVID-19 and orthopaedic surgery: evolving strategies and early experience

Aims

COVID-19 has changed the practice of orthopaedics across the globe. The medical workforce has dealt with this outbreak with varying strategies and adaptations, which are relevant to its field and to the region. As one of the ‘hotspots’ in the UK , the surgical branch of trauma and orthopaedics need strategies to adapt to the ever-changing landscape of COVID-19.

Methods

Adapting to the crisis locally involved five operational elements: 1) triaging and workflow of orthopaedic patients; 2) operation theatre feasibility and functioning; 3) conservation of human resources and management of workforce in the department; 4) speciality training and progression; and 5) developing an exit strategy to resume elective work. Two hospitals under our trust were redesignated based on the treatment of COVID-19 patients. Registrar/consultant led telehealth reviews were carried out for early postoperative patients. Workflows for the management of outpatient care and inpatient care were created. We looked into the development of a dedicated operating space to perform the emergency orthopaedic surgeries without symptoms of COVID-19. Between March 23 and April 23, 2020, we have surgically treated 133 patients across both our hospitals in our trust. This mainly included hip fractures and fractures/infection affecting the hand.

Conclusion

The COVID-19 pandemic is not the first disease outbreak affecting the UK, nor will it be the last. The current crisis has necessitated rapid development of new hospital guidelines and early adaptive strategies in our services. Protocols and directives need to be formalized keeping in mind that COVID-19 will have a long and protracted course until a definitive cure is discovered.