COVID-19: lessons learnt and priorities in trauma and orthopaedic surgery

Impact of the Coronavirus Disease 2019 Pandemic on Utilization of Emergency Medical Services in New York City

Background: This study evaluates trends in the utilization of emergency medical services (EMS) in New York City, the "epicenter" of the first "wave" of the coronavirus pandemic. We hypothesize that EMS call volumes decreased overall in New York City during the first year of the pandemic, specifically with respect to trauma/injury calls. Contrarily, we posit that calls for "sick" events increased given pervasive fear of virus transmission. Materials and Methods: Retrospective New York City EMS calls data (January 1, 2019 to December 31, 2020) were obtained from the NYC Open Data/EMS Incident Dispatch database. Total EMS calls, trauma/injury calls, and "sick" event calls were collected for New York City and for all five boroughs. Census data for each borough were used to weigh daily EMS calls per 100,000 individuals. Mann-Whitney U tests were used to compare pre-pandemic (2019 to March 2020) versus pandemic (April 2020 to December 2020) EMS call volumes, p = 0.05. Results: Median daily EMS calls per 100,000 individuals decreased 21.6% at the start of the pandemic across New York City (pre-pandemic, 3,262 calls; pandemic, 2,556 calls; p < 0.001) and similarly decreased when stratified by borough (all, p < 0.001). Median daily trauma/injury and sick event calls per 100,000 also decreased in New York City and the five boroughs from pre-pandemic to pandemic time periods (all, p < 0.001). Discussion and Conclusions: These data reflect an unprecedented window into EMS utilization during an infectious disease pandemic. As decreased EMS utilization for multiple conditions likely reflects delayed or impeded access to care, utilization data have important implications for provision of acute care services during possible future disruptions related to the pandemic.

Oxford hip and knee scores deteriorate in patients awaiting lower limb arthroplasty during the COVID-19 pandemic and predict a health state 'worse than death'

The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state 'worse than death' (WTD). In this prospective cohort study, preoperative Oxford hip and knee scores (OHS/OKS) were recorded for patients added to a waiting list for THA, TKA, or UKA, during the initial eight months of the COVID-19 pandemic, and repeated at 14 months into the pandemic (mean interval nine months (SD 2.84)). EuroQoL five-dimension five-level health questionnaire (EQ-5D-5L) index scores were also calculated at this point in time, with a negative score representing a state WTD. OHS/OKS were analyzed over time and in relation to the EQ-5D-5L. A total of 174 patients (58 THA, 74 TKA, 42 UKA) were eligible, after 27 were excluded (one died, seven underwent surgery, 19 non-responders). The overall mean OHS/OKS deteriorated from 15.43 (SD 6.92), when patients were added to the waiting list, to 11.77 (SD 6.45) during the pandemic (p < 0.001). There were significantly worse EQ-5D-5L index scores in the THA group (p = 0.005), with 22 of these patients (38%) in a health state WTD, than either the TKA group (20 patients; 27% WTD), or the UKA group (nine patients; 21% WTD). A strong positive correlation between the EQ-5D-5L index score and OHS/OKS was observed (r = 0.818; p < 0.001). Receiver operating characteristic analysis revealed that an OHS/OKS lower than nine predicted a health state WTD (88% sensitivity and 73% specificity). OHS/OKS deteriorated significantly among patients awaiting lower limb arthroplasty during the COVID-19 pandemic. Overall, 51 patients were in a health state WTD, representing 29% of our entire cohort, which is considerably worse than existing pre-pandemic data.

Utilising the impact of COVID-19 on trauma throughput to adapt elective care models for more efficient trauma care

BACKGROUND

Coronavirus disease 2019 (COVID-19) has necessitated adaptations in local trauma services, with implementation of novel methods of practice, strategic adaptations, and shifting of resource management. Many of these may serve the driver for landmark changes to future healthcare provision.

AIM

To analyse the impact of COVID-19 on service provision by comparing throughput and productivity metrics with preceding years to identify differences in practice that were successful, cost-effective, and sustainable.

METHODS

We quantified orthopaedic trauma care provision at a single University Teaching Hospital over a three consecutive year period, from 1^st January 2018 to 31^st December 2020. Each year was split into four phases based on the 2020 national COVID-19 pandemic periods. We quantitatively analysed change in rates of inpatient trauma operative case load, sub-specialty variation, theatre throughput, and changes in management strategy. Qualitative analysis was based on multidisciplinary team interviews to highlight changes to care pathways.

RESULTS

Of 1704 cases were admitted in 2020, 11.9% and 12.4% fewer than 2019 and 2018, respectively. During phase 1, hip fractures encompassed the majority (48.8%) of trauma throughput, with all other subspecialties seeing a reduction. Mean length of stay was shorter during phase 1 (5.7 d); however, the time in theatre was longer (144.3 min). Both, Charlson (0.90) and Elixhauser (1.55) Comorbidity Indices indicated the most co-morbid admissions during 2020 phase 1.

CONCLUSION

COVID-19 has resulted in a paradigm shift in how care is accessed and delivered, with many evolving changes and adaptations likely to leave an impression upon healthcare provision in the future.

Moral Distress Among Operating Room Personnel During the COVID-19 Pandemic: A Qualitative Study

Introduction

The ongoing COVID-19 pandemic has necessitated the reallocation of healthcare resources, and a minimization of elective activities. Healthcare personnel involved in COVID-19 care have been negatively affected by the associated excess stress. The existing COVID-19 research has focused on the experiences among healthcare personnel in general, and not particularly on the operating room team members, who have often been relocated to overburdened workplaces. Therefore, we aimed to explore the experiences in this particular group.

Methods

This study has a qualitative inductive design based on interviews with a strategic sample of 12 operating room team members: surgeons, anesthesiologist, specialist nurses, and nurse assistants. The interviews were analyzed using content analysis.

Results

Three themes were identified: “Feeling safe in the familiar and anxiety in the unknown”, “To be the ones left behind”, and “The possibility for recuperation in a seemingly everlasting situation”. The participants described working hard, although their efforts were experienced as not enough according to their moral ideals. We interpreted this as feelings and signs of moral distress, a commonly described concept in previous studies during the COVID-19 pandemic, and a risk for burn out.

Conclusions

The operating room team members emphasized the negative stress of being in the unknown, performing work tasks in an unfamiliar place and situation, and experiencing conflicting feelings of relief and guilt. Organizational strategies toward a functional leadership and support should be emphasized. Such strategies might reduce the risk of psychological consequences such as burn out.

The overall impact of COVID-19 on healthcare during the pandemic: A multidisciplinary point of view

BACKGROUND AND AIMS

The Coronavirus disease 2019 (COVID-19) pandemic globally changed the priorities of medical and surgical procedures. It has caused many healthcare systems to stop performing their routine screenings. Altering medical clinics to COVID-19 referral centers, lockdowns, and the public fear to refer to medical centers caused a significant reduction in the referral rate; especially in the elderly. This short review article highlights the transform in clinical practice during the post-COVID era and the need for future medical revolutions.

METHODS

A comprehensive literature search was separately performed by both authors. The articles published between 2019 and August 2021 were included in this study and selected according to a quality appraisal method.

RESULTS

We have summarized the possible corresponding changes in the diagnosis and treatment of all fields of medical care including internal medicine, surgical, and minor subcategories after the COVID-19 pandemic. We have also discussed the potential impacts of the pandemic on all these different categories and subcategories of medicine, including the outpatient setting and clinical work. We do believe that the lack of routine check-ups has led to an increase in the stage of disease in patients with a previously diagnosed problem. On the other hand, the dramatic change in the lifestyle of the population including restricted mobility and increased consumption of unhealthy food has caused metabolic syndrome and other new diseases that have not been diagnosed and properly managed.

CONCLUSION

Our findings revealed the urgent need for public health awareness. It indicated the need to carry out both psychological and screening approaches in the post-COVID era to not miss patients with a chronic disease and new cases who were undiagnosed during the COVID pandemic.