Ortopedska kirurgija v primežu COVID-19

JBJS Orthopaedic Forum: Novel Coronavirus and Orthopaedic Surgery

Early Experiences from Singapore

Zhen Chang Liang, MBBS, MRCS, DipSpMed, PhD, MBA, Wilson Wang, MBBS, FRCS, DPhil, Diarmuid Murphy, MBBS, FRCS*, and James Hoi Po Hui, MBBS, MD, FRCS*

Investigation performed at the Department of Orthopaedic Surgery, National University of Singapore, National University Health System, Singapore

“As part of the larger healthcare ecosystem, orthopaedic surgeons also have a crucial role to play in reining in this pandemic.”

How the Practice of Orthopaedic Surgery in Singapore Has Been Affected by This Crisis

“Patients requiring urgent or early orthopaedic care will still be attended to at the earliest possible setting, no different from routine workflows. This largely pertains to patients with musculoskeletal trauma and tumors. The musculoskeletal trauma and tumor teams have been allowed to continue operating their surgical lists as scheduled. Other elective surgical cases have been postponed to allow hospitals to free up beds for treatment of patients with confirmed or suspected COVID-19.”

“However, there has to be some balance struck between providing continuity of patient care and containing the COVID-19 spread. Day surgical cases (requiring £23 hours of hospital stay) have also been allowed to continue. This largely includes arthroscopies (shoulders, knees, and ankles) and simple day procedures (e.g., soft-tissue surgical procedures and implant removals). These patients with day cases can be discharged expediently (thus reducing their risk for nosocomial COVID19 infections). Given their relatively short hospital stays, these patients do not pose a major drain on health-care resources. Hospital beds can still be freed up quickly, if required, for emergency admissions.”

“Elective, non-urgent procedures requiring >23 hours of hospitalization have accordingly been postponed or cancelled. This has predominantly affected knee and hip arthroplasty, spinal deformity corrections, and pediatric elective surgical procedures. Patients undergoing these procedures generally require longer hospital stays (3 to 5 days in the local context), which increases their risk of nosocomial infections. As these cases may be more complex, they may contribute an additional burden to limited health-care resources, which are already being stretched thin in dealing with the ongoing epidemic outbreak. For these reasons, non-urgent elective procedures necessitating a stay of >23 hours have been postponed with immediate effect.

“Clinical work has also been scaled down to ensure that services can run without putting our personnel and patients at risk. In the outpatient setting, we have encouraged home delivery of refill prescriptions. Clinicians have also been advised to prolong the duration between non-urgent follow-ups to avoid patient overcrowding in hospitals.”

“The orthopaedic patient demographic group is very varied, with surgeons treating patients at the extremes of ages. Arthroplasty surgeons see an older patient demographic group (often with multiple comorbidities), whereas sports surgeons frequently see younger, more active, and healthier patients. This is of relevance given the still relatively indeterminate pathophysiology of COVID-19 infection. Recent studies have alluded that older patients with medical comorbidities are more adversely affected by COVID-19 infections owing to their diminished functional reserves and weakened immune systems.”

“All patients attending outpatient clinics are screened for risk factors and have their temperature checked with a thermal scanner. Febrile patients with respiratory tract symptoms, especially those with a positive travel or contact history, will be referred to the emergency department for further evaluation to minimize disease spread. All visitors must register via a visitor management system that limits the number of visitors for each patient at any particular time but can also be used for contact tracing if required. The orthopaedic teams have been advised to wear surgical masks for all patient encounters and to follow strict hand hygiene practices.”

“Interdepartmental referrals are an inevitability in our line of work. We often receive referrals for inpatients who require orthopaedic consultations and, in turn, refer our own patients for whom non-orthopaedic consults are required. Herein lies the risk of potential disease transmission and spread. In Singapore, when reviewing patients suspected of or diagnosed with COVID-19, whether in the emergency department, the clinic, or the isolation wards, all staff have been instructed that they must wear full personal protective equipment (PPE) and have been taught how to don and remove PPE (surgical caps, goggles, N95 masks, powered air purifying respirators [PAPRs], surgical gowns, and gloves) safely. Strict compliance with hand hygiene has been enforced. Patients suspected of or diagnosed with COVID-19 infections requiring orthopaedic care have been housed in negative-pressure isolation units and will be co-managed together with help from our infectious disease colleagues.”

Dedicated orthopaedic contamination teams comprising attending physicians and residents have been established. These teams are responsible for reviewing and operating on suspected or confirmed cases and can be swiftly activated in the case of emergencies. When a subspecialist review is required (e.g., spine), relevant subspecialist attending physicians will be mobilized into and remain part of these contamination teams until they are cleared to return to normal clinical work. Importantly, these teams are kept segregated from the rest of the department to minimize the risk of crosscontamination.

“We have also segregated into an inpatient team that attends to patients on wards, operates, and provides on-call service, and an outpatient team that runs our specialized orthopaedic outpatient service. These teams do not come into contact with each other and alternate on a weekly basis.”

“Although non-urgent clinics and surgical procedures have been postponed until the situation improves, we must ensure that we maintain the quality of care given to our patients. The emergence of such a crisis provides a timely opportunity for us to reflect and evaluate the use of novel technologies in the workplace. This includes the adoption of telemedicine and telerehabilitation initiatives, allowing patients to be reviewed in the comfort of their own homes. Technologies such as wearable sensors and videoconferencing tools can be adopted to monitor patient outcomes remotely (e.g., knee range of motion after knee arthroplasty), without subjecting patients to cumbersome hospital visits. In addition to ease of monitoring, technology-assisted rehabilitation (e.g., online educational platforms or game-based therapy) has also been demonstrated to result in significantly improved patient satisfaction, pain, and outcome scores compared with conventional therapy.”

“During this COVID-19 crisis, orthopaedic residents, together with their counterparts from various other specialties, have been rostered for shifts in the emergency department to assist with the screening of suspected cases. In addition to helping alleviate the manpower crunch in the emergency department, this has provided an opportunity for residents to band, as well as bond, together as a medical community regardless of specialty, to combat this raging viral epidemic.”

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