Perioperative Considerations in Urgent Surgical Care of Suspected and Confirmed COVID-19 Orthopaedic Patients

Operating Room Protocols and Recommendations in the Current COVID-19 Pandemic

Mohamed E. Awad, MD; Jacob C.L. Rumley, DO; Jose A. Vazquez, MD, FACP, FIDSA; John G. Devine, MD, FAOA

Disclosures

J Am Acad Orthop Surg. 2020;28(11):451-463. 

In This Article

Abstract and Introduction

Abstract

By April 7, 2020, severe acute respiratory syndrome coronavirus 2 was responsible for 1,383,436 confirmed cases of Coronavirus disease 2019 (COVID-19), involving 209 countries around the world; 378,881 cases have been confirmed in the United States. During this pandemic, the urgent surgical requirements will not stop. As an example, the most recent Centers of Disease Control and Prevention reports estimate that there are 2.8 million trauma patients hospitalized in the United States. These data illustrate an increase in the likelihood of encountering urgent surgical patients with either clinically suspected or confirmed COVID-19 in the near future. Preparation for a pandemic involves considering the different levels in the hierarchy of controls and the different phases of the pandemic. Apart from the fact that this pandemic certainly involves many important health, economic, and community ramifications, it also requires several initiatives to mandate what measures are most appropriate to prepare for mitigating the occupational risks. This article provides evidence-based recommendations and measures for the appropriate personal protective equipment for different clinical and surgical activities in various settings. To reduce the occupational risk in treating suspected or confirmed COVID-19 urgent orthopaedic patients, recommended precautions and preventive actions (triage area, emergency department consultation room, induction room, operating room, and recovery room) are reviewed.

Introduction

In October 2019, the Department of Health and Human Services'—The Office for Civil Rights took a corrective action against an orthopaedic surgeon who unlawfully canceled an elective surgery for an HIV-positive patient. This action was justified via the requirements of Section 504 of the Rehabilitation Act of 1973 that prohibits discrimination on the basis of disability (including HIV/AIDS) in health programs or activities that receive Health and Human Service funding.[1] Over the past few decades, many guidelines and recommendations have been established to reduce the occupational risk while educating surgeons to make them better prepared to operate on HIV-positive patients.[2] The severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) (Coronavirus disease 2019 [COVID-19]), which seems to be highly contagious and has easily spread worldwide, is a much different virus causing a much different disease. Orthopaedic surgeons should be fully aware of the current situation regarding the COVID-19 pandemic and prepare to take proper precautions against the occupational risk of exposure, especially in asymptomatic and mildly symptomatic surgical patients. By April 7, 2020, the SARS-CoV-2 was responsible for 1,383,436 confirmed cases of COVID-19, involving 209 countries around the world; 378,881 cases have been confirmed in the United States. As an example, Centers of Disease Control and Prevention (CDC) reports an estimated 2.8 million trauma patients hospitalized in the United States. In addition, 791,000 older patients are treated in emergency departments for fall injuries each year.[3] Gleaning from the trauma literature, these data suggest an increased likelihood of engaging in COVID-19 orthopaedic patients in our hospitals. Thousands of healthcare providers (HCP) have been infected with COVID-19, despite their adherence to infection control measures.[4] Approximately 14% of Spain's confirmed cases are in medical professionals, per the Spanish minister of health. Despite the current definitions for diagnosing symptomatic COVID-19 patients, the transmission from an asymptomatic carrier has been documented between 25% and 50%.[5]

It is necessary for the orthopaedic community to be prepared for this global pandemic emergency. This is an occupational hazard not only to orthopaedic surgeons and other healthcare providers but also to the families and neighbors of exposed healthcare providers. There is still no definitive consensus of the pandemics' behavior, COVID-19 mode of transmission, diagnostic criteria, and management protocols. Preparation for a pandemic involves considering the increasing levels of protection and infection control and how they should be implemented during different phases of the pandemic. In the operating room (OR) setting, these measures include the following: modification of healthcare infrastructure and processes, educating staff and patients, implementing infection control strategies, and administrative and clinical measures. The surgical management of traumatic injuries requires a complex environment with multiple stakeholders including surgeons, anesthesiologists, nurses, OR attendants, and medical staff; it can be a real challenge to align the perspectives and concerns of all parties The primary aim of this article is to help define the COVID-19 crisis and discuss effective management strategies. This article provides a brief summary of the current situation and understanding of the pandemic, diagnostic criteria, and attempts to forecast the extent and prognosis. Finally, recommending precautions and preventive actions to reduce the occupational risk in treating clinically suspected/confirmed COVID-19 surgical patients.

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