key: cord-306016-2gudro8v
authors: Pelt, Christopher E.; Campbell, Kevin L.; Gililland, Jeremy M.; Anderson, Lucas A.; Peters, Christopher L.; Barnes, C. Lowry; Edwards, Paul K.; Mears, Simon C.; Stambough, Jeffrey B.
title: The Rapid Response to the COVID-19 Pandemic by the Arthroplasty Divisions at Two Academic Referral Centers
date: 2020-04-21
journal: J Arthroplasty
DOI: 10.1016/j.arth.2020.04.030
sha: 
doc_id: 306016
cord_uid: 2gudro8v

The COVID-19 pandemic has created widespread changes across all of healthcare. The impacts on the delivery of orthopaedic services has been challenged as a result. In order to ensure and provide for adequate health care resources in terms of hospital capacity, personnel and personal protective equipment (PPE), service lines such as adult reconstruction and lower limb arthroplasty have stopped or substantially limited elective surgeries and have been forced to re-engineer care processes for a high-volume of patients. Herein, we summarize the similar approaches by two arthroplasty divisions in high volume academic referral centers in 1) the cessation of elective surgeries, 2) workforce restructuring, 3) phased delivery of outpatient and inpatient care, and 4) educational restructuring.

Academic Referral Centers 2 3

Abstract: 4

The COVID-19 pandemic has created widespread changes across all of healthcare. The 5

impacts on the delivery of orthopaedic services has been challenged as a result. In order to 6 ensure and provide for adequate health care resources in terms of hospital capacity, personnel 7 and personal protective equipment (PPE), service lines such as adult reconstruction and lower 8 limb arthroplasty have stopped or substantially limited elective surgeries and have been forced 9

to re-engineer care processes for a high-volume of patients. Herein, we summarize the similar 10 approaches by two arthroplasty divisions in high volume academic referral centers in 1) the 11 cessation of elective surgeries, 2) workforce restructuring, 3) phased delivery of outpatient and 12 inpatient care, and 4) educational restructuring. 13 14 15

Introduction: 16

In December 2019, a novel coronavirus (COVID-19) broke out in Wuhan, Hubei 17 Province, the People's Republic of China. The first reported case in the US was in Washington 18

State on January 19, 2020. Since that time the COVID-19 pandemic has affected most of the 19 world and there are currently over 450,000 cases and over 17,000 deaths reported in the US 20

alone. The unprecedented viral pandemic has motivated rapid societal change, primarily with 21 efforts directed at social distancing in an effort to flatten the peak of the pandemic curve and has 22 also substantially strained health care resources to manage the exponential burden of the 23 disease. Although front-line health care providers involved in the diagnosis and treatment of the 24 respiratory transmitted virus deserve most (all) credit, the pandemic has also created challenges 25

for other medical service lines, including orthopaedic surgery. In order to ensure and provide for 26 adequate health care resources, hospital capacity, personnel and personal protective 27 equipment (PPE), service lines such as adult reconstruction and lower limb arthroplasty have 28 stopped or substantially limited elective surgeries and have been forced to re-engineer care 29 processes for a high-volume of patients. 30

Our adult reconstruction and arthroplasty practices are located within two large 31 quaternary academic referral centers. One serves the entire Intermountain West region, a large 32 geographic area of 7 states and a population area of over 18 million people, and the other 33 serves the entire state of Arkansas, with some referrals from neighboring areas of Oklahoma, 34

Texas, Louisiana, Tennessee and Missouri and a catchment area of over 3.5 million people. 35

Our arthroplasty services are both comprised of four high-volume fellowship-trained lower limb 36 arthroplasty surgeons, as well as a combined ten advanced practice clinicians (APCs), seven 37 registered nurses (RNs), and multiple other providers including medical assistants (MAs), 38 physical therapists (PTs), administrative assistants and support staff. Our first response as a part of the planning for the impending COVID-19 pandemic was 85

to form a platoon of health care provider teams [1] . The previously formalized resident surgeon 86 subspecialty rotations based on broad educational platforms and goals were halted, and 87 resident teams were formed to cover sites of care rather than orthopaedic subspecialty services. 88

The sites of care were set up to be covered by the minimum essential staff on a rotating weekly 89 coverage schedule. Residents not currently in the active direct patient care platoons have been 90 assigned work from home and provided enhanced educational assignments (described below). 91

At Utah, fellows entered a platoon to alternate with the residents to further mitigate the burden 92 across additional individuals needing to be present at any one time on the inpatient service. 93

To reduce exposure and prevent the mixing of our workforce, the attending surgeons 94 and the APCs were separated. The APCs were assigned to cover in- surgeries were deemed non-essential and were cancelled and placed into a rescheduling que. 118

During phase 1, it was not exactly clear how prioritization of cancelled cases would be 119 structured. 120

To clear the OR schedule, in Utah, we initially set out to delay or reschedule surgeries 121

week-by-week, with our schedulers, MAs and APCs calling patients on the upcoming weeks' 122 schedule and informing them that surgery would be postponed. However, as the projected data 123 became clear that the likely duration of the pandemic was going to be prolonged, it became 124 obvious that this strategy was unfair to patients who were being cancelled as it created a "leap 125 frog" scheduling scenario: patients being cancelled had likely signed up for surgery prior to the 126 patients the week after, creating confusion and staff chaos. Additionally, the short notice we 127 provided to our patients was likely inadequate due to travel, work and family scheduling. 128

Further, we were giving false hope of surgery to patients not yet cancelled. Finally, this 129 approach failed to account for the urgent/complex cases that may have warranted surgery more 130 expediently than other patients due to the potential for ongoing and/or irreversible damage with 131 prolonged delay. In Arkansas, the decision was initially made to reschedule all elective, non-132 urgent cases until the end of April with the understanding that we would call to reschedule. On 133

April 7, 2020, the decision was made to extend this approach until May 31, 2020. 134

In anticipation for Phase 4 (ramp up/return), described below, the Utah team has created 135 a ranking list of all patients who are awaiting surgery. Two scoring scales were put into place. 136

The first scale is for complexity (joint destructive/erosive arthritis, loose/failed implants 137 compromising bone stock, stage 2 reimplants awaiting surgery to be able to advance 138 activity/motion/weightbearing/return to work, etc). The second scale is for predicted length of 139 stay in order to determine who will likely be successful with outpatient surgery based upon 140 patient health, independence, and support structure. Each scoring system is created to account 141

for two potential limitations that may exist on the "ramp up/return" phase 4 (see below). 142 143

Phase 2: 144

The messaging to our patients during Phase 2 was focused on rescheduling and 145 postponing in-person visits. To continue to provide clinical services to our patients in the setting 146 of the widespread cancellations of non-urgent in-person visits, we quickly ramped up our 147 telehealth and virtual visits by APCs/clinic staff. These virtual visits provided our patients with 148

timely guidance for navigating their home recovery in the setting of the pandemic and helping 149 them with peri-operative home care instructions. 150

Given the focus on in-person visit cancellations and clinic visit resecheduling, our offices 151 experienced a significant increase in patient-generated phone calls. Patients were calling about 152 a variety of concerns including: surgery cancellation updates, logistical topics such as booking 153

(or cancelling), travel to our medical center, and non-operative treatment recommendations. In 154 addition to the influx of incoming calls, our staff was also making more outbound calls to 155 coordinate care. Combined, this strained our clinical resources and created unwanted 156 redundancy as staff members were answering similar questions throughout each day and 157

contacting patients frequently to share updates with them. 158

Given this new challenge, the Utah group looked for a more efficient solution to help 159 keep our patients updated and engaged using systems that we already had available. Prior to 160 the pandemic, we were using a text-messaging program to coach our patients before and after 161 surgery (StreaMD, Chicago, IL, USA). We adopted a new use of this system that enabled us to 162

send text alerts to all of our patients awaiting surgery. The content included general updates 163 from our office in regards to surgery scheduling, general information about COVID-19 for 164 patients with end-stage arthritis awaiting joint replacement, AAHKS-sponsored patient education 165 content regarding COVID-19, messages of empathy and encouragement from our staff, and 166 personalized video messages from the attending surgeons. 167

The final portion of Phase 2 revolved around the provision of postop rehabilitation to our 168

patients. Prior to this pandemic, our PT teams had been using some tools to remotely provide 169 our patients with virtual or video-based therapy services in the efforts of avoiding unnecessary 170 outpatient PT visits. In response to the pandemic, and in an effort to continue to provide 171 therapy and rehabilitation instructions for our post-operative patients and keep them out of 172 outpatient and in-home therapy visits to the extent possible, our physical therapists increased 173 the use of remote patient rehabilitation via phone, email, and online videos using our pre-174 existing tele-rehab systems. 175 176

Phase 3: 177

As we await the peak-surge of COVID-19, our clinical teams have reached a new state 178

of clinical normalcy and equilibrium and our patient messaging has gone through a shift from 179 "cancellation" to "invitation" as we communicate that we are still open for business -just in a 180 different way. We are no longer cancelling or delaying clinic visits, but rather we are shifting to 181 virtual visits and embracing technology to care for our patients remotely to the extent possible. 182

While avoiding unnecessary in-person visits, we still will perform them selectively when needed 183 due to conditions not able to be assessed via telemedicine. 184 185

Phase 4: 186

The critical phase of ramp up or return to elective surgery is still on the horizon, but 187

preparations are underway to be ready for a return to normal state. As we have seen the 188 COVID-19 "curve" flattening, the projected surge date is postponed as is our likely return to 189 "normal" timeframe. As patients and surgeons wait, the anxiousness and frustration of both no 190 doubt grows in both prevalence and intensity. The decisions on when to return to more normal 191

elective practice and what criteria to use to implement these plans are still dynamic and may 192 vary from state to state based on the level of COVID-19 impact on our various healthcare 193

systems. 194

As we look at returning to normal operating room practices at our academic hospitals 195 and outpatient surgery centers, we will likely be faced with difficult decisions regarding 196 prioritization of patients secondary to limited resources within our system. The most likely limited 197 resource will be that of operating room availability and anesthesia providers along with 198 nursing/support personnel as all surgeons within the system will be trying to work through the 199 large backlog of scheduled cases. The second potential resource restriction will be that of 200 limited PPE. If inadequate PPE exists, cases with short operative times and higher volumes are 201 likely to burn through more PPE than longer/complex cases, where fewer gowns/gloves/masks 202 would be used by default due to less changes throughout the day. In this scenario, the short 203 operative time surgeries may be less appropriate to push into the system during early ramp up 204 of elective surgery, even in healthy and likely outpatient surgical candidates. The third potential 205 resource limitation may come in the way of limited hospital space/capacity in terms of bed 206 availability or nursing capacity. If hospital beds remain the limited resource, longer/complex 207 cases in patients with higher comorbidity burden are less desirable, and the healthy patients 208 that can be done efficiently and safely sent home are more likely to be more suitable in this 209 scenario. Finally, the availability of testing screening for providers and patients may be a 210 resource limitation if it remains a limited resource, or perhaps just as likely, a potential variable 211 that allows for an accelerated return to increased clinical care if the resource is readily available. 212

It remains unclear as to the timeline of availability of widespread testing. It is likely that a 213

negative COVID-19 test will be needed in the preoperative preparation phase before surgery. 214

Our academic institutions have 34 and 28 orthopaedic surgeons respectively, and an 215 additional several hundred other surgeons in each academic health system, all postponing a 216 high volume of surgeries. To date within our Orthopaedic Surgery Departments alone, we have 217 postponed a combined of over 1450 elective cases that will need to be rescheduled across 218 multiple subspecialities. Due to the aforementioned resource restrictions, either we will all be 219 trying to push through as many relatively young healthy cases all at once, or trying to get 220 through the more urgent, and often more difficult cases. It is unclear which of these scenarios 221

we will begin with, or if it will be a hybrid of the two. However, we are preparing ourselves to be 222 nimble in this time of transition and quickly adjust our surgical scheduling with the use of the 223 scaling systems described above in the Phase 1 description. The two scoring systems of 224 surgical complexity, predicted length of stay as well as patient age and comorbidities will help us 225

to properly stratify our patients and adapt to whatever ramp up strategy we are faced with in 226

Phase 4 of this pandemic. Weighing this with institutional PPE and health care provider 227 availability, it is our hope is that we will be positioned to efficiently, within our arthroplasty 228 division, as well as within the orthopaedic department and across try to continue to get as much volume done early while the prevalence of disease is low in our 263 hospitals and community on the front end of the curve? Or should we stay strong in our resolve 264 to aid our own hospitals and surrounding health care community planning and preparation by 265 avoiding adding perioperative patient burden to the healthcare system at a critical time while 266 also using potentially critical resources. And when should we return to operating on elective 267 arthroplasty cases again? 268 CMS attempted to provide guidance in a public release: "Non-Emergent, Elective 269

Medical Services, and Treatment Recommendations." [4] In that attempted guidance, a 270 "tiered framework is recommended to prioritize services and care to those who require 271 emergent or urgent attention to save a life, manage severe disease, or avoid further 272 harms from an underlying condition." The initial early guidance from CMS included 273 example procedures in each tier, and included hip and knee replacement in Tier 2a, which 274 recommended considering postponing surgery for intermediate acuity surgery, a healthy 275 patient with non-life threatening but potential for future morbidity and mortality. Later 276 revisions of that CMS public statement (last update April 7, 2020) removed reference to 277 particular procedure types and expanded considerations that should help guide decisions 278 of the cessation of surgeries to include the surrounding region, and not just the practice or 279

hospital, given that we are all members of a larger healthcare delivery system to a 280 population, as opposed to an isolated silo of care within the walls of a single institution. 281

Given the lack of firm guidance, most centers have created written and internally 282 monitored criteria to follow. At our centers, this has included emergent surgeries due to 283 life and limb threat, the potential for significant harm if ongoing delay due to severe joint 284 destruction, bone loss or uncontrollable pain, in addition to fractures, infections and 285 dislocations. 286

The ethical struggles we have all experienced internally, as we have significantly 287 restricted care for total hip and knee arthroplasty patients, have been further complicated 288 by the decision of some surrounding hospitals to continue elective surgeries. Due to the 289 continued expenditure of resources, including PPE that could be mobilized to centers in 290 need, among the other burdens that the care of these patients places on the surrounding 291 healthcare community and infrastructure, as a referral center, our groups worry about the 292 difficulty in being able to fully offer assistance in the event of complications of the surgical 293 or medical conditions of those patients. 294

Whether considering offering surgical care in our own facilities, or observing it 295 occur in the surrounding area, it is clear that patients receiving surgery at this time are at 296 risk. They are leaving their houses when officials are recommending the public to "stay 297 safe and stay home." Patients accessing healthcare facilities for their surgeries and 298 clinical visits are potentially risking exposure during the surgical visits as well as 299 perioperative visits and postoperative and rehabilitative care. The currently poorly 300 understood prevalence of asymptomatic carriers along with the potential inability of 301 current testing to detect cases in the early state of COVID-19 infection can lead to us 302 further falsely believing that we could bring in a "healthy" patient, who in fact may even be 303 a carrier, and risk exposing our healthcare teams or even risk worse creating outcomes 304 for the patient. Recent studies have suggested that the act of surgery may worsen the 305 outcomes in some patients in the unrecognized incubation period [5] . Even for the 306 healthiest of patients, beyond the potential exposure risk, there is a burden for the 307 perioperative care that is placed in the supporting healthcare system which is already 308 taxed with the preparation for and care of COVID-19 related cases. This infrastructure 309 must be protected until we can safely move forward as unified healthcare community. 310

Beyond restricting offering elective care to even the healthiest of patients, we have also 311 struggled with even offering expedited care to the most severe orthopaedic cases, many of 312 which would be justifiable to offer surgery on at this time due to the disease severity and 313 potential for worsening condition with delay. We have taken a cautious approach in many of 314 these cases as well, as it is these patients with the worst orthopaedic conditions who often also 315 have advanced age, severe medical or social comorbidities and additional risk factors. These 316 are also the patients most likely to require postsurgical stays in inpatient facilities, which could 317 add further risk of exposure [6] . Surgery in many of these patients goes beyond exposure 318 operating room, but extends into the inpatient facilities, outpatient or home health nurse or 319

therapists, skilled nursing facilities, laboratories, imaging centers and the community through 320

which they must navigate in order to receive their perioperative care. The decision to operate in 321 these patients exposes them to many risks beyond our standard joint replacement risks, 322

significantly challenging the risk-reward balance. 323

The decision to operate and when remains a challenging one, but the onus remains on 324 us to be stewards of health for both our own patients and their orthopaedic conditions, but also 325 their overall health risk and the risk to the surrounding health care community and population as 326

whole requiring imaging or in person visits are accommodated today, as they will be in the future, 357 additional efficiencies, including offering patients the opportunity to receive labs and imaging 358 remote locations, even at sites outside our own healthcare networks, are also likely to prove 359 beneficial to both patients and providers moving forward. 360

Educationally, surveys of the trainees have revealed positive reviews of the improved 361 curriculum, content, and delivery of materials. While no question, some of this has been 362 afforded due to the lower surgical volume during this time, the benefit of remote conferences to 363 allow for clinical care at remote sites, the increased number of potential attendees, and the 364 improved content will likely be able to be long lasting changes and improvements with the 365 ongoing use of virtual meeting platforms to supplement the in-person teaching. 366

Our past underutilization and even undervalue of technology which allows us as 367 providers to communicate and care for our patients and provide education to our trainees 368

remotely is now clearer than ever. In our specialty, and throughout healthcare, the changes 369 made in response to the COVID-19 pandemic are likely to shape the practice of academic 370 medicine as we go forward 371 372

Conclusion: 373

The COVID-19 pandemic has created widespread changes within our academic health 374 systems and our adult reconstruction and lower limb arthroplasty practices. To manage our 375 clinical and educational responsibilities during this pandemic, we created a model that consisted 376 of four phases of care delivery. We are prioritizing the health and safety of our patients and 377

workforce along with efforts to preserve resources including PPE and hospital capacity by 378 cancelling non-essential surgeries, creating a ranking list based on system utilization 379 requirements, and relying on telehealth/virtual visits/patient engagement and educational 380 platforms to keep our patients and trainees informed, educated, and engaged. 381 382

Managing Resident Workforce and Education During the COVID-19 Pandemic. The 385

The 387

Orthopaedic Forum Survey of COVID-19 Disease Among Orthopaedic Surgeons in 388

People's Republic of China

Novel Coronavirus and Orthopaedic 391 Surgery: Early Experiences from Singapore

Public Recommendation on Nonemergent Medical Elective Procedures

Clinical characteristics and outcomes of patients undergoing surgeries during the 398 incubation period of COVID-19 infection

Epidemiology of Covid-19 in a Long-Term Care Facility in King 404 County