key: cord-0057428-0xbwsneu authors: Chesser, Tim J.S.; Handley, Robert; Kloos, Johannes; De Wachter, Gerrit; Putzeys, Guy; Gómez-Vallejo, Jesús; Sánchez-Pérez, Coral; Chana-Rodríguez, Francisco; Raggini, Filippo; Pari, Carlotta; Paderni, Stefania; Contini, Achille; Belluati, Alberto; Daskalakis, Ioannis; Sperelakis, Ioannis; Kostakos, Athanasios; Tosounidis, Theodoros H.; Halvachizadeh, Sascha; Pape, Hans-Christoph; Bouillon, Bertil; de Bruin, Berend-Jan; Ponsen, Keesjan J. title: International trauma care: initial European approaches during the COVID 19 pandemic date: 2021-03-15 journal: OTA Int DOI: 10.1097/oi9.0000000000000112 sha: d2b9a700e939e1491240656df83a76ae2e52675c doc_id: 57428 cord_uid: 0xbwsneu The world was not prepared for the global of pandemic in early 2020 with the arrival of COVID 19. Europe has some of the most developed health care systems in the world and this article explains the initial response to the pandemic from an orthopaedic and trauma viewpoint from 8 nations. Italy reported the first cluster in February, which then rapidly spread around the continent, requiring a rapid reorganization of services. The reports highlight how elective surgery was universally stopped, surgical services were reconfigured, and new practices, such as the widespread use of telemedicine, may well become permanent. It also emphasizes how the pandemic has re-educated us on the importance of a consistent and central approach to deal with a global health crisis, and how medical services need to remain flexible and responsive to new ways of working. Europe developed its first cases of COVID-19 in late January, 2020, exacerbated by clusters in Northern Italy and Madrid, which rapidly spread across the continent. While the European borders are freely open, each country is responsible for its own health care system. Reports from 8 countries are combined (United Kingdom, Belgium, Spain, Italy, Greece, Switzerland, Germany, and Netherlands). Each health system had to rapidly adapt and learn from each other, and due to the continuing evolving situation, this report is a position of each country's orthopaedic and trauma's services response at the end of June, 2020. At the time of writing, each country was dealing with local outbreaks at the same time while reintroducing normal services. Whilst the countries comprising the United Kingdom reacted in a similar manner to COVID-19 this information applies primarily to England. Through February and March 2020, the public experienced a period of progression through awareness, interest, anxiety, and fear with a consequent motivation of preparation. A perceived advantage of a unified system of health care is that it allows for a coordinated consistent response to problems. On March 3, the headlines included: "NHS bosses have declared coronavirus as a 'level 4 incident' -a move which allows NHS England to take command of all NHS resources across England." There was hesitation in the general political national action, and it was on March 23 that the lockdown in the UK began. On that day, there were just under 1000 new positive tests and 74 COVID deaths reported. However, health planning as a response to an impending surge in Coronavirus infections and admissions had begun before this time. Naturally, the major focus was on dealing with the direct respiratory problems of COVID-19, but there was a realization that all heath care services, including the traumarelated services, needed to be ready. The British Orthopaedic Association posted guidance under the title "Orthopaedic Trauma and COVID-19" on its website on March 16 , 2020 that appeared on NHS England's website a few days later. [1] This document was subsequently modified to include references to nontrauma work and remained as NHS England's guidance. The aim of the initial guidance was to encourage that essential trauma work carried on, but to do so in a way that put a minimum demand on resources and took into account the safety of patients and staff. Physicians needed to continue to be advocates for their patients. It was predicted that the areas of the NHS that would need the greatest protection from unnecessary work were the emergency departments and those involved in respiratory support, particularly anesthetists. Consequently, recommendations were made to divert musculoskeletal injury away from emergency departments directly to Trauma and Orthopaedic services. Similarly, to reduce the load on operating theaters and, with the likelihood of anesthetist being redeployed to the airway management of COVID patients and intensive care, greater consideration was to be given to nonoperative management of fractures. There are no reliable general activity figures for orthopaedic trauma. Even comparisons within a single geographic region are difficult as often trauma patients followed different pathways and were treated in different facilities as part of the reorganization. Two surveys were carried out by the British Orthopaedic Association utilizing the network of British Orthopaedic Clinical Directors Society (BODS); the first on the weekend of March 28 and the second on the weekend of May 15. In the first survey 54 hospital trusts responded. All reported that performing elective surgical procedures had ceased, with only 2 having had some elective clinical consultations. The prepandemic norm in England for the initial receipt of a patient with limb injuries was that they were seen by emergency department staff and then referred as appropriate to trauma and orthopaedics. By the emergence of the pandemic, 30% of patients with limb injuries bypassed the emergency department completely. In well over half of hospitals, the initial first contact assessment was carried out by trauma and orthopaedic consultants, which represented a complete change of practice from a few weeks before. In a follow-up study being organized by NHS England on the potential beneficial changes that may be continued post COVID, early senior physician input into patient management had the most support. In a recent webinar organized by the British Orthopaedic Foot & Ankle Society, 1 presentation on the potential for post-COVID-19 increases in malunions and mistreated fractures was countered with a suggestion that the more frequent the involvement of senior surgeons in early injury management, the fewer the problems that may arise. Another notable finding from this early survey was the interest in and anxiety relating to personal protection equipment (PPE) with a clear desire for greater central guidance and clarity as to what precautions should be taken. Additionally, there were a multitude of questions relating to PPE. By the time of the second survey, [2] the general environment in most trusts had changed. There was a significant decline in the number of ventilated COVID-19 patients, yet, there was no resumption of normal workflow. PPE remained a significant issue; 10% of trusts reported that they did not have sufficient PPE for theater use. However, what had become particularly evident were the consequences that the required PPE and theater precautions took on the time to complete surgical procedures. Seventy-six trusts responded to the second survey. One question asked surgeons to estimate the increase in resources required for surgical procedures. Beginning with a baseline of what previously could have been completed in 10 surgical lists, surgeons were asked to estimate what resources were required under their current conditions. The responses demonstrated that the work of 10 surgical lists prepandemic, required 16 to be available postpandemic. In an environment where some staff members were absent, sick, or quarantining, these obstacles were compounded. In an attempt to guide units in prioritizing their surgical work, a cross specialty prioritization document was drawn up by the Royal Colleges of Surgeons. [3] This document has helped provide some structure to the progressive expansion of surgical activity as resources increasingly become available. However, as can be imagined, cross-specialty agreement has not been easy to achieve. Some definitions used were confusing. The word "suspected" seemed to have 2 meanings in relation to COVID-19. For the medical patient attending the Emergency Department, it was someone who exhibited symptoms compatible with COVID-19; whereas for a surgical patient, it appeared to be anyone who was not proven to be negative. The definition of an aerosol-generating procedure in relation to COVID-19 was particularly problematic with Public Health England not introducing a distinction to include the source of the aerosol when using power tools until June 18, 2020. [4] The aerosol-generating procedure definition changed from bone drilling or cutting to that only when working on the respiratory tract or para-nasal sinus. This, naturally, has had very significant implications for trauma and orthopaedic surgery, reducing the requirements for PPE and allowing improved theater efficiency. In summary, in the early stages of the pandemic, there was a ready acceptance by both the NHS and practitioners that control would be centralized. As time has passed, there has been less willingness to produce generalized guidance, which has led to hesitation, uncertainty, and significant variations in practice around the country. There is, however, a great desire to make the most of any advances in practice and, in particular, the opportunities for change that the crisis has brought. As noted above in the initial surveys, there has been support for early definitive decision-making for patients with early input of senior staff. The other message that has been emphasized by many is that whilst preparation for the "worst" is appropriate and necessary, this is not synonymous with ceasing the normal care of patients. This issue must continue to be appropriately prioritized and continued where possible. Belgium is a small but centrally located country with a high population density of 373 inhabitants per km 2 . [5, 6] On July 1, 61,598 cases of COVID-19 (5.39 cases per 1000 inhabitants) were reported since the beginning of the pandemic, whereof 28.8% were hospitalized. Twelve percent of the hospitalized patients were admitted to the intensive care unit (ICU). [7] With 9761 deaths through July 1, Belgium has one of the highest reported mortality rates (case-fatality ratio of 15.85%). [8] Thirty-nine percent of the reported deaths were not confirmed by reverse transcription polymerase chain reaction and/or chest computed tomography (CT) due to the initially restricted testing policy, but remains registered as probable COVID-19-related deaths following WHO guidelines. [7, 9] The first lethal case in Belgium was reported on March 10 and, about 1 month later, the highest 1-day mortality due to COVID-19 was registered (343 deaths on April 12). [7] The early days of the pandemic were marked by a narrow case definition (fever as a mandatory symptom) leading to restrictive testing, the scarce availability of PPE, and a single reference laboratory for the whole country. Since then, numbers have been decreasing in a slow but steady way, with an average drop in incidence and mortality of 10% per week. On July 1, 203 patients were hospitalized in Belgium with 37 cases in the ICU, and an average of 85 new confirmed cases were registered per day during the week before July 1. [5] This evolution is the result of a progressive lockdown [10] imposed by the National Security Council starting on March 14, including the closure of schools and restaurants. From March 18, nonfood businesses closed as well and nonessential trips (except for food purchases and work) were prohibited. Country borders were closed for nonessential trips on March 20. [11] In the health care sector, all nonessential surgeries and outpatient clinics were cancelled beginning on March 14 to save resources and staff for the emergency room (ER) and intensive care unit (ICU). A strict visitor restriction was applied to all hospitals and health care facilities. [12] Recovery areas of the operating rooms (OR) were transformed into ICUs and operating room staff were retrained to run them, leading to a decrease in surgery-related resources such as scrub nurses, respirators, anesthetics, surgical masks, and gowns. As an example, Jessa hospital is an accredited regional institution with 981 beds, 45,391 emergency admissions, and 41,183 surgical interventions in 2018, accounting for the 5th biggest nonuniversity hospital in the country. [13] It is situated in the capital city of Limburg, the hardest hit province of Belgium (7.54 cases per 1000 inhabitants). [7] During the peak period in the second week of April, 134 patients were hospitalized in this center and 31 out of 40 patients in the ICU needed invasive ventilation. Surgical capacity dropped from 21 to 4 functional ORs. In this article, to demonstrate specific management protocols and challenges, the management of surgical trauma cases in this center during the early phase of the lockdown period, from March 14 to May 4, is described. [14] 3.1. Organizational actions made to the trauma services Alarmed by the dramatic evolution in Northern Italy, a pathway to separate potential COVID-19 patients from those without suspicious symptoms was rapidly developed using container shelter-in-places and a designated radiology area for X-ray and CT scan. On March 5, the case definition had been broadened and the laboratory testing capacities were increased by the federal authorities, and screening became mandatory for every patient being hospitalized in our center on April 10. Chest CT was initially added to increase sensitivity [15] until the prevalence of positive radiologic findings dropped under 2%. [16] Trauma patients admitted to the ER showing symptoms compatible with the early case definition of COVID-19 (fever and cough or dyspnea) were separated as early as possible and isolated individually in designated ER rooms. Health care providers (HCPs) working in these areas were equipped with PPE composed of filtering face piece (FFP)2/N95 masks, level 1 gowns, gloves, and face shields. FFP3/N99 masks were only used during swab testing, intubation (in ER, OR, and ICU), and level 3 or 4 gowns were only used in situations with high risk of contact with patient's body fluids (wound care, etc) following guidelines. [17] Once PPE availability increased, every HCP at the ER was equipped with FFP2/N95 masks. Tested patients were kept isolated and transferred from the ER to a COVID-19-specific transit hospitalization unit awaiting their results before being redirected to their definitive hospitalization unit. Patients not fulfilling all criteria for testing were immediately hospitalized at the trauma ward without transit hospitalization. Once the availability of surgical masks was increased, HCPs at the non-COVID-19 wards as well as negatively tested patients were asked to wear one if social distancing of 1.5 m could not be respected. Gloves were not advised, except for actions with potential contact with patient's body fluids. Life-and limb-threatening emergencies as defined by the AAOS [18] were transferred to a COVID-19-designated OR without further delay, where patient recovery after surgery was supervised until transfer to the transit hospitalization unit was possible, awaiting test results. SARS-CoV-2-positive patients were hospitalized in single rooms (with an air lock if available) on dedicated wards, staffed with HCP wearing the same PPE as their colleagues in the ER. For all patients, the hospital stay was kept as short as possible. The use of calls/video calls was encouraged to keep contact with family and friends. Trauma patients with urgent surgical indications and a negative test result were cleared for surgery for the next 48 hours. If surgery needed to be postponed for more than 48 hours for any reason, a new reverse transcription polymerase chain reaction test had to be performed. The OR designated for surgery on COVID-19 infected or suspected patients, including life-and limb-threatening emergencies, was situated on another floor and equipped with an air lock and negative air pressure. Operating room staff wore FFP2/N95 masks, level 3 or 4 gowns (depending on the type of surgery), 2 pairs of surgical gloves, and face shields. A second circulating nurse was deployed to pass needed supplies to the air lock. Interventions on patients with negative test results were performed in 1 of the 3 remaining clean ORs, with HCPs wearing surgical masks, level 3 or 4 gowns, surgical gloves, and goggles. Urgent consultations for nonsurgical trauma patients (wound and plaster clinics) and essential postoperative consultations continued with reduced capacity to diminish waiting room traffic and provide time to disinfect used instruments, surfaces, and examination tables. Both patients and HCPs wore surgical masks, but the systematic use of gloves was discouraged. COVID-19 patients were scheduled on specific dates in designated facilities, allowing coordination of logistics and radiology department to isolate the patient at every single step throughout the hospital. They wore surgical masks, whereas HCPs wore FFP2/N95 masks, level 1 gowns, gloves, and face shields. Isolation measures were taken during a period of 5 weeks after the first positive test result. Remote consultations were not used for the early follow-up of trauma patients. With the restart of nonessential consultations and elective surgery from May 4, [14] the page was turned and a new way of working with COVID-19 was to be defined. Although it is impossible to quantify the effect of these measures, so far none of the orthopaedic surgeons working during the crisis have contracted the virus. This provides HCPs with the confidence that these measures have been highly effective, but certainly further research is needed to establish the efficacy of each of these measures. Since the pandemic was declared on March 11, 2020, the environment in Spain underwent totally unimaginable changes from just a few weeks prior. [19] The pandemic began with a few cases scattered in larger cities and expanded throughout the nation asymmetrically, with Madrid becoming the epicenter of the pandemic in mid-March. Spain has been one of the countries with the highest mortality rates, with approximately 1000 deaths per day in the first week of April. Twenty percent of health workers tested positive, posing problems for the health care force and return to hospital normal activities. The data published on July 6, 2020 by the Spanish Ministry of Health showed a total number of 251,789 confirmed infected cases, 125,572 required hospital admission, 11,706 required admissions to an intensive care unit (there are a total of 4404 beds across Spain under normal circumstances), and a total number of 28,388 deceased patients. [20] During the peak of the COVID-19 pandemic, the orthopaedic and traumatology surgeons could mainly impact 3 areas: avoiding the unnecessary use of overburdened facilities; preventing the exhaustion of resources; and controlling and protecting patients and health care workers. The Spanish Society of Trauma and Orthopaedic Surgery (SECOT) published a guide with recommendations to facilitate these goals. [21] Urgent surgical cases continued, while all nonurgent surgeries were suspended at most hospitals, and same-day surgery was encouraged, minimizing the unnecessary use of hospital beds. [22] These steps preserved critical resources, including hospital beds, supplies, and personnel. As nonurgent surgery was reduced, these surgical facilities, equipment, and staff were reallocated to address COVID-19 patients. [23] When patients entered an emergency room, they were screened for COVID-19 according to the standards of the Spanish Ministry of Healthcare. The patients with negative tests were taken to a segregated area for nonsuspicious cases of COVID-19, where standard care is provided in a COVID-19-free area, including that confirmed radiologically, with universal PPE usage. If the patient's presenting condition required hospital admission from the emergency department and/or urgent surgery, all patients were screened with a PCR test and a chest x-ray before their admission. In patients classified as probable or positive COVID-19 cases, they were transferred to an isolation area and followed primarily by a COVID-19 specialist, with the help of a trauma team for stabilization; again with complete PPE use. If a patient presented after polytrauma and their COVID-19 status was unknown, the patient was treated as if they were positive, performing all the tasks with PPE and in a specialized room. Chest imaging with a CT scan additionally was helpful for the screening of the disease. [24] In those hospitals where trauma patients coexisted with COVID-19 patients, COVID-19-free areas, where patients and health workers were unlikely to develop the disease, were created, recognizing that negative PCR tests did not guarantee the absence of disease (false-negative PCR tests have been reported to be as high as 30%). [25] If the center was specialized for COVID-19 care or had most of its facilities available for the treatment of this disease, urgent surgery was discouraged and referral to another facility was recommended. For the classification of areas, a triple nomenclature classification was recommended by SECOT, as the common classification of just 2 areas (COVID-19 and non-COVID-19) does not take into account the presence of external personnel in the health care center. This classification was as follows: Green area: Patient, staff, and material spaces shared by Non-COVID-19 cases according to the Spanish Ministry of Health; Yellow area: Outpatient, external staff, or visitors transit spaces, such as entrance halls or corridors, that cannot be guaranteed to be used only by Non-COVID-19 individuals; and Red area: COVID-19 positive, probable or possible patient spaces; these areas were isolated and never in contact with green areas. As a general rule, each emergency was treated as it would normally be treated pre-COVID-19, but with the spaces prepared for each patient according to their COVID-19 classification. Delay in the result of a test was not an excuse to delay the treatment of an urgent condition. COVID-19-negative patients found in the "green circuit" were treated with the standard rules for each operating room. With regards to face protection, if the surgical procedure produced aerosols, N95/ffp2-3 mask protection was used together with surgical or bidirectional masks. Operating rooms, corridors, and other rooms in the operating room area were green areas. Surgery was carried out according to the general rules of each hospital. PPE was recommended for standard cases with aerosol production during the surgical process with utilization of a double mask to avoid contamination of the surgical field. Unless there were contraindications, the typical surgical techniques were not changed. Long-lasting dressings and wound closure techniques were utilized when possible. Studies in other specialties have demonstrated the successful use of telemedicine during the COVID-19 pandemic. [26] SECOT has provided recommendations for the establishment of a telemedicine program for those services where this resource had not previously been established. The benefits of telemedical consultation for trauma and orthopaedic surgery have already been www.otainternational.org demonstrated with excellent patient perceptions. [27, 28] The General Data Protection Regulations that apply in the European Union include a clause accounting for work done in the public's interest. [29] 4.6. Other important/unique experiences and lessons learned Orthopaedic care in environments where COVID-19 care was provided evolved during the epidemic peak for COVID-19 in Spain. Standard, pre-COVID management protocols needed to change, making them more complex, with a reduction in elective care and focus on the treatment of emergent and urgent musculoskeletal conditions such as fractures, infections, and tumors. On March 11, 2020, the World Health Organization declared a pandemic of a new type of coronavirus disease, COVID-19, which is responsible for symptoms that included a severe acute respiratory syndrome. [30] Italy was one of the first countries in the world to have active COVID-19 cases. The first case was diagnosed in Lombardy (Codogno, February 20, 2020), [31] and the disease spread uncontrollably throughout the entire county, accounting for 239,000 cases and 34,767 deaths by June 30, 2020. The region Emilia-Romagna, became the third Italian region with a major number of cases (after Lombardy and Piedmont) with 28,492 positive patients and 4260 deaths by the end of June, 2020. [32] On January 31, the Italian Council of Ministers declared a national state of emergency related to health risks for 6 months. On February 21, the Minister of Health quarantined those who had been in contact with COVID-19-positive people and activated surveillance and home stays for those who had traveled to the risk areas in the previous 14 days. To contain the infection, the areas with the highest number of cases were isolated. The so called "Lockdown" was declared by the Government on March 9 throughout the Italian territory and the Italian Phase 1 began. Our Regional Health Care Systems, such as Emilia Romagna, and the entire Italian National Health Care System, had to quickly adapt its organization to meet the needs of COVID-19-positive patients. It was decided to establish a hub-and-spoke organizational design, identifying regional macro area centers of excellence in infectious diseases. Specifically, hubs had the capacity for extracorporeal membrane oxygenation; spokes, instead, were secondary treatment institutions that offered more limited services. Hubs, with active 24-hour-a-day services, had different pathways for COVID-19-positive and negative patients, and several specific hubs were selected as COVID-19 free for trauma, neurosurgical, neurological, and cardio-vascular emergencies. In April 2020, the Emilia-Romagna network became a national referral network for intensive care unit (ICU) management, establishing protocols for ICU COVID-19 therapy. The network had 146 beds that could be used to assist infected and symptomatic patients. Within the Emilia-Romagna network, the Ravenna Hospital-Area Vasta Romagna was identified as a hub center and promptly reorganized. Surgical activity was rationed, cancelling all elective surgery and performing only trauma cases to minimize the potential overlap of COVID-19 patients with postoperative COVID-19-negative patients. During Phase 1, the ICU was converted in a COVID-19 ICU area, while some of the operating rooms, normally used for elective surgery, became a COVID-19-free ICU. A collaboration network was created between the ICUs of the entire Region to maximize the care of those patients who needed mechanical ventilation. The anesthesia groups and emergency room staff were increased to serve the network. Novel care pathways were created, starting at the triage area. Every patient was given a COVID-19 questionnaire to search for possible flu-like symptoms or contacts with infected individuals during the previous 14 days. Vital signs were taken. Patients with negative medical histories, no respiratory symptoms, temperatures