key: cord-0697907-uf03rpwk authors: Majid, Ibrar; Al Ali, Tahani Fowzi; Serour, M. A.; Elsayed, Hisham M.; Samir, Yousra; Dsouza, Ajay Prashanth; Al-Saadi, Hayder Saleh; Alshryda, Sattar title: Paediatric Orthopaedic Surgery During The SARS-CoV-2 Pandemic. A Safe and Pragmatic Approach to Service Provision date: 2021-09-06 journal: Surgeon DOI: 10.1016/j.surge.2021.08.004 sha: a3867650f10bbd09513d301666617ed0937fc178 doc_id: 697907 cord_uid: uf03rpwk The SARS-COV-2 pandemic has brought unparalleled challenges to healthcare provision. Being a newly discovered virus, there is a lack of previous experience and published evidence to guide healthcare providers on how to deliver services. We would like to share our approach to service delivery in a newly open children’s hospital in the United Arab Emirates with a particular focus on paediatric orthopaedic services. The world is currently facing one of the most challenging healthcare crisis in memorable history. The identification and subsequent spread of the novel Corona virus has brought an unprecedented healthcare, social and economic crisis. It started as a pneumonia of unknown cause detected in Wuhan, China. This was first reported to the WHO Country Office in China on 31 December 2019. The spread was so alarming that the outbreak was declared a Public Health Emergency of International Concern on 30 January 2020; only one month from the first case report. On 11 February 2020, the WHO announced a name for the new coronavirus disease: COVID-19 and on 11 March 2020, the WHO characterized SARS-COV-2 as a pandemic. (1) On 3 May 2020 the WHO reported that 3.27 million people have been infected with the virus and 229,971 have died. (2) Governments, healthcare organizations, hospitals and healthcare providers have taken extreme measures to curb the devastating effect of SARS-COV-2. Many countries imposed total or partial lockdown. Some countries closed their borders and national spaces. Airlines were grounded and J o u r n a l P r e -p r o o f public transports stopped services; restaurants, malls, social clubs and gyms were closed. (3, 4) In Northern Italy, for instance, the overwhelming number of SARS-COV-2 patients required a complete reorganization of the healthcare system. (5, 6) . Hospitals and healthcare providers have faced three main challenges during the current wave. First, to provide treatment to the ever rising number of patients with SARS-COV-2 while protecting their staff. Second, to continue a safe level of care to non SARS-COV-2patients. Third, to maintain adequate revenue to cover fixed and ongoing costs, including staff salaries. (7) Furthermore, while healthcare providers are dealing with the ongoing pandemic, preparation for the next wave must not be ignored. (8) With little evidence or previous experience of a newly emerged disease whose clinical features have not been deeply analysed (9) , hospitals have adopted various crises management strategies to deal with this unprecedented situation. As a newly opened children's hospital in the United Arab Emirates, we were facing several challenges in initiating services from the scratch, writing local policies, clinical guidelines and standard operating procedures of daily practices. Most of our doctors and nurses were recruited from various parts of the world and majority relocated to the country within a year or two. The whole situation was surreal. In this article, we describe our hospital strategy to deal with the SARS-COV-2 pandemic crises with a particular focus on paediatric orthopaedic services. The simplicity of our approach was a key to accurate execution and compliance. The prompt collaboration between front line staff, managers and healthcare regulatory bodies to create patients centered guidelines and pathways secured legal protection should mistakes happened. The hospital has responded to the crises by setting up three command and control committees (Gold, Silver and Bronze). Each committee has proportionate representations from various services and was assigned with specific tasks related to the three aforementioned challenges. The department of infectious disease took the lead in establishing the work flow for patients and staff safety. The hospital has been divided into SARS-COV-2 specific areas and SARS-COV-2 free areas. The hospital corridors and lifts have been designated accordingly so that SARS-COV-2 patients and staff caring for them do not mix with other patients and staff. Staff who are at higher risk of SARS-COV-2 such as the elderly, those with diabetes, high blood pressure or immune-comprised staff were asked to work from home as is the case with all non-clinical staff who can perform their duties without being on hospital premises. The level of personal protection and the appropriate personal protective equipment (PPE) were enshrined in hospital policy. Enforcement steps were instituted to ensure compliance. (10-12) All non-urgent hospital attendances were triaged by treating physicians into one of three categories: postpone attendance, telemedicine virtual video consultation or face to face attendance. Patients and parents' preferences were considered in the triage process. The decision to which category a patient was assigned followed the same principle for the surgical screening tool below. Patients who were asked to attend in person underwent a screening process to indicate their risk of having SARS-COV-2 ( Figure 1 ). Patients were classified into higher risk or lower risk. High risk patients were seen with staff wearing full SARS-COV-2 PPE (Appendix 1) whereas patients in the lower risk group required routine handwashing, face mask and gloves. (13) A surgical screening tool was developed to triage patients who required surgery ( who have a lower pain score and surgery has very low impact on hospital resources (can be done as a day case, they do not require a high dependency unit bed or blood transfusion) are offered surgery after DHCRA approval. However, if surgery for these patients with low pain score would have impact on the hospital resources, it will be postponed. Patients will be reviewed at regular intervals determined by the treating physicians. It was anticipated that some patients may present with conditions that do not fit the pathway neatly or patients get triaged inappropriately. Therefore, a subcommittee comprising of three surgeons, two anaesthetists and a theatre manager was created to advise on these patients. The pathway and work flows were communicated to staff through hospital wide communications and supplemented with several virtual meetings to ensure thorough understanding. Various departments developed workflows based on the pathway to streamline services. Here, we describe the application of workflows relevant to pediatric orthopedic services. Most of these patients come through the pediatric emergency department. They are already screened for SARS-COV-2 using the screening tool (Figure 1) , triaged for their injuries and seen by emergency physicians. This group of patients is always a heterogeneous mix, ranging from those who needed an immediate operation to save their life or limb, to children with trivial injuries who only need re-assurance and discharge. Children with severe injuries are often referred to the pediatric orthopaedic team immediately; however, all children including those with less substantive injuries are discussed with the on call team, and are referred to fracture clinic to be seen, either face to face or via video consultation, by a paediatric orthopaedic surgeon within a week. The application of the pathway meant that all these patients are either seen by, or discussed with, the orthopaedic team on the day of presentation. Injuries are triaged according to the pathway and treatment is instigated by the appropriate experts to enhance outcomes, minimize complications and reduce any unnecessary visits. Substantive numbers of patients required a cast or a splint. These were applied by expert technicians, and where appropriate soft cast or splints were uses rather than Plaster of Paris cast. (19, 20) This approach has prevented a multitude of patients with clavicle fractures, ankle sprains, wrist fractures, knee injuries, shoulder injuries and back pain from attending fracture clinics as per previous workflows, and has also identified fractures that need early surgery. Patients who underwent surgery and have a follow up clinic appointment were triaged and the above pathway was applied. If a patient was in a cast, or had wires that required removal, an appointment was made for them to attend for the cast to be removed to prevent stiffness or disuse atrophy, and wires to prevent infection. Similarly, for patients with wounds that needed physical dressing, or review, the physician would arrange a face to face appointment until such time as they could be moved to video consultations. For most other patients, including those who needed a timely post-operative follow up, the default was to offer a video consultation. This allowed physicians to see the child and parent, speak with them about progress and address any concerns. If either parent or physician felt the video consultation was not satisfactory then arrangements were made for a face to face consultation. A large number of patients required x-rays screening to confirm healing or alignment. The treating physicians would discuss the necessity of this x-ray with patients and parents and weigh the risk of patient's attendance to hospital. If x-ray was deemed important to progress to another stage of treatment, then the patient was asked to attend. In liaison with the radiology department, standard operating procedures for safe imaging were implemented for all modalities to reduce the risk of SARS-COV-2infection both during initial visit to the emergency department and during the follow up visits. Orthopaedic clinic attracts a very wide range of conditions. From children with normal variants to those with serious orthopaedic problems such as bone tumours, infections, joint dislocations or deformity. Even within these serious conditions, there are grades of seriousness. For example, a child who present with a swelling around the knee could have osteosarcoma or an osteochondroma. The former requires immediate investigations and treatment and the latter requires re-assurance and a follow up visit in a few months. Two of the most common conditions seen in elective paediatric orthopaedics are the newborn with developmental dysplasia of the hip (DDH) and congenital talipes equinovarus (CTEV). (21) (22) (23) (24) In both these conditions early treatment is prognostic for better outcomes and fewer complication. However, we are able to defer Pavlik harness treatment for DDH in a two-week old child until they are three months old without significant sequlae, in a way we cannot do for a four-month old infant who presents for the first time with DDH, and would need immediate treatment with a Pavlik harness to ensure we do not lose the window of opportunity to employ this treatment modality. Similarly, the onset of treatment for CTEV deformities can be delayed up to three months postpartum if necessary without significant effects on outcome. In such cases, and others, the treating orthopaedic surgeon reviewed all available information and applied the above pathway to ascertain the level of harm that delaying appointments may have on these patients. If information was not optimum, a video consultation appointment would be arranged to gather more information to reach the correct decision. This also allowed the treating physician to meet with the parents, explain the condition to them, signpost them for further information, advice and support, and reassure them regarding the proposed treatment plan. Clinical guidelines and pathways have increasingly become a familiar part of clinical practice. They help clinicians, managers and hospital to provide evidence-based and high quality care for their patients. (25, 26) Since SARS-COV-2a plethora of guidelines have been published to inform clinical practice during this pandemic. As an example, the British Society for Children's Orthopaedic Surgery J o u r n a l P r e -p r o o f (BSCOS) have listed several very useful guidelines on its website. (19) These are proven of great value; however, they should modified to individual countries or institutes as one size does not fit all, and the impact of SARS-COV-2and resources available can vary significantly. (27) Having critically reviewed the published and relevant guidelines, we considered several factors when we developed our local pathway and workflows. (28) (29) (30) We strongly believe that the treating physicians are the best professionals to triage their patients. They were trusted to take the right decision for patients before the SARS-COV-2pandemic and there are no reasons to believe that things should be different during the pandemic. The second important factor that we considered is that the pathway should be simple enough to understand and apply. Surgery that saves lives, limbs or prevent disabilities or complications should not require approval and surgeons should be given the autonomy to perform these surgeries without further approval. Painful conditions that are not life or limb threatening such as avascular necrosis, osteoarthritis or osteochondritis dissecans can theoretically wait until the operating situation is safer, but we feel it is inhumane to leave children with pain. We chose a score of eight and above out of ten as severe pain and a child with such pain should be considered for surgery. The cut off pain score can be modified according to local risk, belief, or practice. The third consideration is that every condition can present with a spectrum of seriousness and complexity and treatment should be tailored to the presentation. One example is that the treatment of a closed minimally displaced clavicle fracture is different from open displaced clavicle fracture. Another example is that of DDH in a two week-old child is treated differently if the child is 13 months of age. The best people to understand these differences and are able to act accordingly are the treating physicians. (31) The final consideration is the need for a perioperative committee to ensure compliance and continuous guidance. This committee should be representative of main stakeholders (surgeons, anaesthetists and theatre managers) but small enough to speed the decision making process. So far the pathway has worked well with only five cases that have been escalated to the committee. The strength of our approach stems from its simplicity and the adherence to the three basic principles of healthcare management. Saving life or limbs requires urgency and takes a priority over other non-urgent medical conditions. There is a spectrum of urgency even within a single disease. Physicians, being the experts in their fields, must be involved in designing the hospital's response to healthcare crises. In summary, planning is essential to overcome crises like the one we are facing. The lack of previous experience and published evidence necessitates innovation that is based on simple principles and developed by front line staff who know their resources, patient population and conditions they treat, and who work in a multi-disciplinary way to plan and deliver healthcare. Pandemic and epidemic diseases 2020 WHO. Coronavirus sitution report COVID-19: Weighing the Endeavors of Nations, with Time to Event Analysis. Osong Public Health and Research Perspectives Operating room efficiency and timing during coronavirus disease 2019 outbreak in a referral orthopaedic hospital in Northern Italy Italy and COVID-19: the changing patient flow in an orthopedic trauma center emergency department COVID-19: not a contraindication for surgery in patients with proximal femur fragility fractures Orthopaedic Guidelines for the COVID-19 Period: Experience from Wuhan, People's Republic of China. The Journal of bone and joint surgery American volume Preparation for the next COVID-19 wave: The European Hip Society and European Knee Associates recommendations. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA ):178. 10. WHO. World Health Organisation. Infection prevention and control of epidemic-and pandemicprone acute respiratory infections in health care Effectiveness of Masks and Respirators Against Respiratory Infections in Healthcare Workers: A Systematic Review and Meta-Analysis COVID-19: towards controlling of a pandemic Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2020. 14. DHCR. COVID-19 Update On Elective And Non-Urgent Surgeries DHA. GUIDELINES FOR THE MANAGEMENT OF COVID-19 INFECTION IN HEALTH FACILITIES 2020 A process of pain assessment in children 016-Nurses' Perceptions of Pediatric Pain Assessment Scales Defining mild, moderate, and severe pain in persons with multiple sclerosis BOA. Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic 2020 Paediatric Orthopaedics: An Evidence-Based Approach to Clinical Questions International Interdisciplinary Consensus Meeting on the Evaluation of Developmental Dysplasia of the Hip Evidence based treatment for developmental dysplasia of the hip in children under 6 months of age. Systematic review and exploratory analysis. The surgeon : journal of the Royal Colleges of Timing for Ponseti clubfoot management: does the age matter? 90 children (131 feet) with a mean follow-up of 5 years Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations Virtual Assessment and Management in Foot and Ankle Surgery During the COVID-19 Pandemic: An Irish Experience. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Prolonged social lockdown during COVID-19 pandemic and hip fracture epidemiology Foot and Ankle Service in North District Hospital During the COVID-19 Pandemic The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons Fracture management during COVID-19 pandemic: A systematic review Recommendations for the Care of Pediatric Orthopedic Patients During the COVID Pandemic