key: cord-0728447-x1t8bbas
authors: Powell, Sarah N.; Mullen, Timothy; Young, Lynn; Morgan, Christina; Heald, Duane; Powell, Elisha T.
title: Experiences from the SARS-CoV-2 Pandemic: How One Orthopaedic Practice Pivoted to Serve Their Community
date: 2020-04-29
journal: J Bone Joint Surg Am
DOI: 10.2106/jbjs.20.00690
sha: d372e2a9955ba54ecbebfd44f30a68172d1beb45
doc_id: 728447
cord_uid: x1t8bbas

nan

Health-care workers in Wuhan, China, worked tirelessly to understand and contain what has since become a pandemic while the majority of the planet welcomed the new decade, blissfully unaware of the emergence of a novel coronavirus causing severe pneumonia and acute respiratory distress syndrome (SARS) 1 . Yet a mere 4 months later, SARS-CoV-2 and its associated disease, COVID-19, have had devastating, worldwide effects on the population, health-care system, and economy. The explosion in demand for health-care workers in hotspots is balanced by a devastating drop in demand for all others elsewhere. Surgical specialties were among the hardest hit because of nationwide and statewide mandates prohibiting elective surgeries. In an effort to make sure individual practices remained viable on the other side of this pandemic, many practices needed to drastically reduce overhead 2 . Most practices elected to terminate or furlough staff, massively reduce pay, and employ other cost-saving measures, merely to survive the economic impact of COVID-19 on their respective practices 3 .

Although this is undoubtedly a time of great stress for many orthopaedic physicians, this pandemic has also presented unique opportunities for some practices to transform the care they deliver-and how they deliver it-in order to best serve their patients and communities while also keeping their staff employed and their practices financially viable. Orthopedic Physicians Alaska (OPA) is a private practice based primarily out of Anchorage, Alaska, with 16 orthopaedic surgeons, 2 rheumatologists, 1 physiatrist, 27 physician assistants, 25 occupational and physical therapists, and 8 athletic trainers, cover-ing 663,000 square miles of the state. OPA was established in 2001 and has since built up the practice to include in-house physical therapy, imaging, and a surgical center, and the practice currently employs >250 people. When the COVID-19 pandemic shut down elective surgical procedures in Alaska on March 19, 2020, and a stay-at-home order was issued for the state on March 22, the financial outlook of the practice was grim. Without any changes to overhead or operating strategies, OPA would have no longer been financially viable after June 15 without substantial loans or financial relief; however, a unique opportunity to partner with the Municipality of Anchorage, serve their community, and remain financially viable during the COVID-19 pandemic was presented to OPA.

Within Anchorage, the homeless and transient population relative to the population of the city is disproportionally large, with >3,000 people experiencing homelessness in a city of only 300,000 4-6 . On any regular day in Anchorage, the number of beds available in the shelters is >400 beds short of meeting the demand 6 . Social distancing at the existing shelters was impossible because of space constraints, and prior outbreaks of invasive infectious diseases have spread rapidly through the homeless community 7 . Because of the outsized effects that COVID-19 has on individuals with underlying health issues and the propensity of a transient population to act as unwilling vectors throughout a city, the Municipality of Anchorage emergently created temporary shelters to house and screen this population to prevent COVID-19 deaths on a tragic scale.

As one might expect in Alaska, the largest available indoor areas were ice rinks. The Sullivan Arena and an adjacent arena were converted into separate male and female housing shelters for the vulnerable and homeless, allowing 480 cots to be placed 6 feet (1.8 m) apart (Fig. 1) . Ice was rapidly melted over a period of 4 days at 2 more rinks across the city to convert these rinks into quarantine and isolation facilities; however, the resources of paramedics, emergency medical technicians, and Health Department staff were already stretched thin responding to COVID-19 on a citywide basis, so the Municipality reached out to some of the larger health-care practices in the city to see if they were willing to redeploy their staff to provide health-care workers to support the new mass shelters for the homeless. Because of the potential scope of COVID-19 infection within the most vulnerable population in Anchorage, the lack of beds in hospitals and intensive care units, and the looming disaster facing one of the most geographically isolated states with limited personal protective equipment, OPA accepted the request for help.

The scope of the request included manning and creating workflows for COVID-19 screening in a large homeless and transient population at 9 existing and 4 new temporary shelters, writing population screening tools and questionnaires for COVID-19, establishing logistics for COVID-19 testing, and providing around-the-clock medical oversight at the isolation and quarantine facilities (former ice rinks) using medical assistants, athletic trainers, physical therapists, nurses, and physician assistants with physician oversight. With only days until screening was set to commence at these temporary shelters, OPA went into full training mode with its staff and executive team. The entire staff was briefed on this project at virtual town hall meetings because of restrictions on mass gatherings and in accordance with social distancing. OPA is fortunate to have military veterans experienced with the donning and doffing of chemical-warfare protective gear, and these veterans were used to train other OPA personnel on the proper use of personal protective equipment. Contracts needed to be completed with the city for OPA to be paid an hourly rate compatible with Federal Emergency Management Administration reimbursement for services provided. Because the physician assistants were needed to staff medical screenings at the homeless shelters, all surgeons in the practice agreed that they would no longer have physician assistants providing clinical or surgical assistance services for urgent and emergency surgical procedures and that surgeons would assume all clinical duties. Physician supervisors were identified for each shelter, and on-site management was initiated. Physical therapy at 3 separate locations was closed to provide needed manpower. Meetings with city lawyers regarding the intricacies of quarantine and isolation for potential unwilling individuals were completed. OPA was able to transform an orthopaedic practice delivering musculoskeletal care to a focused COVID-19 health-care entity within 5 days and perform emergency medical screenings at multiple homeless shelters across the city of Anchorage (Fig. 2) while also avoiding furloughing any staff. Because of this quick response, 1,400 homeless and vulnerable individuals are now being medically screened daily by OPA staff, and because of this screening, an individual at high risk due to recent travel history was successfully tested and isolated before entering the shelter. This individual ended up being COVID-19positive, and without these screenings, the individual could have unwittingly infected >200 individuals, nearly doubling the current number of COVID-19 infections in Alaska.

Although none of this sounds glamorous or falls within the scope of a normal orthopaedic practice, cooperation with the Municipality of Anchorage has helped to flatten the curve for the community, keep the most vulnerable population safe, and maintain Alaska as one of the states with the lowest number of COVID-19 infections 8 . Although the current situation is less than optimal for many in health care around the country, unique opportunities exist for specialty and orthopaedic practices to make substantial impacts to their communities to help fight the COVID-19 pandemic. n 

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