key: cord-0748182-jnb4ad03
authors: Michael Meneghini, R.
title: Resource Re-Allocation During the COVID-19 Pandemic in a Suburban Hospital System: Implications for Outpatient Hip and Knee Arthroplasty
date: 2020-04-22
journal: J Arthroplasty
DOI: 10.1016/j.arth.2020.04.051
sha: f7a76fcd2482b97037268b6f3f292e896903841f
doc_id: 748182
cord_uid: jnb4ad03

Abstract The COVID pandemic of 2020 has emerged as a global threat to patients, healthcare providers and to the global economy. Due to this particular novel and highly infectious strain of coronavirus, the rapid community spread and clinical severity of the subsequent respiratory syndrome created a substantial strain on hospitals and healthcare systems around the world. The rapid surge of patients presenting over a small time period for emergent clinical care, admission to the hospital and intensive care units with many requiring mechanically assisted ventilators for respiratory support demonstrated the potential to overwhelm healthcare workers, hospitals and healthcare systems. The purpose of our article is to describe an effective system for re-deployment of healthcare supplies, resources and personnel to hospitals within a suburban academic hospital system to optimize the care of COVID patients, while treating orthopaedic patients in an equally ideal setting to maximize their surgical and clinical care. This article will provide a particular focus on the current and future role of a specialty hip and knee hospital and its partnering ambulatory surgery center in the context of an outpatient arthroplasty program.

The COVID pandemic is the result of the spread of the SARS-CoV-2 virus, which results in 20 severe acute respiratory syndrome and in the most severe cases, death. Its origin is in Wuhan, 21 People's Republic of China, with the first cases reported there in December of 2019 and has 22 rapidly spread worldwide since that time. In March 2020, the World Health Organization 23 declared COVID-19 a world pandemic and to date, over two million people worldwide have been infected with the SARS-CoV-2 virus and it will continue to spread throughout the world 25 over the coming months to years. Its health and economic consequences have been profound and 26 have affected nearly all countries across the globe. [1] 27 28 Due to emerging information and epidemiologic modelling leading up to its rapid spread here in 29 the United States, many institutions were able to prepare and enact a coordinated response in 30 anticipation of what has been termed the "COVID-19 surge," and the anticipated shortage of 31 personal protection equipment, ("PPE"), intensive care unit beds and respiratory ventilators.

This article will discuss how a suburban hospital region within a large academic health system 33 was able to cohort COVID patients in hospitals with optimal capability and expertise to care for 34 those patients with severe respiratory illness, while utilizing a smaller orthopedic focused 35 hospital, Indiana University Hip and Knee Center at Saxony Hospital, to treat the urgent 36 orthopedic cases. This article will discuss the successful resource re-allocation methodology 37 with a particular emphasis on the outpatient and ambulatory setting. to stop all elective, non-urgent hip and knee arthroplasty surgery on 03/17/2020 and based on evolving data that became clear, the ambulatory aspect of patient care also ceased immediately.

From a hip and knee arthroplasty perspective, appropriately triaging patients based on the extent 49 of their clinical condition and acuity was paramount. arthroplasties. There are multiple factors that will need to be accounted for and the ASCs will 118 likely play an expanded role in access to surgical care for patients with hip and knee arthritis.

First are the protocols that must be developed in order to safely perform hip and knee 121 arthroplasty in the COVID-19 era. It is probable that every patient regardless of symptoms, will 122 need to be tested for COVID-19 prior to elective surgery within a certain time prior to surgery.

This will need to be embedded in the perioperative medical pathways which are typical for hip 124 and knee arthroplasty programs. It is also likely that all the surgical care teams and providers in 125 the ambulatory surgery centers will need to self-monitor and document they are afebrile and do 126 not have any COVID-19 type symptoms at a minimum before caring for the patients for the day 127 and as rapid testing is further developed and accessible, may need to be done on a regular basis 128 to the OR personnel since asymptomatic shed of the virus can occur with some frequency. As It is important to understand that the specific COVID-19 testing is not a minimal requisite to 135 performing total hip and knee arthroplasty in patients with the expectations for same day 136 discharge. Over the past few years, there has been substantial research that provides guidance on 137 safe patients selection, optimal pathways and protocols and the essential elements for successfully and safely performing hip and knee arthroplasty in the outpatient and/or ASC to safely discharge the same day. This conserves bed capacity for the larger inpatient hospitals 19. This impact with not only be prevalent in the short term, but will also be lasting as it has 162 become known that COVID-19 will continue in our society for the next few years until larger, 163 broad based immunity is enacted through a vaccine and consistent exposure to the virus by the 164 population. ASC infrastructure will face a challenge in terms of capacity to handle these larger In summary, the ambulatory and outpatient setting will not be exempt from the significant 192 change and paradigm change occurring as a result of the COVID-19 pandemic. ASCs and 193 hospitals will have a unique set of challenges and also a unique opportunity to be the beneficiary 194 of an accelerated push for the hip and knee arthroplasty to be performed in the outpatient setting.

Subsequently, there should be a significant effort and commitment to putting together pathways, 196 protocols, resources and facilities that can safely care for the hip and knee arthroplasty patient 197 with a plan for same day discharge, in order to spare and conserve healthcare resource 198 consumption. From our own personal experience and implementation of rapid redeployment of 199 resources, staff and supplies with a close partnership and collaboration with our ASCs, Indiana 200 University Health was able to successfully treat all of the COVID-19 patients without 201 overburdening the system and we anticipate also being able to treat these patients safely going 202 forward with a renewed emphasis on early discharge, both from the ambulatory surgery center as 203 well as from within the hospital itself. 

Novel Coronavirus COVID-19: Current Evidence and 208

Guidelines for Ambulatory Surgery Centers for the Care of 210

Surgically Necessary/Time-Sensitive Orthopaedic Cases during the COVID-19

Outpatient Joint Arthroplasty-213

Patient Selection: Update on the Outpatient Arthroplasty Risk Assessment Score

The American Association of Hip and Knee Surgeons

Rapid Discharge in Total Hip Arthroplasty: Utility of the Outpatient 219

Arthroplasty Risk Assessment Tool in Predicting Same-Day and Next-Day Discharge

Identifiable Risk Factors to Minimize Postoperative Urinary 222 Retention in Modern Outpatient Rapid Recovery Total Joint Arthroplasty

Inpatient Versus Outpatient Hip and Knee Arthroplasty: Which Has 225

Higher Patient Satisfaction?

Can Total Knee Arthroplasty Be Performed Safely as an