This study was conducted in 24 patients from the Department of Orthopedic and Spine surgery at Zydus hospitals and healthcare research center, Ahmedabad, India during the period of 11th March-8th May, 2020 over a period of two months. Study was implemented with protocol set by the hospital management as soon as World Health Organization (WHO) announced Covid-19 a pandemic. Selection of patient for admission and surgeries were done prospectively as per guidelines and analysis was carried out retrospectively. There were 14 male and 10 female patients with an average age of 56.2+/-19.4 years (range, 6-83 years) in the study. All patients related to the orthopedic and spine surgeries were included in this study. There were 8 and 16 patients who were admitted through outpatient and flu clinic (Emergency), respectively. At both locations the criteria for the examination and admission were followed up with multidisciplinary approach as below (Fig. 1):
Management for Outpatient Clinic: All patients who wanted to consult specialists were given appointment at least a day prior to visit for the preparation by the hospital. Any patient presented without prior appointment was directed to emergency room (ER) for further procedure. All patients were given consultation time with an interval of at least 20 minutes between two consultations. They were instructed to present at entrance of the hospital premise at least 30 minutes prior to their consultation time where all patients and their relatives screened using thermal screening. Each person (patient and relative both) has to fill and sign self declaration form regarding any symptoms such as fever, cough, sore throat, body ache, head ache, history of close contact to Covid patient, history of travel or returning from international destination. Any patient or relative having positive history from the form or raised temperature on thermal screening was directed to the special Flu clinic which was created before ER . Rest of the screened patients with one relative was allowed to attend outpatient department (OPD) where social distancing were strictly monitored during entire patient cycle. All patients and relatives were given disposable surgical masks to wear all the time till leave the hospital premise. Consultant would attend patient in OPD with precautions wearing N-95 mask, hospital gowns and gloves, with maintaining limited presence of patient and one relative in the chamber.
Management for ER patients: All patients without prior appointment or in emergency has to pass through special flu clinic for Triage . This is created just before entrance of ER for the screening purpose of suspected Covid-19 patients. A team of internal medicine specialist, pulmonologist, emergency medicine experts and critical care specialist using multidisciplinary approach handled flu clinic, and team decides who will attend patient. All doctors and paramedical staff attending the flu clinic wear personal protective equipment (PPE). Any suspected patient was directed to the Covid-19 special center from the flu clinic itself for further management. Other patients were attended for general examination, routine blood work-up (complete blood count, erythrocyte sedimentation rate, c-reactive protein, and x-ray chest). After obtaining clearance from flu clinic team, consultant from orthopedic or spine team would attend patient in flu clinic for consultation.
Investigations: If patient requires further investigations such as blood investigation, x-rays, MRI, CT scan or ultrasound examination in OPD or in ER, doctor would inform the front desk immediately so that the communication to the laboratory or radiology department reach immediately and further process go smoothly without delay. A turn around time of the process was within 2 hours (for primary screening) or within 4 hours (for post consultation investigations) and re-consultation of patient with the primary consultant was followed. In any case patient should move out of the hospital after completion of treatment within 4 hours maximally if admission is not required. To ensure that this process was strictly adhered to, zonal managers from Medical services and Operations were positioned at essential touch points like emergency area, entry points of the hospital, Radiology, sample collection centers and Flu clinic.
Patient requiring admission: Any patient from either specialty requiring admission must get approval from the internal medicine, pulmonology or critical care specialist team as a protocol. All patients seeking admission either from OPD or flu clinic were directed to the physician where x-ray chest were re-examined with patient. In any doubt, high-resolution CT (HRCT) of thorax was advised before getting clearance for the admission . One relative policy was implemented for all patients. The patient shall be attended by the same relative from admission to discharge, and the relative shall be wearing a mask at all times. The patients who were suspected for Covid-19 was advised to get RT-PCR for Covid-19 report at special testing centers before admission. This procedure was explained to patients and their relatives in detail prior to following the process. Entire exercise would increase admission time, and therefore, any emergency medical treatment were initiated in flu clinic to alleviate the pain for orthopedic or spine patients.
Management of patient in wards: Upon admission of a patient in ward, immediate medical treatment started for every patient before preoperative investigations. All patients were explained that they would be kept only in single occupancy rooms instead of keeping in sharing room for their safety purpose [18, 20]. Payment of the additional cost for the single room from the less-affording patients was not asked by the hospital. All routine preoperative investigations, cardiac work-up, preoperative physician and anesthetist clearance and additional investigations related to surgeries, such as MRI or CT scans were carried out from the wards with help of residents . If any patient having complains of sore throat, fever, cough or breathlessness found, we shifted that patient to isolation ward immediately, and investigated for Covid-19 RT-PCR . If any patient reported positive, immediately shifted to Covid-19 special care facility. If report comes negative, patient would be shifted to the ward again.
Surgical procedure- Transfer, Operation room, Induction, Operation, Extubation and transfer back to ward : Transfer of patient (patient with surgical mask) to OR was done by trained staff members wearing N-95 masks and disposable gowns. Patients were shifted directly to OR without waiting in holding area to reduce exposure time in OR. The entire process was preplanned before sending call from OR. Meanwhile OR scrub nurse would prepare all necessary arrangements and preparation of operating trolley and leave operation room before patient enters in. Once patient enters in OR, minimum number of staff, anesthesiologist, technician, nursing staff and runner remain present wearing N-95 masks. Anesthesiologist would be ready wearing PPE kit (Fig. 2). After the timeout procedure is completed, anesthesiologist proceeds for induction of patient. Regional or general anesthesia was given according to patient and surgical requirement under strict protocol and air-conditioning system was switched off 10 minutes prior to induction. Each general anesthesia was guided with video laryngoscopy to avoid direct blow on the face (Fig. 3). Once induction is done, operating surgeon would enter and give position and necessary preparation for surgery. Surgeon, assistant surgeon and scrub nurse would wear kit and perform surgery . The senior surgeon would perform all surgeries and teaching would be avoided to complete the procedure as fast as possible. Additionally, surgeon would avoid using high-speed burr, electro-cautery, suction machine, drilling tools to minimize aerosol particles formation inside OR (Or use with transparent plastic sheet as a barrier) (Fig. 4), thus preventing cross-infection. Operation room and its preparations would follow a standard set protocol published in literature [1, 21, 22]. Air-conditioning system is again switched off at least 10 minutes prior to the completion of surgery. Once surgery is over, patient would be extubated in OR and depending upon his condition and establishing his normal airway and saturation in isolation recovery ward, patient would be shifted to ICU or ward with preplanning.
Postoperative care in wards and discharge: Postoperatively all orthopedic and spine patients were monitored in wards, except those requiring ICU care, till the discharge. Consultant, physiotherapist, resident doctor and nurse separately, followed up all patients. Communication of each postoperative event and update were done immediately to avoid any lapse. Washing hands with soap-water immediately before and after visit were strictly followed. Additionally hospital has set up an announcement call for all the staff members to wash their hands with soap-water every hourly as a rule to avoid any possible transmission of contagious disease. Physiotherapist followed mobilization, chest and limb physiotherapy twice a day regularly for all patients to enhance recovery. Senior consultant took ward rounds with presence of only one staff member to maintain social distancing and implementing the actions on time. A day prior to the discharge, summaries of all patients were preliminarily prepared by residents and checked by attending consultant. On the day of discharge, final discharge summary were checked and signed by consultant, discharge were marked and billing was completed within two hours to avoid any delay in the discharge. All patients were explained about discharge medications and further follow-up with home-care instructions by the consultant to avoid any communication error. All patients and their relative were given discharge along with the surgical masks that was mandatory during their entire stay in the hospital.
Analysis: Twenty-four patients operated for orthopedic and spine surgeries were included in the study after triage for urgent surgeries [7, 12, 19, 22, 23]. Their postoperative improvements and clinical score for pain (visual analogue scale- VAS) were recorded. For all patients, time from OPD/ER to admission in wards, additional investigations, duration from admission to operation, number of days of hospital stay and additional amount of hospital bill in percentage to final bill were analyzed. Analysis was done to replicate similar situation if patient presented without emergency, however, needs surgical procedure to improve quality of life.