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COVID-19 Patients: Better Breathing After Fracture Surgery

COVID-19 infections spread rapidly in northern Italy from February to April of 2020. During that time, the orthopaedic unit at Humanitas Gavazzeni Hospital in Bergamo focused on elderly patients with both a femoral neck fracture and COVID-19. In a fast-tracked JBJS study, Catellani et al. report on what happened to 16 COVID-19-positive patients who were admitted to the hospital’s emergency department with a proximal femoral fracture:

  • 3 patients died from severe respiratory insufficiency and multiple-organ failure before surgery could be considered or performed.
  • 10 patients underwent fracture surgery on the day after admission; 3 had surgery on the third day after admission to allow washout of direct thrombin inhibitors.
  • Oxygen saturation improved in all patients who underwent surgery except 1
  • Hemodynamic and respiratory stability was achieved in 9 patients at an average of 7 days postsurgery.
  • 4 patients who underwent surgery died of respiratory failure—1 on the first day after surgery, 2 on the third day after surgery, and 1 on the seventh day after surgery.

In general, the advantages of early treatment of proximal femoral fractures in the elderly include early mobilization and better pain control. On the other hand, orthopaedists consider severe respiratory insufficiency to be a contraindication to anesthesia and surgery. The anesthesiology team working with Catellani et al. recommended early surgery in these patients if their oxygen saturation was >90% and their body temperature was <38°C. Spinal anesthesia was used for all patients to avoid sedation and was combined with a peripheral femoral nerve block to achieve better pain management.

The authors concluded that most of these COVID19-positive patients who presented in less critical condition and underwent carefully planned and executed surgery for proximal femoral fractures experienced a notable stabilization of their respiratory parameters.

A Primer on Coding and Documentation for Telemedicine

Under the best of circumstances, coding and documenting medical visits and procedures for Medicare and private payers can be a headache. Now, with the pandemic-related increased use of electronic communication between physicians and patients—including video, telephone, and portal-based email—things have gotten even more challenging. Thankfully, in a recent fast-tracked JBJS article, Hinckley et al. offer some valuable assistance with how to code and document telemedicine and other electronic interactions with patients.

The authors summarize the electronic-communication guidelines from the Centers for Medicare and Medicaid Services (CMS) for documenting these visits and for selecting the appropriate CPT codes and modifiers as of April 20, 2020. They emphasize that private payers may not follow CMS guidelines, so “continued attention to CMS, CPT, and private payer websites is necessary.”

Hinckley et al. also emphasize that CPT codes now distinguish between telemedicine (video) visits, email visits, and telephone services. One of the most useful tools the authors offer appears in an Appendix, where 4 sample grids for musculoskeletal documentation and coding are provided.

It might be wise to familiarize yourself and/or your office staff with these new policies, procedures, and codes, because, as the authors conclude, whatever “new normal” eventually emerges, electronic communication with patients “will likely become a more prominent aspect of our clinical presence and platforms.”

Virtual-Meeting Best Practices from OrthoEvidence

In addition to medical appointments between physicians and patients, many medical meetings and conferences have moved to online platforms due to the COVID-19 pandemic. That prompted the OrthoEvidence team, led by renowned orthopaedic surgeon and researcher Mohit Bhandari, MD, to publish a 32-page, downloadable resource titled “Best Practice Recommendations for Virtual Meetings.”

The document—developed from extensive reviews of the literature and private and public-sector documents, consultation with experts, and stakeholder surveys—is designed to help guide healthcare and academic groups as well as policymakers and funders.

The guidelines are organized into 5 sections:

  • Preplanning Considerations
  • Planning
  • Accomplishing goals
  • Response
  • Engaging the audience for future activities

A virtual-meeting planning checklist, a helpful table of virtual-meeting platform vendors, and many other practical resources are included in the document’s 6 Appendices.

How to Safely Restart Elective Surgery Amid a Pandemic

OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Chad A. Krueger, MD, co-author of a recent fast-tracked review article in JBJS.

I’ll admit that when I first started hearing about COVID-19, I didn’t pay much attention. Life was busy, and I wasn’t going to worry about something that I figured would come and go without much fuss over the next few months. While that was obviously a faulty assumption, I think few of us could have predicted just how deadly, anxiety-provoking, and disruptive this virus would be. We are now 5 or so months into this pandemic and nothing is ”normal,” but some of the measures we have taken to help flatten the curve seem to be working. In the months ahead, figuring out how to safely regain some normalcy in our lives will require careful planning, nimble adjustments, and well-coordinated cross-functional execution.

Those three actions were also required to produce the fast-tracked Current Concepts Review article in JBJS about resuming elective orthopaedic surgery during the pandemic, which I had the privilege to co-author. Amazingly, that article progressed from an idea to a published manuscript, with input from 77 physicians, in the span of 2 weeks. This fast-paced project was driven by our knowledge that many facilities worldwide were getting ready to start performing elective surgeries again, and we wanted to ensure that practical, accurate, and relevant information was available as those plans were being made.

All the expert author-contributors offered unique insights as to how the pandemic was affecting healthcare delivery in their region of the globe, allowing us to keep the recommendations as balanced as possible. Although much of the research incorporated in this review came from outside the orthopaedic literature, it all touched on our ability to safely care for patients. The process of creating this article was a great example of how strong leadership, teamwork, and compromise can help us navigate through all aspects of these uncharted waters. Everyone who worked on this manuscript, including the peer-review and editorial teams at JBJS, had one goal in mind: to help orthopaedic surgeons safely return to caring for their patients.

The international consensus group that created this review is well aware that some of the recommendations will need to be updated, changed, or maybe even scrapped altogether as we learn more about the behavior of this virus. We drafted, discussed, and revised these guidelines while appreciating that some regions of the world have not been as adversely affected as others and that there are stark global differences in testing capabilities and supplies of personal protective equipment and other resources. We are painfully aware that some of our strongest recommendations might be impossible to implement in certain settings.

Developing a one-size-fits-all framework for restarting elective orthopaedic surgery was not possible; there are simply too many variables at play with this pandemic that are beyond any individual’s or health system’s control. However, this review provides as much evidence-based guidance as possible so that individual surgeons, practices, hospitals, and municipalities can make informed decisions about how elective surgery should reemerge. We are fully aware that some people may object to some of the recommendations in this article, even though 94% to 100% of the 77-member consensus group agreed on all of them. Nevertheless, we hope that this guidance—and updates to it as more evidence becomes available—will help us all continue to make highly informed decisions before, during, and after elective surgery to keep ourselves and our patients safe.

Chad A. Krueger, MD is an orthopaedic fellow in adult reconstructive surgery at the Rothman Institute and former Deputy Editor for Social Media at JBJS.

Number of COVID-19 Infections: Vastly Underestimated?

Many scientists worldwide are engaged in predicting the course of the COVID-19 pandemic, but the exact nature of this disease and the “novel” virus that causes it remains largely mysterious.

The numbers of confirmed cases in media reports are dependent on the extent of testing, which has varied markedly from region to region in North America. The scientific community has cautioned policymakers not to rely entirely on “observable” data (i.e., testing-confirmed COVID-19 cases) because such measures are likely to under-report the extent of the problem. That’s one reason why orthopaedic surgeon Mohit Bhandari, MD and his colleagues applied machine-learning tools to estimate the number of “unobserved” COVID-19 infections in North America.

The authors’ stated goal was to contribute to the ongoing debate on detection bias (one form of which can occur when outcomes—infections in this case—cannot be reliably counted) and to present statistical tools that could help improve the robustness of COVID-19 data. Their findings suggest that “we might be grossly underestimating COVID-19 infections in North America.”

The authors’ estimates relied on 2 sophisticated analyses: “dimensionality reduction” helped uncover hidden patterns, and a “hierarchical Bayesian estimator approach” inferred past infections from current fatalities. The dimensionality-reduction analysis presumed a 13-day lag time from infection to death, and it indicated that, as of April 22, 2020, the US probably had at least 1.3 million undetected infections, and the number of undetected infections in Canada could have ranged from 60,000 to 80,000. The Bayesian estimator approach yielded similar estimates: The US had up to 1.6 million undetected infections, and Canada had at least 60,000 to 86,000 undetected infections.

In contrast, data from the Johns Hopkins University Center for Systems Science and Engineering on April 22, 2020, reported only 840,476 and 41,650 confirmed cases for the US and Canada, respectively. Based on these numbers, as of April 22, 2020, the US may have had 1.5 to 2.02 times the number of reported infections, and Canada may have had 1.44 to 2.06 times the number of reported infections.

The authors emphasize that the “real” number of asymptomatic carriers cannot be determined without widespread use of validated antibody tests, which are scarce. Bhandari et al. conclude that policymakers should “be aware of the extent to which unobservable data—infections that have still not been captured by the system—can damage efforts to ‘flatten’ the pandemic’s curve.”

8 Work-from-Home Tips

During the COVID-19 pandemic, perhaps the luckiest among us are working from home (WFH), although doing so brings multiple challenges. On yesterday’s Scholarly Kitchen blog, Gabe Harp, Digital Products & Software Services team leader at the MIT Press, shared 8 hard-learned tips for sane and successful WFH. Whether you work in healthcare or some other field, you should be able to apply at least a few of these practical pieces of advice.

His “favorite and most earnest” recommendation: trim 15 minutes from all your meetings. But Harp saves the most important WFH reminder for the end of his post: be grateful for stable employment in a relatively safe environment, reliable internet, good health, and the many other privileges that much of the world’s population lacks right now.

Updated Guidelines on COVID-19 Submissions to JBJS

Since the start of the COVID-19 pandemic, The Journal of Bone & Joint Surgery and our associated journals have received >175 submissions related to the novel coronavirus; we have accepted >40 of those manuscripts and have already published three-quarters of the accepted papers.

Due to the unprecedentedly large number of submissions, the only new submissions on this topic that we will consider for peer review and possible publication are those with scientific data and with a truly unique perspective on this topic. In this way, we will keep our readers informed with the highest-quality orthopaedic information related to the pandemic and keep our COVID collection relevant and useful.

We appreciate the efforts of current and future authors of accepted papers for providing potentially life-saving guidance for patients and orthopaedic surgeons during this pandemic.

Marc Swiontkowski, MD
JBJS Editor-in-Chief

Orthopaedic Redeployment in Anchorage: A Win-Win

Because of government mandates prohibiting elective surgeries, surgical specialties have been among the hardest hit economically during the COVID-19 pandemic. To reduce overhead, some orthopaedic practices have terminated or furloughed staff or implemented steep pay cuts. But as Powell et al. explain in the latest JBJS fast-tracked COVID-19 article, the pandemic presented a unique opportunity for Orthopedic Physicians Alaska (OPA)–a private, vertically integrated practice based in Anchorage–to transform itself, serve its community, and keep its staff employed and the practice afloat.

Alaska shut down elective surgeries in response to COVID-19 on March 19, 2020, and a statewide stay-at-home order was issued on March 22. While OPA leaders confronted the fact that, under those conditions, the practice would not be financially viable after June 15, the Municipality of Anchorage presented a partnership opportunity to OPA and other local healthcare entities.

Anchorage has a disproportionately large population of homeless people. On any given day in the city of 300,000, the number of shelter beds available is >400 short of meeting the demand. To help prevent COVID-19 deaths on a tragic scale among the homeless, the city emergently created temporary shelters, most of them, apropos of Alaska, in de-iced ice rinks.

But the number of available healthcare workers to staff those facilities was insufficient, so the municipality asked OPA and the other larger healthcare practices in the city whether they’d be willing to provide workers to support both existing and new shelters for the homeless. The proposed tasks were definitely not orthopaedic in nature, Powell et al. report. They included creating workflows for COVID-19 screening, establishing logistics for COVID-19 testing, and providing around-the-clock medical oversight at the isolation and quarantine facilities.

OPA said “yes.” With only days until shelter screening was set to commence, the staff and executive team went into full training mode. Meanwhile, contracts were signed with the city for OPA to be paid an hourly rate compatible with Federal Emergency Management Agency reimbursement for services provided. The surgeons in the practice agreed to assume all clinical orthopaedic duties so physician assistants and other clinical staff could serve at the shelters (see photo above).

OPA transformed an orthopaedic practice delivering musculoskeletal care to a focused COVID-19 healthcare entity within 5 days–while avoiding any furloughs. OPA staff are now screening 1,400 homeless and vulnerable individuals daily. Although the work is neither glamorous nor within the scope of a normal orthopaedic practice, the authors conclude that “cooperation with the Municipality of Anchorage has helped to flatten the curve for the community [and] keep the most vulnerable population safe.”

An Orthopaedic Dispatch from Iran

By definition, a pandemic is a global public health crisis. Consequently, along with reports from North American orthopaedists, JBJS fast-tracked COVID-19 coverage has included data from Singapore, China, Italy, and Portugal. The most recent report, authored by Askari et al., comes from Iran.

Iran announced its first report of COVID-19 on February 19, 2020. As of April 21, 2020, the country had >83,505 documented cases, and the Iranian Ministry of Health (MoH) had reported at least 3,739 deaths from the virus.

Two weeks after the detection of the first COVID-19 cases in Iran, the MoH sent an official letter to all health-care centers—governmental and private—to stop all elective surgeries. Some private-sector hospitals obtained permission to restart elective surgeries, but orthopaedic departments at all governmental healthcare centers saw and treated only trauma patients. Ironically, with self-quarantining in Iran, the number of traffic-related trauma cases has decreased because fewer people are commuting.

Within 1 month after the first official reports of COVID-19 in Iran, most private-sector hospitals completely stopped all their surgeries, and some started seeing patients online. All empty hospital beds were designated for the treatment of patients with COVID-19.

While most orthopaedic surgeons were sidelined from the operating room, the Iranian Orthopaedic Society (IOS) and its branches created multiple social media groups to maintain an open channel for the exchange of scientific ideas and to promote orthopaedic research. Meanwhile, orthopaedic residents, somewhat demoralized because of the cancellation of classes and hospital grand rounds, maintained a level of practical education through trauma surgeries and seeing patients in the emergency department.

The Iran University of Medical Sciences in Tehran is now holding online orthopaedic webinars to maintain orthopaedic education for residents and to exchange up-to-date information regarding COVID-19. In addition, the IOS and its subspecialty divisions have further maintained their case studies using e-learning platforms. However, there are large disparities across the country and among universities in the development and implementation of distance-learning programs.

Overall, Askari et al. concur with orthopaedic surgeons elsewhere in the world that the pandemic has shown that the role of orthopaedists can—and at times must—go far beyond “only tending to fractures.”

Best COVID-19 Practices for Orthopaedic Surgeons

In response to the COVID-19 pandemic, an abundance of clinical orthopaedic information has been  disseminated in a short period of time. Some of that has been compiled and commented upon here in OrthoBuzz.

On April 12, 2020, the editors of OrthoEvidence, led by Mohit Bhandari, MD, published a report of global recommendations that puts forth evidence-based principles to guide musculoskeletal care in the face of the coronavirus pandemic. The carefully referenced, 65-page report identifies pandemic-related best practices in outpatient care, elective procedures, urgent/emergent procedures, and peri-/postoperative care.

Nearly three-quarters of the 72 publications analyzed for the report were based on expert opinion and/or clinical experience; just over one-quarter were developed using evidence-based methods alone or a combination of evidence-based methods plus expert opinion. Using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach, the report’s authors assign strength ratings for all the recommendations compiled in the review.

The detailed information is best digested from the report itself, but here is a summary of the report’s overarching recommendations for orthopaedic management at this time:

  • Ensure patient and staff safety.
  • Stay up-to-date about evolving clinical guidelines and your institution’s capacity issues.
  • Prevent unnecessary use of personal protective equipment and make contingency plans for supply shortages.
  • Schedule only urgent or emergent surgical cases.
  • Perform only operative interventions that can be expected to have superior outcomes relative to nonoperative management.
  • Convene teams to make decisions about definitive management in semi-urgent or controversial cases.
  • Prevent unnecessary follow-up visits.