Is it safe to restart elective day-case surgery? Lessons learned from upper limb ambulatory trauma during the COVID-19 pandemic

Abstract

Background
The COVID-19 pandemic has impacted on the provision of elective and trauma orthopaedic surgery worldwide with millions of operations cancelled. The risk of patients developing COVID-19 after undergoing ambulatory procedures in hospitals is unknown. This paper aims to investigate the risk of developing COVID-19 from day-case and overnight stay upper limb procedures during the peak of the pandemic in London, and to discuss the implications for the safe management of elective hand and upper limb patients in the coming months.

Methods
56 patients underwent emergency trauma upper limb procedures as a day case or with a single overnight stay from 1st March to May 31, 2020 at two central London hospitals that were also key players in the pan-London COVID response. Data was collected retrospectively from clinical and theatre records. Patients were contacted post-operatively and answered a structured questionnaire, including whether patients had experienced any of the symptoms suggestive of COVID-19 in the 14 days prior or 30 days following surgery.

Results
Of 56 patients, one patient reported COVID-19 symptoms, which were minor and did not require hospitalisation. Five patients experienced minor post-operative complications such as stiffness and scar hypersensitivity; one patient had a superficial wound infection. The mean age was 46 years (20–90) with 68% patients ASA I, 25% ASA II and 4% ASA III. 9% had LA, 30% a regional block and 61% had a GA. The most common operation was a distal radius open reduction and internal fixation. The average time spent in hospital was 11 h (3–34 h) and 12 patients required an overnight stay. The median length of face-to-face follow up was 38.5 days.

Conclusion
Our study suggests that, with appropriate precautions, elective upper limb ambulatory surgery can be safely restarted with a low risk of contracting COVID-19 or its complications.

Full text

Original article
Is it safe to restart elective day-case surgery? Lessons learned from
upper limb ambulatory trauma during the COVID-19 pandemic
Samuel Trowbridge
a
,
*
, Warran Wignadasan
b
, Dominic Davenport
a
, Shahrier Sarker
a
,
Alistair Hunter
b
, Sam Gidwani
a
a
Department of Orthopaedics, Guy’s and St Thomas’NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK
b
Department of Orthopaedics, University College London Hospitals NHS Trust, 235 Euston Rd, London, NW1 2BU, UK
article info
Article history:
Received 30 June 2020
Received in revised form
21 July 2020
Accepted 22 July 2020
Available online xxx
Keywords:
COVID-19
Elective surgery
Ambulatory trauma
abstract
Background: The COVID-19 pandemic has impacted on the provision of elective and trauma orthopaedic
surgery worldwide with millions of operations cancelled. The risk of patients developing COVID-19 after
undergoing ambulatory procedures in hospitals is unknown. This paper aims to investigate the risk of
developing COVID-19 from day-case and overnight stay upper limb procedures during the peak of the
pandemic in London, and to discuss the implications for the safe management of elective hand and upper
limb patients in the coming months.
Methods: 56 patients underwent emergency trauma upper limb procedures as a day case or with a single
overnight stay from 1st March to May 31, 2020 at two central London hospitals that were also key players
in the pan-London COVID response. Data was collected retrospectively from clinical and theatre records.
Patients were contacted post-operatively and answered a structured questionnaire, including whether
patients had experienced any of the symptoms suggestive of COVID-19 in the 14 days prior or 30 days
following surgery.
Results: Of 56 patients, one patient reported COVID-19 symptoms, which were minor and did not require
hospitalisation. Five patients experienced minor post-operative complications such as stiffness and scar
hypersensitivity; one patient had a superficial wound infection. The mean age was 46 years (20e90) with
68% patients ASA I, 25% ASA II and 4% ASA III. 9% had LA, 30% a regional block and 61% had a GA. The most
common operation was a distal radius open reduction and internal fixation. The average time spent in
hospital was 11 h (3e34 h) and 12 patients required an overnight stay. The median length of face-to-face
follow up was 38.5 days.
Conclusion: Our study suggests that, with appropriate precautions, elective upper limb ambulatory
surgery can be safely restarted with a low risk of contracting COVID-19 or its complications.
©2020 Delhi Orthopedic Association. All rights reserved.
1. Introduction
The first cases of the novel Sars-CoV-2, coronavirus disease
(COVID-19) occurred in Wuhan, China in December 2019.
1
The
World Health Organisation (WHO) have since declared the disease
a global pandemic, with spread to almost every country and more
than 10 million confirmed cases.
2
In response to the pandemic,
elective orthopaedic surgery in the UK was suspended in order to
avoid unknown risks associated with the disease and also to re-
allocate hospital resources appropriately to respond to a
perceived peak in patients admitted with COVID-19 requiring a
higher level of care.
3
It has been estimated that worldwide, over 28 million opera-
tions have been suspended during the peak 12 weeks of the
pandemic.
4
Due to COVID-specific theatre protocols, anaesthetic
guidelines and requirement for additional personal protective
equipment, procedures are also taking longer and theatre capacity
effectively reduced, with one study demonstrating that trauma
procedures were taking 65e80% longer than prior to COVID-19.
5
Furthermore, the delay to obtaining face-to-face outpatient clinics
in this time, is likely to result in an increased surgical burden in the
long term.
As healthcare systems adjust to COVID-19 restrictions the
*Corresponding author. Department of Orthopaedics, St Thomas’Hospital,
Westminster Bridge Road, SE1 7EH, United Kingdom.
E-mail address: samuel.trowbridge@gstt.nhs.uk (S. Trowbridge).
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma
journal homepage: www.elsevier.com/locate/jcot
https://doi.org/10.1016/j.jcot.2020.07.023
0976-5662/©2020 Delhi Orthopedic Association. All rights reserved.
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
Please cite this article as: Trowbridge S et al., Is it safe to restart elective day-case surgery? Lessons learned from upper limb ambulatory trauma
during the COVID-19 pandemic, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.07.023

reinstatement of elective orthopaedic surgery presents a number of
challenges. The relationship between surgery, anaesthesia and
COVID-19 is still poorly understood. Theoretically, procedures that
can occur under regional and local anaesthetic may reduce risk to
staff and patients and minimise the length of hospital stay.
6
How-
ever, at present, the risk of patients developing COVID-19 following
travel to, admission and treatment in hospital for ambulatory or
short stay elective procedures is unknown.
During the pandemic urgent and emergency surgery has
continued, including those ambulatory patients with orthopaedic
injuries requiring intervention. This study aims to investigate the
risk of developing COVID-19 from day-case and overnight stay
upper limb procedures that have occurred during the pandemic at
two central London teaching hospitals that have both acted as
COVID-19 specialist treatment units, and discuss the implications
this may have on the current safe management of pathways for
day-case and short stay elective orthopaedic surgery.
2. Methods
Patients who underwent emergency trauma upper limb pro-
cedures as a day case or with a single overnight stay from March 1
to May 31 2020 were identified at both units following local ethical
approval. Data was collected retrospectively from both clinical and
theatre records including patient demographics, co-morbidities,
operation details, time frames around the procedure and admis-
sion, mode of anaesthesia and results of any peri-operative viral
swabs. Follow up letters were also reviewed for any wound or other
post-operative complications.
Patients were then contacted and, following verbal consent,
symptomatic screening was conducted using a structured ques-
tionnaire. This included determining whether patients had expe-
rienced any symptoms suggestive of COVID-19 in the 14 days prior
to surgery or 30 days following surgery; details regarding confir-
mation of diagnosis and treatment of COVID-19 if they had been
symptomatic; any isolation precautions the patient had taken
before and after surgery; and what method of transport patients
had taken to and from hospital. Symptoms considered suggestive of
COVID-19 included fever, cough, myalgia, fatigue, altered sense of
taste or smell and diarrhoea based on previous reports in the
literature.
7,8
All patients were treated in the trauma departments of our
central London hospitals. Theatres were located in the same hos-
pital buildings as wards and intensive care units that were being
used to treat patients with COVID-19. Early in the pandemic, pa-
tients were screened for COVID symptomatically, and swabs only
taken if a patient was symptomatic. As time progressed, it became
routine to take COVID-19 screening swabs in all patients who
would be attending hospital for a procedure. Patients were
admitted and discharged from the day surgery unit or a ward
considered to be free of COVID patients.
Operations were conducted using full personal protective
equipment (PPE), including visors and FFP3 masks, as well as sur-
gical gown, gloves and hat. Theatre traffic was kept to a minimum
and work flows through theatre were optimised with separate
‘donning’and post-operative ‘doffing’areas. Face-to-face in-
teractions before and after surgery were also conducted using basic
PPE (visor, mask, apron and gloves) based on public health guide-
lines, and follow up was kept to a minimum.
3. Results
Across both sites a total of 56 patients were identified with a
mean age 46 years (range, 20e90) and a male to female ratio of
31:25. As would be expected from ambulatory trauma patients, the
vast majority were ASA grade I or II (93%, grade I: 38, grade II: 14).
Demographics, co-morbidities and procedures are summarised in
Tables 1 and 2.
The mean time spent in theatre, including anaesthetic, pro-
cedure and recovery time was 150 ±65 min (range, 50e381). The
average time spent in hospital was just over 11 h (range, 3e34 h),
with 12 of the 56 patients requiring a single night stay in hospital
post-operatively. For day-case patients, the length of stay was
lower in patients receiving a regional block or local anaesthetic
rather than general anaesthetic (GA), at 6 h 34 min compared to 8 h
28 min. The average time from diagnosis to surgery was 2.6 ±2.5
days (range 0e12), The most common methods of transport to and
from hospital was private car or walking (34.9% and 32.6%), with a
lower proportion using a taxi (18.6%) or public transport (13.9%).
The median length of in-clinic follow up was 38.5 days. Post-
operative wound infection was noted in only one patient, who
had undergone a tendon repair. This was successfully treated with a
course of oral antibiotics. Four patients had been referred to hand
therapy specifically for post-operative stiffness (3 distal radius
fractures, 1 K-wire fixation of a finger), one patient had scar hy-
persensitivity following a laceration repair, and another patient had
superficial radial nerve paraesthesia, which had resolved at latest
follow up.
48 of the 56 patients were contactable for telephone follow up
at a minimum of 30 days post-operatively. The eight patients who
were not contactable via telephone had all been seen in follow up
clinics and no symptoms of COVID had been noted. Two patients
reported pre-operative symptoms of COVID-19, but both of these
were at least two months prior to surgery. Both had negative
COVID-19 polymerase chain reaction (PCR) samples and were
symptom-free at the time of surgery. At the beginning of the study
sample period, patients were screened for COVID based on symp-
toms and only tested if symptomatic. However, towards the end of
the sample period pre-operative PCR screening became routine for
asymptomatic patients. In total, 12 patients had pre-operative
COVID-19 PCR screening, all of which were negative.
Post-operatively, only one of 56 patients (1.8%) reported post-
operative COVID symptoms. This was a 72 year-old lady with a
medical history of sleep apnoea, who underwent a distal radius
open reduction and internal fixation under GA and required an
Table 1
Patient demographics and co-morbidities.
Patient characteristics n (%)
Age, mean (range) 46 (20e90)
Sex
Male 31 (55)
Female 25 (45)
ASA grade
I 38 (68)
II 14 (25)
III 4 (7)
Co-morbidities
Hypertension 5 (8.9)
COPD 2 (3.6)
Cardiac disease 2 (3.6)
Hypothyroidism 2 (3.6)
Diabetes 1 (1.8)
Asthma 1 (1.8)
Sleep apnoea 1 (1.8)
Hiatus hernia 1 (1.8)
Anaesthetic
Local 5 (9)
Block 17 (30)
General 34 (61)
S. Trowbridge et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx2
Please cite this article as: Trowbridge S et al., Is it safe to restart elective day-case surgery? Lessons learned from upper limb ambulatory trauma
during the COVID-19 pandemic, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.07.023

overnight stay in hospital. The patient developed symptoms of
anosmia and breathlessness, and was subsequently reviewed by
paramedics at home, but did not require admission to hospital. No
laboratory diagnosis was made to confirm the diagnosis, and the
patient was well and symptom-free at the time of telephone
consultation. However, these symptoms occurred three weeks
following surgery. Based on the current estimates of COVID-19 in-
cubation period, these symptoms are unlikely to be associated with
the hospital admission.
4. Discussion
Restarting elective surgery in the wake of the COVID-19
pandemic is a major challenge faced by health care systems.
There is growing discussion regarding the risk of hospital-acquired
COVID-19 infection but reliable data is still lacking.
9
Guidelines
aimed at the restarting of elective services have called for safety
risks to be explained to patients during their consent process,
although the risk profile is still not fully understood.
10
To our
knowledge, no study has reported on the risk of developing COVID-
19 in day-case or overnight stay upper limb surgery. In our study at
two central London teaching hospitals during the height of the
pandemic, only one of the 56 upper limb trauma patients became
symptomatic post-operatively, with all others reporting no COVID
symptoms for 30 days following surgery.
With reports of high mortality in COVID-positive surgical pa-
tients, it is understandable that patients and healthcare pro-
fessionals alike are cautious when considering pathways for
managing the COVID-19 related risk in elective surgery. Early re-
ports estimated a mortality rate of 20.5% in 34 patients who un-
intentionally underwent elective surgery during the incubation
period of COVID-19
8
, whilst initial reports from the COVIDsurg
collaborative have estimated a similar rate of 23.8%.
11
Gruskay et al.
found a mortality rate of 17% in urgent orthopaedic surgical pa-
tients who tested positive for COVID-19 (two of 13 patients, one
patient died pre-operatively).
12
The potential for significant
morbidity and mortality associated with surgery in the context of
COVID-19 is evident and pre-operative screening is therefore an
essential tool in the restarting of elective services.
There have been many potential strategies and methods for risk
management in elective surgery pathways suggested in the litera-
ture, generally based on risk stratification of the patient, underlying
diagnosis and intended surgical procedure.
6,13,14
In a large meta-
analysis including over 50,000 patients, it was shown that age
over 50 years, any co-morbidity and smoking were associated with
severe COVID-19 infection.
15
The COVIDsurg collaborative also re-
ported mortality due to COVID-19 to be associated with advanced
age and ASA grade.
11
Therefore, a pragmatic approach to selecting
patients for upper limb day-case or overnight stay elective surgery
might focus treatment on younger patients, non-smokers and those
with few or no co-morbidities.
10
In our study the majority of pa-
tients eligible for ambulatory day-case trauma surgery were young
(mean age 46 ±16) with few co-morbidities (ASA grade 1-2 (93%,
38 ASA 1, 14 ASA 2)).
General anaesthesia is an aerosol generating procedure and
there is concern about putting theatre staff and patients at risk.
16,17
Regional and local anaesthesia therefore offers the theoretical
benefit of minimising potential transmission by maintaining a pa-
tient’s own respiratory effort, avoiding airway manipulation and
allowing patients to wear a mask during the procedure. The ma-
jority of cases in our series underwent surgery under GA and there
appears to be no increased risk of acquiring COVID-19 in patients
who received a GA compared to regional or local anaesthesia.
However, length of stay in day surgery patients who had a block
was shorter than those who received a GA, and less time in hospital
may lead to a lower risk of exposure to COVID-19 in the peri-
operative period.
Elective surgical guidelines have recommended a two week self-
isolation period prior to surgery to avoid the risk of concurrent
COVID-19 infection, consistent with the observed 14 days
maximum incubation period.
6,18
Due to the urgent requirement for
treatment for the upper limb trauma patients in our study, this
period of self-isolation was not possible. Our study would suggest,
in the context of upper limb conditions suitable for a procedure as a
day-case or overnight stay, if symptom free in the 14 days prior to
surgery, there is a low risk of patients developing symptoms of
COVID-19 or becoming unwell in the postoperative period.
Our study has a number of limitations related to its retrospective
nature and reliance on patient reported symptoms to screen for
COVID-19. However, the negative predictive value of symptom-
based screening has been found to be 91.4%, making it relatively
reliable for ruling out infection.
11
The implications of this study
should be interpreted with caution in other regions, as there may
be geographical variables in the ongoing COVID-19 pandemic that
are yet to become apparent.
5. Conclusions
Minimising the risk from COVID-19 in elective surgical path-
ways is complex, with little data pertaining to specific patient
populations. We describe an upper limb trauma cohort where the
operation was conducted as day-case or overnight stay in COVID
specialist units, without the possibility of pre-operative isolation of
the patients. The findings suggest that, particularly with extra
precautions in place, upper limb and other elective ambulatory
surgery pathways could be managed effectively, with low risk of
significant COVID infection.
Author contribution
Samuel Trowbridge: Data curation, Formal analysis, Writing -
original draft. Warran Wignadasan: Data curation, Formal analysis.
Dominic Davenport: Data curation, Formal analysis, Writing - re-
view &editing. Shahrier Sarker: Data curation, Formal analysis,
Writing - original draft. Alistair Hunter: Writing - review &editing.
Sam Gidwani: Conceptualization, Writing - review &editing.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
None.
Table 2
List of operations performed.
Surgical procedure n
Distal radius open reduction and internal fixation 24
Wound management of forearm or hand 9
Finger or metacarpal K-wire fixation 7
Olecranon open reduction and internal fixation 4
Thumb ulna collateral ligament repair 3
Ulna open reduction and internal fixation 2
Radial head open reduction and internal fixation 2
Tendon repair 2
Scaphoid open reduction and internal fixation 1
Capitellum open reduction and internal fixation 1
Removal of metalwork 1
S. Trowbridge et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx 3
Please cite this article as: Trowbridge S et al., Is it safe to restart elective day-case surgery? Lessons learned from upper limb ambulatory trauma
during the COVID-19 pandemic, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.07.023

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S. Trowbridge et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx4
Please cite this article as: Trowbridge S et al., Is it safe to restart elective day-case surgery? Lessons learned from upper limb ambulatory trauma
during the COVID-19 pandemic, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.07.023