Abstract
Background:
Coronavirus disease 2019 (COVID-19) posed a major threat to the clinical practice of orthopedic surgeons, especially in the emergency department. We aim to present: (1) the criteria established by the Surgery Management Committee of Taipei Veterans General Hospital in response to COVID-19 and (2) the impact of COVID-19 screening on orthopedic trauma patients in the emergency department.
Methods:
From April 1 to April 30, 2020, all orthopedic trauma patients in the emergency department were screened for COVID-19 if they fulfilled any of the following: (1) travel from abroad within 14 days, (2) high-risk occupation, (3) contact or cluster history with a COVID-19–positive patient, and (4) any associated symptom, including fever up to 38°C, cough, sore throat, rhinorrhea, loss of taste or smell, muscle soreness, malaise, or shortness of breath. We recorded details on the injury, fever, management, and associated outcomes.
Results:
Of the 163 orthopedic trauma patients presenting to the emergency department, 24 were screened for COVID-19; of these, 22 received surgery. Sixty-two patients received surgery without screening for COVID-19. Fever was the most common reason to screen for COVID-19 (N = 20; 83.3%). No patients were COVID-19 positive. Screened patients had a significantly longer mean interval from presentation to the emergency department to surgery (2.7 ± 2.5 vs. 1.5 ± 0.8 days, p = 0.037). Of the 20 patients screened because of fever, the focus was not identified in 12 (60.0%) patients. The other eight had urinary tract infection (N = 6; 27.2%), septic hip (N = 1; 4.6%), and concomitant pneumonia and urinary tract infection (N = 1; 4.6%). The mean duration of fever and hospital stay was 4.3 ± 4.6 and 8.7 ± 4.9 days, respectively. There were no thromboembolic events, surgical complications, or in-hospital mortality.
Conclusion:
We developed safe and reliable screening criteria for this COVID-19 pandemic. The delay in surgery was reasonable and did not adversely affect in-patient outcomes.
Keywords: Coronavirus, COVID-19, Emergency service, hospital, Fever, Taiwan, Trauma
1. INTRODUCTION
Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2), which is highly contagious and has presented major threats to global health and economic systems.1 The initial outbreak of COVID-19 was from Wuhan, Hubei, China, and from there the disease spread widely to other countries, such as Thailand, Japan, Korea, Vietnam, Germany, the United States, and Singapore. The first case in Taiwan was reported on January 21, 2020. The World Health Organization (WHO) issued a Public Health Emergencies of International Concern alarm on January 30, 2020,2 and recent global data from WHO showed 50 030 121 confirmed cases with 1 252 072 deaths as of November 9, 2020.3
Since the first death in Taiwan on February 16, the source of the majority of cases has changed from importation to suspected local transmission.4 Thus, widespread community transmission was anticipated. Although the services of elective and emergent orthopedic surgery were reduced during this COVID-19 pandemic,5 the impact on our practice in the emergency department was also potentially significant. Criteria were needed to screen orthopedic trauma patients for COVID-19 in the emergency department, especially for those patients who needed to receive surgery. As one of the largest tertiary trauma centers in Northern Taiwan, our hospital modified our clinical criteria for COVID-19 screening until the end of March, when a final version was decided upon and applied to all patients who came to the emergency department. In this study, we aim to present the criteria, results, and impact of screening for COVID-19 on orthopedic trauma patients in the emergency department.
2. METHODS
2.1. Patient selection
We conducted a retrospective, observational study in a tertiary trauma center from April 1, 2020 to April 30, 2020. This study was approved by our institutional review board. All patients who came to the emergency department with orthopedic trauma during this study period were eligible for assessment (N = 163). According to our screening criteria, 24 patients (14.7%) received COVID-19 rapid screening test, whereas the other 139 patients did not. Twenty-two of the 24 patients underwent surgery for their injuries. The other two patients were treated conservatively and discharged from the emergency department. Of the 139 patients who were not screened for COVID-19, 62 received surgery and the other 77 received conservative treatment (Fig. 1, CONSORT).
Fig. 1.
CONSORT flow diagram. COVID-19 = coronavirus disease 2019.
2.2. Criteria for screening
The first patient diagnosed with COVID-19 in Taiwan was reported on January 21, 2020. From January 21, 2020 to March 31, 2020, the Surgery Management Committee of Taipei Veterans General Hospital developed the screening criteria for COVID-19: positive history of travel, occupation, contact, or cluster (TOCC) AND associated symptoms. The definition of positive TOCC history included travel history to level-3 countries within 14 days, high-risk occupation, contact or cluster history. The associated symptoms included fever up to 38°C, cough, sore throat, rhinorrhea, loss of taste or smell, muscle soreness, malaise, or shortness of breath.
The number of infected patients and the risk of community spread were both significantly increased by the end of March 2020. The Surgery Management Committee of Taipei Veterans General Hospital then revised the screening criteria for COVID-19 from “positive TOCC history AND associated symptoms” to “positive TOCC history OR associated symptoms.” Moreover, the definition of travel history was expanded from level-3 countries to all foreign countries.
If the patient’s condition fulfilled any one of the aforementioned criteria, we checked the real-time reverse transcription polymerase chain reaction of a nasopharyngeal swab and sputum tests for SARS-CoV-2. The interval from obtaining the specimens to obtaining the laboratory results was about 6 hours. Moreover, chest radiograph, laboratory examinations (such as complete blood count and biochemistry tests), and urine analysis were also arranged as indicated. Each patient was isolated until we validated a negative COVID-19 result. We arranged for surgery if the patient fulfilled the following criteria: (1) a negative result for COVID-19 and (2) no other fever focus could be detected (eg, urinalysis or chest radiograph). If there was a positive COVID-19 result, the patient was transferred to the negative pressure isolation ward for care. Infection and chest specialists were consulted for a further treatment plan for COVID-19 and the possible time point for surgery.
2.3. Data collection
Twenty-four orthopedic trauma patients underwent rapid screen testing for COVID-19 and 22 received surgery. There were 11 (50.0%) male and 11 (50.0%) female patients. Mean age was 59.2 ± 24.3 (range, 6-92) years. With regard to clinical characteristics, we recorded the Charlson’s Comorbidity Index (CCI), Injury Severity Score (ISS), injury site, associated injury, and procedures performed. To evaluate the impact of COVID-19 screening, we recorded the reason for COVID-19 screening, the interval from admission to the emergency department to the start of surgery, duration of fever, fever focus, and length of hospital stay.
2.4. Statistical analysis
Data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Data were represented as mean ± SD or median and range for continuous variables, or number and percentage for categorical variables. The Fisher’s exact test and independent t test were used to compare differences between groups for each discrete variable. A value of p < 0.05 was considered to represent statistical significance.
3. RESULTS
Twenty-four of 163 (14.7%) orthopedic trauma patients presenting to the emergency department were screened for COVID-19. The reasons for screening included fever (N = 20; 83.3%), upper respiratory tract symptoms (N = 3; 12.5%), and travel history (N = 1; 4.2%). Of the 24 patients screened for COVID-19, 22 received surgery. During the same period, another 62 patients underwent surgery without being screened for COVID-19. Mean age, sex distribution, and CCI did not differ between the two cohorts. Patients who had been screened for COVID-19 had significantly longer intervals from admittance to the emergency department to their time of surgery (2.7 ± 2.5 vs. 1.5 ± 0.8 days, p = 0.037). Patients screened for COVID-19 also had significantly longer hospital stays (8.7 ± 4.9 vs. 5.7 ± 4.8 days, p = 0.017), possibly because of their significantly higher ISS (10.0 ± 3.7 vs. 4.3 ± 3.1, p < 0.001). Because all the screening results for COVID-19 were negative, the increased length of hospital stay might have been associated with the treatment for the injury, not COVID-19 (Table 1).
Table 1.
Clinical characteristics of orthopedic trauma patients who had or had not been screened for COVID-19
| Screen for COVID-19 (N = 22) | Not screen for COVID-19 (N = 62) | p value | |
|---|---|---|---|
| Age, y | 59.2 ± 24.3 | 56.8 ± 22.9 | 0.675 |
| Sex | 0.513 | ||
| Male | 11 (50%) | 36(58%) | |
| Female | 11 (50%) | 26(42%) | |
| Charlson’s Comorbidity Index | 2.7 ± 1.9 | 3.5 ± 3.7 | 0.189 |
| Injury Severity Score | 10.0 ± 3.7 | 4.3 ± 3.1 | <0.001 |
| Interval from ED to surgery, d | 2.7 ± 2.5 | 1.5 ± 0.8 | 0.037 |
| Injury site | 0.311 | ||
| Upper extremity fracture | 5 (22.7%) | 23 (37.1%) | |
| Lower extremity fracture | 10 (45.5%) | 14 (22.6%) | |
| Osteoporotic hip fracture | 5 (22.7%) | 14 (22.6%) | |
| Multiple trauma | 1 (4.5%) | 5 (8.1%) | |
| Others | 1 (4.5%) | 6 (9.6%) | |
| Length of hospital stay, d | 8.7 ± 4.9 | 5.7 ± 4.8 | 0.017 |
COVID-19 = coronavirus disease 2019; ED = emergent department; Others = soft tissue injuries, including tendon ruptures.
The injury sites of the 22 patients who had undergone surgery after screening for COVID-19 included lower extremity fractures (N = 10; 45.5%), senile hip fractures (N = 5; 22.7%), upper extremity fractures (N = 5; 22.7%), multiple fractures (N = 1; 4.6%), and quadriceps tendon rupture (N = 1; 4.6%). Six (27.2%) patients had other associated injuries, including rib fractures, head injuries, or facial bone fractures (Table 2).
Table 2.
Clinical information of patients who had been screened for COVID-19 at ED before receiving surgery
| Patient number | Age/sex | CCI | ISS | Interval from ED to surgery, d | Injury site | Procedure | Associated injury | Duration of fever, d | Fever focus | Length of hospital stay, d | Reason for screening |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 80/female | 6 | 9 | 2 | Femoral neck fracture | ORIF | Nil | – | – | 4 | Positive TOCC history |
| 2 | 85/female | 4 | 9 | 1 | Distal femur fracture | ORIF + TKA | Nil | 16 | UTI | 17 | Fever |
| 3 | 65/male | 2 | 19 | 11 | Distal clavicle fracture | ORIF | Rib fracture | 2 | Unknown | 15 | Fever |
| 4 | 62/female | 2 | 9 | 1 | Forearm fracture | ORIF | Nil | 3 | UTI | 6 | Fever |
| 5 | 55/male | 4 | 9 | 3 | Femoral neck fracture with septic hip | THA | Nil | 4 | Septic hip | 8 | Fever |
| 6 | 79/female | 3 | 9 | 3 | Tibia shaft fracture | ORIF | Nil | 4 | Unknown | 8 | Fever |
| 7 | 28/male | 0 | 11 | 2 | Distal radius fracture | ORIF | Nil | 2 | Unknown | 3 | Fever + headache + upper respiratory tract symptoms |
| 8 | 57/female | 1 | 9 | 1 | Tibial plateau fracture | ESF/ORIF | Head injury | 6 | Unknown | 13 | Fever + upper respiratory tract symptoms |
| 9 | 25/male | 0 | 4 | 2 | AC dislocation | ORIF | Nil | 2 | Unknown | 6 | Fever |
| 10 | 53/female | 1 | 9 | 1 | Distal radius fracture | ORIF | Nil | 2 | Unknown | 4 | Fever |
| 11 | 86/male | 5 | 9 | 3 | Femoral neck fracture | ORIF | Nil | 1 | Unknown | 15 | Fever |
| 12 | 35/female | 2 | 9 | 1 | Femoral neck fracture | ORIF | Nil | 3 | UTI | 5 | Fever |
| 13 | 78/female | 3 | 10 | 2 | Tibial plateau fracture | ORIF | Head injury | 3 | UTI | 11 | Fever |
| 14 | 92/male | 6 | 9 | 4 | Femoral neck fracture | HA | Nil | 6 | UTI + pneumonia | 13 | Fever |
| 15 | 19/male | 0 | 14 | 2 | Femoral shaft fracture | ORIF | Facial bone fracture + head injury | 7 | Unknown | 9 | Fever |
| 16 | 75/male | 4 | 9 | 8 | Pelvis fracture | ORIF | Facial bone fracture + head injury | 1 | Unknown | 10 | Fever |
| 17 | 6/male | 0 | 9 | 0 | Femoral shaft fracture | ORIF | Nil | – | – | 2 | Upper respiratory tract symptoms |
| 18 | 79/female | 4 | 13 | 1 | Distal femur fracture | ORIF | Nil | 2 | Unknown | 5 | Fever |
| 19 | 67/male | 2 | 9 | 2 | Femoral neck fracture | HA | Nil | 3 | UTI | 6 | Fever |
| 20 | 74/female | 4 | 9 | 3 | Femoral shaft fracture | ORIF | Nil | 4 | UTI | 6 | Fever |
| 21 | 60/female | 2 | 20 | 3 | Clavicle fracture, tibial fracture | ORIF | SAH | 19 | Unknown | 20 | Fever |
| 22 | 42/male | 4 | 4 | 3 | Quadriceps tendon rupture | Repair | Nil | 3 | Unknown | 6 | Fever |
AC = acromioclavicular; CCI = Charlson’s Comorbidity Index; COVID-19 = coronavirus disease 2019; ED = emergent department; ESF = external skeletal fixation; HA = hemiarthroplasty; ISS = Injury Severity Score; ORIF = open reduction and internal fixation; SAH = subarachnoid hemorrhage; THA = total hip arthroplasty; TKA = total knee arthroplasty; TOCC = travel, occupation, contact or cluster; UTI = urinary tract infection.
For the patients screened for COVID-19 who had undergone surgery, the mean duration of fever was 4.3 ± 4.6 (range, 1-19) days. None of these patients had a positive screening result for COVID-19. We found positive fever focus in only 8 (36.3%) patients, including urinary tract infection (N = 6), septic hip (N = 1), and concomitant urinary tract infection and pneumonia (N = 1). The fever focus remained unknown until discharge in the other 12 patients (60.0%), but fever in all 20 patients subsided before discharge. The average length of hospital stay was 8.7 ± 4.9 (range, 2-20) days (Table 2). There were no thromboembolic events, surgical complications, or in-hospital mortality. None of these 163 patients were subsequently diagnosed with COVID-19 based on data from Taiwan Centers for Disease Control (Taiwan-CDC).
4. DISCUSSION
In this study, we validated the impact of screening COVID-19 on orthopedic trauma patients in the emergency department during the COVID-19 pandemic. A substantial proportion of patients (N = 24; 14.7%) fulfilled the criteria for screening for COVID-19, with fever as the most common reason (N = 20; 83.3%). On average, the fever lasted for 4.3 days. However, no fever focus could be identified in 60% of patients after a thorough survey. COVID-19 screening was associated with a delay of 2.7 days from admittance to the emergency department to time of surgery. Despite that significant delay, no thromboembolic events, surgical complications, or in-hospital mortality was noted.
Although the clinical manifestations of COVID-19 can be varied,6–8 fever (83.3%) and upper airway respiratory symptoms (60.3%) are the most common.9 According to a study of trauma patients, up to 40% of patients who had experienced trauma and were sent to the emergent department had fever symptoms during the first 48 hours after admission, possibly a manifestation of the stress response. Despite a thorough workup for fever, no source of infection was found in 70% of febrile patients.10 In our study, we found a similar rate of negative results of fever workup (60%). Fever, a common presentation in trauma patients, can be very stressful to medical personnel during a COVID-19 pandemic, who are the medical practitioners at highest risk of being exposed and infected.11–15 Therefore, the need to screen for COVID-19 in orthopedic trauma patients involves more than the ability to diagnose COVID-19; such patients must be screened to help protect these most vulnerable medical personnel, because this population will often require surgery. This is also why we did not list radiographic features based on chest radiograph or computed tomography as one of the criteria for screening, although that information has proven helpful.9,16 To address the global pandemic nature of COVID-19 infection, we added TOCC history to our criteria for screening, even if the patients were asymptomatic.
Although Taiwan had been expected to have the second highest number of COVID-19 cases due to its location near China,17 the epidemic seemed to slow down, because there were no new cases for the 13 days before May 20. We should attribute this preliminary success to the early recognition by our government of the crisis and its proper management of the imported cases. The screening strategy can differ from that used in situations with a community spread. A more comprehensive screening strategy for COVID-19 might be necessary in areas with community spread, whereas a more specific strategy can be formulated in places where local, second-generation, or third-generation cases are rare, such as in Taiwan.18–20 Based on our screening criteria, results from the 22 patients who underwent surgery were negative for COVID-19. Because of this negative result, the delay from the emergency department to surgery was reasonable (2.7 days). Notably, none of these patients experienced thromboembolic events, surgical complications, or in-hospital mortality. In comparison, a longer delay from injury to surgery (8.7 days) because of positive COVID-19 screening results might be associated with adverse outcomes such as cardiovascular events, thromboembolism, or pneumonia.21
Our study has some limitations. First, this study had such a small sample size because the protocol was started after the outbreak of local transmission. Second, although the investigated hospital was one of the designated hospitals for receiving COVID-19 suspect cases from primary care, none of the orthopedic trauma patients were diagnosed with COVID-19 based on our screening protocol. Third, although the diagnostic testing in the investigated hospital was approved by the Taiwan-CDC, the sensitivity and specificity of the assay are unknown at present.
In conclusion, our criteria to screen for COVID-19 in orthopedic trauma patients appears safe and reliable. There was a reasonable delay in surgery, but it did not adversely affect the in-patient outcomes.
Footnotes
Conflicts of interest: The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article.
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