A COVID-19 Pivot Plan to Resume Elective Surgeries at the Hartford Healthcare Connecticut Orthopaedic Institute

Abstract

BackgroundThe Connecticut Orthopaedic Institute (COI) conceptualized a Pivot Plan during an elective surgery moratorium at the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic with the goal of planning and executing orthopedic procedures safely. With the resumption of elective surgeries and the continued planning of surgical recovery over the months (and possibly years) to follow, facilities must brace themselves for repeat waves of COVID-19. Thereby, herein we share the Pivot Plan, its implementation process, evaluation of patient safety, and program performance during a pandemic. This could inform the efforts of other institutions seeking to restart non-emergent surgeries during similarly trying times in the future. MethodsThe COI formed a multidisciplinary team of leaders that met weekly to design a Pivot Plan and a dashboard to guide the resumption of surgeries and assess the performance of the Pivot Plan. The plan revolved around four domains: safety, space, staff, and supplies. It was implemented in two COI-affiliated facilities: MidState Medical Center (MMC) and St. Vincent's Medical Center (SVMC). Monthly metrics from May to November 2020 were compared to the six-month averages for the pre-pandemic baseline period from September 2019 to February 2020. ResultsThe total number (N) of elective orthopaedic cases prior to the pandemic pre-COVID averaged 372 cases per month for MMC and 197 cases for SVMC. During the pandemic post-COVID, N averaging at 361 for MMC and 243 for SVMC illustrates COI was able to perform elective surgeries amid a worsening pandemic. Sameday (SD) discharge rates for total joint arthroplasty (TJA) pre-COVID averaged 8% for MMC and 3% for SVMC. Post-COVID, the SD average was 16.7% for MMC and 11.4% for SVMC. This data indicates that orthopaedic providers were cognizant of length of stay in order to reduce the risk of in-hospital exposure to COVID-19. The 30-day readmission (30R) rate for TJA pre-COVID averaged 1.4% for MMC and 2.7% for SVMC. A high level of care and follow-up is reflected in a lower average 30R post-COVID, 1.1% for both MMC and SVMC. Transitions for TJA patients to their home settings after surgery also reflect the quality of care and the efficiency of the patient throughput process with necessary precautions in place. Post-COVID, the patient transition to home (T) averaged 98.1% for MMC and 97.5% for SVMC compared to T = 96.8% for MMC and 88% for SVMC pre-COVID. No patients experienced deep vein thrombosis or pulmonary embolism during the time period of the project. Positive COVID-19 diagnosis 23 days after discharge was 0% at MMC and 0.2% at SVMC. ConclusionThe COI Pivot Plan was successfully implemented at two different hospitals offering elective orthopaedic surgeries to a varied patient population. The precautions taken by COI were effective in controlling the spread of the SARS-CoV-2 virus while returning to elective orthopaedic surgery. Furthermore, data collected before and after the onset of the COVID-19 pandemic indicated ...

Delay of total joint replacement is associated with a higher 90-day revision rate and increased postoperative complications

“…Plans and models must be drawn up to deal with these consequences from a medical and financial point of view. Meanwhile, there are already research foci dealing with the perioperative management of elective surgery in times of the COVID-19 pandemic [ 46 , 47 ]. Perhaps, this study can help to initiate more research in this area of elective surgery to minimize the risk of surgical revisions and postoperative complications.…”

Interventions to Improve Patient Safety During the Covid-19 Pandemic: A Systematic Review

“…For example, 14 studies employed triaging and modified patient pathways which included creation of clean surgical sites 22 , outpatient rather than inpatient care 23 , novel approaches to ambulatory surgeries 24 , COVID-19-minimal pathways [25][26][27][28] , and operating room modifications [29][30][31] . Studies also examined redesign/reorganization [32][33][34][35] , prioritization protocols 36 and pivot plans for resumption of services 37 . Examples of studies which utilized risk stratification 38,39 and information technology strategies 7,28,42 includes testing protocols based on guidelines and input from interdepartmental team members 40,41 .…”

“…A unique, pharmacologic approach to stress testing 18 was used to improve diagnostic safety. Novel guidelines were implemented across four studies spanning pressure injuries and falls 58 and surgical safety 30,36,38 , and using a pivot plan 37 to allow resumption of elective surgeries. The pivot plan was developed to help find safe pathways for elective surgeries during a pandemic, and consisted of guidance to support a resumption of services across procedural areas.…”

Impacto da pandemia COVID-19 nos eventos tromboembólicos após artroplastia: revisão integrativa

“…Ocorreram modificações no atendimento aos pacientes, com diminuição da exposição, preservando pacientes e profissionais além de recursos para os pacientes com COVID-19 (Thaler et al, 2021). Estudo estimou que até 28 milhões de cirurgias eletivas poderiam ser postergadas ou canceladas em todo mundo (Vaidya et al, 2021). Durante a pandemia observou-se um aumento da taxa de complicações tromboembólicas, advindas dos fatores de risco usuais e outros de possíveis causas diretas pela infecção pelo SARS-COV2 (Aly et al, 2021).…”

“…Em estudo realizado com pacientes submetidos a artroplastia de quadril devido a fratura, portanto uma cirurgia de urgência e não eletiva, demonstrou baixa incidência de contaminação pelo COVID-19 durante a internação hospitalar (Stoneham et al, 2020). Assim, as cirurgias eletivas foram retomadas paulatinamente (Khan et al, 2020;Vaidya et al, 2021), seguindo protocolos de segurança e avaliação pré-operatória, adiando por poucas semanas aqueles que testaram positivo, sem prejuízo, não ocorrendo infecções intra-hospitalares dos pacientes ou da equipe de saúde (Zangrilli et al, 2021). O tromboembolismo venoso, complicação reconhecida após cirurgias de artroplastias, pode estar presente em 40 a 60% dos pacientes pós cirurgia ortopédica de grande porte e a embolia pulmonar fatal com incidência estimada em 2 a 3% pós-artroplastia do quadril (Khan et al, 2020).…”