COVID-19: The First 30 Days at a UK Level 1 Trauma Centre and Lessons Learnt

Abstract

Aims To analyse the learning points from the first 30 days of the COVID-19 lockdown at our institution. Patients & methods Following ethical approval, data were collected prospectively on all patients admitted under orthopaedics between March 23, 2020, and April 22, 2020. This included baseline demographics (sex, age), biochemical (blood tests), radiological (chest X-ray (CXR), computed tomography (CT)), nature and mechanism of injury, comorbidities, regular medication, observations, specific respiratory symptoms of COVID-19, management, operations, time to theatre, and outcome including mortality incidence. The nature of injury and operations performed were compared to the same period of the previous year (2019). Results During the study period, 162 (74 males) patients were admitted, with a mean age of 60.7 (range 1-101, SD 2.1). On admission, 66 (41%) patients were tested for COVID, out of which eight (13.7%) patients tested positive. Subsequently, another four patients tested positive, who developed symptoms after admission. Four out 12 (33%) confirmed COVID patients died. During this period, 4/150 other patients also died of other causes (mortality incidence 2.6%). The average ages of COVID non-survivors vs survivors were 88, SD 1, vs 76, SD 12, respectively; 2/4 had concurrent diabetes and cancer, another cancer alone, and another complex autoimmune disease managed by immunosuppressive medication. Overall admissions significantly reduced by almost 50% compared with the previous year (162 vs 373, p=<0.05), including cases of polytrauma (15 vs 33). Time to surgery was increased by an average of one day, mainly due to time taken for COVID-19 swab results to come back, and in positive patients, this was an average of 2.75 days (0-13). Lymphopenia was a useful biomarker of COVID, with levels significantly different between groups (p=<0.05). Of the clinical symptoms assessed, 8/12 patients experienced positive chest symptoms or pyrexia but only four had positive CXR changes. Discussion & lessons learnt Eight out of 12 patients who contracted COVID-19 survived without needing intensive care. Non-survivors were older with significant comorbidities. Lymphopenia is a good biomarker of the disease, but suspicious CXR was not sensitive for excluding it. Trauma volume reduced. We have highlighted significant changes to expect should there be a second wave of the virus. Key lessons learnt were that reduction in trauma volume and cessation of elective operating allowed for redeployment, including taking over the minor injury unit; more senior, consultant decision-makers ‘at the front door’ reduced unnecessary admissions. Increased use of conservative practice was effective at reducing operations required. Expedited COVID swab test processing allowed early de-escalation of isolation, reducing time to surgery. We expect approximately 12% of the typical orthopaedic population to be admitted with COVID, and up to 33% of these patients...

The impact of COVID-19 on mortality in trauma patients undergoing orthopedic surgery: a systematic review and meta-analysis

“…The majority of patients in these investigations were > 60 years old. The study characteristics and postoperative mortality findings are shown in Table 2 [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]. The most common injury sites were the hip and femur, followed by other lowerlimb sites such as the patella, tibia, ankle, foot, and upper limb.…”

“…Surgery within 48 hours of hospital admission does not correlate with a lower mortality rate in COVID-19-positive patients [13]. As shown in Table 3 [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24], the mean hospital stay length among COVID-19-positive patients undergoing hip and femur surgery was longer than that among COVID-19-negative patients. This result is in line with the study by Kayani et al [37], which stated that hip surgery in COVID-19-positive patients was associated with a longer hospital stay, longer immobilization, more hospitalizations in the intensive care unit, an increased chance of peri-operative complications, and greater mortality rates.…”

“…We included observational studies like cohort, cross-sectional, and case-control studies but excluded review articles. The validity of the papers included in this study was evaluated using a series of inquiries based on a checklist in line with the kind of study created by the Joanna Briggs Institute [7,8], as shown in Supplementary Table 1 [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] and Supplementary Table 2 [24]. Articles that did not fit the requirements for inclusion were rejected.…”

“…According to Table 2 Complications due to COVID-19 were most commonly reported as the primary cause of postoperative death among COVID-19positive patients. The reported primary causes of postoperative death, complications, underlying disease, and mean hospital stay in both groups are shown in Table 3 [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24]. Eight studies [11][12][13][14][15]19,20,22] did not report the cause of death in their research.…”

“…A total of 1,616 reported surgeries from seven studies [13,[16][17][18][20][21][22] are shown in Supplementary Table 4. In contrast, nine studies [9][10][11][12]14,15,19,23,24] did not specify the surgeries performed in their studies. Only Lim et al [18] reported the type of anesthesia used in both groups.…”