Evaluating the efficacy of a two-site (‘COVID-19’ and ‘COVID-19-free’) trauma and orthopaedic service for the management of hip fractures during the COVID-19 pandemic in the UK

Abstract

Aims Hip fracture patients are at higher risk of severe COVID-19 illness, and admission into hospital puts them at further risk. We implemented a two-site orthopaedic trauma service, with ‘COVID’ and ‘COVID-free’ hubs, to deliver urgent and infection-controlled trauma care for hip fracture patients, while increasing bed capacity for medical patients during the COVID-19 pandemic. Methods A vacated private elective surgical centre was repurposed to facilitate a two-site, ‘COVID’ and ‘COVID-free’, hip fracture service. Patients were screened for COVID-19 infection and either kept at our ‘COVID’ site or transferred to our ‘COVID-free’ site. We collected data for 30 days on patient demographics, Clinical Frailty Scale (CFS), Nottingham Hip Fracture Scores (NHFS), time to surgery, COVID-19 status, mortality, and length of stay (LOS). Results In all, 47 hip fracture patients presented to our service: 12 were admitted to the ‘COVID’ site and 35 to the ‘COVID-free’ site. The ‘COVID’ site cohort were older (mean 86.8 vs 78.5 years, p = 0.0427) and with poorer CFS (p = 0.0147) and NHFS (p = 0.0023) scores. At the ‘COVID-free’ site, mean time to surgery was less (29.8 vs 52.8 hours, p = 0.0146), and mean LOS seemed shorter (8.7 vs 12.6 days, p = 0.0592). No patients tested positive for COVID-19 infection while at the ‘COVID-free’ site. We redirected 74% of our admissions from the base ‘COVID’ site and created 304 inpatient days’ capacity for medical COVID patients. Conclusion Acquisition of unused elective orthopaedic capacity from the private sector facilitated a two-site trauma service. Patients were treated expeditiously, while successfully achieving strict infection control. We achieved significant gains in medical bed capacity in response to the COVID-19 demand. The authors propose the repurposing of unused elective operating facilities for a two-site ‘COVID’ and ‘COVID-free’ model as a safe and effective way of managing hip fracture patients during the pandemic. Cite this article: Bone Joint Open 2020;1-6:190–197.

Thirty-day mortality of patients with hip fracture during COVID-19 pandemic and pre-pandemic periods: A systematic review and meta-analysis

“…However, the difference in the mortality was limited to the COVID-19 + patients as the analysis failed to notice a difference between COVID-19 − patients and pre-pandemic hip fracture patients. The respiratory compromise because of the COVID-19 infection in the perioperative period acts as a second hit phenomenon as the cytokines are already flared up by the traumatic hip fracture[ 18 , 20 , 24 ]. Prolonged recumbency, poor immunity and multiple comorbidities in the elderly individuals are also detrimental[ 43 , 44 ].…”

“…Nevertheless, asymptomatic COVID-19 − patients are not different from the typical elderly cohort. Accordingly, segregations of the hip fracture patients into the COVID-19 positive site or the negative site will minimize cross-infection, and it will help in early delivery of medical care to the non-infected patients[ 24 , 27 ]. The patient may be temporarily held up in a transition zone till COVID-19 test result is available.…”

“…The importance of patient segregation into two different sites has been evaluated by Chui et al [ 24 ] and Segarra et al [ 27 ]. Chui and his associate did not notice a significant difference in mortality between COVID-19 infected and non-infected patients as they could operate 61% of hip fractured patients within 36 h[ 24 ]. It has been reported that the respiratory symptoms have improved after femur fracture stabilization[ 23 ].…”

“…During the pandemic time, when the entire medical services have focused on COVID-19 treatment, delaying of hip fracture surgery might cause increased complication and perioperative mortality. Although it was believed that COVID-19 infected patients with hip fracture might have more incidences of pulmonary complications, pneumonia and perioperative mortality, few studies reported similar mortality rates in both COVID-19 infected and non-infected patients[ 18 , 24 ]. The observational study by the Spanish HIP-COVID group reported a 10% incidence of in-hospital death among fracture patients who were negative for COVID-19[ 16 ].…”

“…Similar observations were reported by Kayani et al [ 18 ], who had a similar incidence of mortality in hip fracture among the COVID-19 infected and non-infected patients. Several cohort studies reported no significant difference in delay in surgery, treatment methods, complications, and 30-d mortality in the hip fracture between the pandemic and the pre-pandemic period[ 24 , 27 ]. Because of the small cohort of hip fracture patients during the pandemic time, such conclusion should be interpreted judiciously as it seems there is no ill-effect of COVID-19 infection per se on the patient and probably there is no severe consequence of slight treatment delay.…”