INTRODUCTION Singapore reported its first confirmed case of COVID-19 on 23 January 2020.[1] Local transmission was confirmed on 4 February 2020 and the Disease Outbreak Response System Condition was changed to 'Orange' on 7 February 2020.[2,3] To reduce widespread community transmission, the Singapore government introduced various preventive measures termed 'circuit breaker' (CB) from 7 April 2020.[4] In the initial phase of CB, the closure of all non-essential workplaces, schools, education centres and all dining-in services, amongst other measures, were mandated. In response to the pandemic, Ministry of Health, Singapore, issued statements and guidelines with regard to hospital operations. All non-urgent major surgeries were to be postponed to free up hospital beds and manpower to treat suspected and confirmed COVID-19 patients. Only emergency orthopaedic surgeries for trauma and musculoskeletal tumours were allowed to proceed. Our institution officially started operations on 18 August 2018 at its current location and is the newest tertiary hospital in Singapore at the time of writing. The close proximity of our hospital to some of the most populated migrant worker dormitories meant that our healthcare workers see a significant number of patients being admitted for COVID-19 and are deployed to out-of-hospital sites to conduct COVID-19 screening and medical outpost operations. The Department of Orthopaedic Surgery in our institution had amalgamated with our medical and surgical colleagues in the fight against COVID-19 both in and out of the hospital. As such, a change in our department team structure and workflow was deemed necessary to account for the cut in available manpower and not least, to reduce the risk of nosocomial COVID-19 infection within the department. We were segregated into three functional groups: (a) an 'inpatient' group comprising four separate teams led by a senior doctor (Associate Consultant or Consultant) to care for all admitted inpatients and new admissions coming through the emergency department (ED); (b) an 'outpatient' group comprising Consultants with combined expertise covering all major sub-specialties providing outpatient consultations at the specialist outpatient clinics; and (c) a 'surgical' group with Senior Consultants from trauma, spine and hand surgery sub-specialties that perform all the emergency surgical procedures during the CB period. The phenomenon of a reduction in trauma burden due to social distancing measures as instituted during the CB period has been described by Stinner et al.[5] An epidemiological study conducted by Wong et al.[6] looking at orthopaedic admissions in Hong Kong public hospitals reported a 44.2% reduction in orthopaedic operations. The proportion of emergency to elective operations increased from 1.27:1 to 3.78:1 during the COVID-19 pandemic. The number of hospitalisations was also reduced by 41.2%. An observational study in North Italy also showed a similar trend.[7] Elective surgery declined rapidly, outpatient admissions were restricted to cases that cannot be postponed, while emergencies increased. However, there has been no evidence in the literature evaluating how COVID-19 and national measures can affect the nature and number of emergency orthopaedic admissions in our local population. In this study, we evaluated the epidemiology of all emergency orthopaedic admissions in our hospital before and during the CB period, and determined the impact of the CB on the epidemiology of emergency orthopaedic admissions. METHODS Inpatient medical records of all patients admitted to the Department of Orthopaedic Surgery of our institution through the ED during the study period were accessed using the electronic healthcare records. The study period was from 17 February 2020 to 31 May 2020. The 7-week period from 17 February 2020 to 6 April 2020, preceding the CB was termed 'pre-CB' and the next 7-week period from 7 April 2020 to 31 May 2020 during the CB was termed 'CB'. We adhered to the STROBE guidelines for the conduct of this study. Patients who were transferred to other disciplines within 24 h of admission were excluded. Any patient who was admitted with a postoperative complication during the study period but had the primary procedure performed outside the study period was excluded. Routine elective orthopaedic admissions were excluded. A total of seven cases were excluded based on these criteria. Demographic data including age and gender were recorded. Other clinical data included the reason for admission, mechanism of trauma, anatomic site of pathology and whether it was a workplace injury and if the patient was a nursing home resident. The nature of the operative procedures and the anaesthetic techniques were recorded. The number of admissions per day was also charted. All the data were recorded, anonymised and verified by two authors for accuracy and completion. The mean (Student's t-test) and median (Kolmogorov–Smirnov Test) number of admissions per day were compared between pre-CB and CB. The number of admissions per day was charted throughout the study period and the Jonckheere–Terpstra test was performed to test the significance of the trend. For the clinical data, the Student's t-test was utilised to compare means and the Z-test was utilised to compare proportions. Statistical significance was defined as P ≤ 0.05. All statistical analyses were performed using IBM SPSS Statistics for Mac version 26 (IBM Corp, Armonk, NY, USA). SingHealth Centralised Institutional Review Board (CIRB) reviewed and exempted the study from ethics approval (CIRB Ref: 2020/2469) as these were audit data. No identifiable patient data have been kept or reported. RESULTS The frequency charts of the number of admissions per day during the study period are shown in Figures 1 and 2. The mean number of admissions per day during the pre-CB was 8.4 ± 2.8 (range 3–14) compared to 6.1 ± 2.3 (range 1–14) during the CB (P < 0.001). The median number of admissions during the pre-CB period was 8 (interquartile range [IQR]: 4) compared to 6 (IQR: 2) during the CB (P < 0.001) [Figure 3]. The trend in the number of admissions per day throughout the study period is illustrated in Figure 4. The Jonckheere–Terpstra test proved that the decreasing trend seen in the number of admissions per day during the study period was significant (P < 0.001).Figure 1: Histogram illustrates the frequency of number of admissions per day.Figure 2: Comparative diagram shows the histogram of the frequency of number of admissions per day during pre-circuit breaker and circuit breaker.Figure 3: Box-plot compares the median number of admissions per day between pre-circuit breaker and circuit breaker.Figure 4: Scatter-plot illustrates the number of admissions per day throughout the study period with best-fit line showing a decreasing trend.There was no difference in the mean age and gender proportions of the patients admitted during pre-CB and CB [Table 1]. While trauma was the most common reason for admission during both periods, there was a significant drop in the proportion of trauma admissions during the CB (P = 0.006). Amongst trauma cases, there was a significant decrease in the proportion of patients getting injured due to road traffic accidents (P = 0.013) and sports injuries (P < 0.001). There was a significant decrease in the proportion of patients admitted for knee (P = 0.021) and spine injuries (P = 0.005). However, there was a significant increase in the proportion of patients admitted for fall from standing height (P < 0.001) and for hip injuries (P = 0.005).Table 1: Comparison of clinical data between groups.The proportion of admitted patients requiring surgery had increased significantly from 47.7% to 56.2% during pre-CB and CB, respectively (P = 0.010). The proportion of internal fixation procedures performed increased from 24% during the pre-CB period to 36% during the CB (P = 0.005). There was a corresponding decrease in arthroscopic procedures (P = 0.039) and joint arthrotomy and washout (P = 0.039) procedures. There was a significant increase in the utilisation of regional anaesthesia (RA) during the CB period as compared to pre-CB (41.4% vs. 23%; P < 0.001). This trend was also evident in the hip fracture surgeries (60.9% vs. 32.1%; P < 0.0001). While there was a significant decrease in the number of surgical procedures performed (P = 0.010), there was an increase in mortality rate from 0.2% in the pre-CB period to 1.5% during the CB (P = 0.032). DISCUSSION Overall, this study found a drop in both the mean and median number of admissions per day when comparing pre-CB and CB periods. The decreasing trend of admissions per day was also found to be significant. Our findings are similar to those reported in a similar study conducted in other countries.[6,7,8] The evident contraction in the number of admissions during the CB period can be largely attributed to the decline in the trauma load. This is even more apparent when we analysed the mechanism of trauma and found that there was a discernible reduction in patients who sustained injuries from road traffic accidents and sport activities. This can be attributed to the government instituted measures of closing schools and non-essential workplaces as well sporting facilities during the CB. With students studying from home and most adults working from home, there will be a drop in road traffic volume and road traffic accidents. A prior study conducted in California, United States of America, found an approximately 50% reduction in total and casualty collisions on state highways during the State's lockdown period during the COVID-19 global pandemic.[9] In fact, even before the emergence of COVID-19, existing research have already looked at how the economy is closely associated with road fatalities through exposure and risk; as economic activity declines, travel decreases and drivers are exposed to a lower risk of collisions.[10] This study showed that there were no significant delays in the time from admission to surgery during the CB despite challenges in workflow processes and manpower deployment. This is testament to the robust 'Business Continuity Plan' of our department. This observation cements our belief that notwithstanding the need to conserve manpower and resources during a disease outbreak, it is imperative to continue running dedicated orthopaedic trauma and emergency operating theatre lists daily to ensure continuity of care. This study showed that despite the drop in the number of road traffic accidents and sports injury admissions, there was an increase in the number of emergency surgical procedures performed during the CB. This is due to the increased proportion of hip fracture patients presenting during the CB. Usually the result of low-energy falls, hip fractures often occur indoors and within the property, and the incidence may not be impacted by social distancing measures that were implemented as part of the CB. It has been shown that sedentarism due to COVID-19 stay-at-home measures can contribute to rapid muscle wasting, which is associated with fibre denervation, neuromuscular junction damage and suppression of muscle protein synthesis.[11] Sarcopaenia resulting from inactivity during the CB in the elderly could have contributed to a higher proportion of hip fractures.[12] The significant rise in the use of RA over general anaesthesia is in concordant with European and American Societies of Regional Anaesthesia COVID-19 recommendations. It states that RA should be preferred over general anaesthesia whenever possible, and practice recommendations for RA during the pandemic have since been published.[13,14] The main advantage of RA over general anaesthesia during the COVID-19 pandemic is the eschewal of potential aerosolisation of COVID-19 viral particles by avoiding airway manipulation. Studies have found that up to 30%–40% of patients infected with COVID-19 may have no symptoms, but they can be equally infectious as patients who display symptoms.[15,16] Hence, by reducing aerosol generating procedures such as general anaesthesia, the risk of nosocomial COVID-19 transmission may be greatly reduced. Furthermore, there are cost savings and conservation of limited and expensive personal protective equipment, which would otherwise be required for general anaesthesia cases.[17] The efficiency of the operating theatre was also optimised by averting time-consuming air changes during the intubation and extubation phase of general anaesthesia.[18] During the CB, the multidisciplinary service provided by the orthogeriatricians for our elderly hip fracture patients was temporarily suspended to reduce the risk of cross-contamination between disciplines and to conserve the diminishing manpower for commitments to the COVID-19 operations. In this study, we found a significant increase in mortality rates from 0.2% (n=1) during the pre-CB period to 1.5% (n=5) during the CB period. Of the five patients, two were elderly patients admitted for hip fractures and another two were elderly patients admitted for pelvic fractures. While we cannot attribute the lack of orthogeriatric services for the increased mortality, we would like to highlight the importance of a multidisciplinary orthogeriatric team management for this vulnerable group of patients, as demonstrated by previous studies.[8] We recommend that orthogeriatric services should be considered an essential requirement during lockdown measures in a pandemic, especially since our findings showed that there was a significant increase in the proportion of patients admitted with pelvic and hip injuries. The limitations of this longitudinal observation study include analysing two 7-week periods in a single institution. This may not be representative of the other healthcare institutions in our nation. While we were able to analyse trends and compare epidemiological data, we could not prove any causality. However, we kept bias to a minimum and the periods analysed were dictated by the evolution of the pandemic locally. In conclusion, this study illustrated the epidemiology of emergency orthopaedic admissions in the setting of a pandemic. This will be useful for planning the norms of departmental manpower and resource allocation for future pandemics. Despite structural reconfigurations in this pandemic, a robust 'Business Continuity Plan' can ensure a continuity of care for patients despite stretched resources and manpower. While the number of admissions dropped during the CB, there was an increase in the proportion of patients requiring surgery, largely comprised of patients with hip fractures. We recommend that orthogeriatric services should be considered an essential requirement during a pandemic, due to the increased number of patients with hip fractures. However, the increase in mortality noted during the CB period requires further research. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
No takes yet. Share an insight, caveat, or question.
Wang et al. (2024) studied this question.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: