PERSPECTIVES

Drs. Minguell, Guerra and Bhandari discussed the second wave of COVID-19, resuming elective orthopaedic surgeries, and healthcare protocols in Spain. Our discussion uncovered 4 core themes. These themes and their supporting insights are highlighted below.

1. Shifts in epidemiological trends during second wave of COVID-19

There has been a sharp rise in COVID-19 cases since the beginning of July in Spain. During the stable period in May and June, there were 100 to 200 new cases per day. Recently, on August 3^rd, there were around 3,000 patients a day that were newly diagnosed with COVID-19.

 

Compared to the COVID-19 pandemic during March and April, the second wave in Spain has characteristics of:

- Lower mortality

- Mild condition

- Lower hospital admissions

- Lower intensive care unit (ICU) admissions

 

New daily deaths reduced significantly. During the first pandemic period in March and April, there was a peak in daily deaths in the beginning of April, nearly 1000 patients died in one day. Although the number of daily new cases has been increasing quickly, fewer deaths occurred compared to March and April. During the 4 weeks in July, the cumulative deaths for the whole country was over 100.

 

According to the data from the beginning of August, among the 127,390 active cases, 617 (0.48%) were in serious or critical condition. In other words, nearly 100% of the new cases have mild conditions, probably because most of the patients are young patients without comorbidities.

 

Drs. Minguell and Guerra shared the data from the University Hospital Vall d’Hebron in Barcelona. There were fewer hospitalizations due to COVID-19 in July, compared to March and April. In March, over 600 COVID-19 patients were admitted to the hospital on the same day, and 165 of them were critical cases. On July 28^th, among the near 800 patients who were hospitalized for any conditions, 37 (less than 5%) were admitted to hospital due to COVID, and 13 of the COVID-19 patients were in the ICU. The condition of patients who were in the ICU was generally less severe than the critical patients in March and April, as these patients were younger and had fewer or no comorbidities. In March, on average 10 COVID-19 patients died per day in this hospital. In the whole month of July, there were no deaths due to COVID-19.

2. Second Wave and the Ease of Restrictions and Relaxing Attitudes

Several factors are associated with the increased risk of COVID-19 spread:

1)     End of state of alarm and isolation

2)     Not respecting rules of the “New Normal”

3)     Increasing confidence about going out or gathering with friends

4)     Summer - specific activities (e.g. visiting beaches)

5)     Seasonal workers travelling from other areas

6)     Social contacts and family reunions

7)     Tourism

8)     Outbreaks associated with nightlife

 

After the ease of COVID-19 restrictions in some areas of Spain (VOA news, May 22), people, especially the young people, started to go out of their homes and visit nightclubs. There were occasions where 100 to 300 people gathered at the same place. Older people are more cautious and they do not go to restaurants. A lot of young people have become relaxed and lost the fear of infection.

3. Resuming Elective Surgeries

Concerning bed occupancy (especially critical patients) and capacity of human resources, the elective surgeries were stopped on March 16^th University Hospital Vall d’Hebron. Between mid March and the end of April, the orthopaedic care team performed surgeries on sporadic cases of poly-trauma patients and other emergency surgeries (2-4 hip fracture surgeries per day). Being the referral center for spinal cord injury in Catalonia, surgeons from the University Hospital Vall d’Hebron also did spinal surgeries with indications of trauma, tumor and neurological deficit. The team was separated into two working teams to minimize risks of getting infected with SARS-CoV-2. They had daily online meetings to support each other and share the workload. COVID-19 surgical areas were set up in operating rooms. Personal protective equipment (PPE) and education were provided to protect the healthcare workers. Five staff members and 3 residents (together accounting for 10% of the orthopaedic care team) were tested to be COVID-19 positive and they were all infected during the first pandemic period in March and April.

 

Surgeons did not expect to start resuming non-urgent elective orthopaedic surgeries as early as May. Based on the data showing a decreasing number of COVID-19 cases, specifically when 80 beds were occupied in the ICU, the director of the hospital and the clinicians made the decision to start the elective surgeries. The types and volumes of orthopaedic surgeries were increased slowly and progressively. In May, they started outpatient surgeries, anterior cruciate ligament (ACL) reconstruction and proximal femoral reconstructions, etc. The surgeons published a study of 61 patients who had surgery for proximal femoral fracture, and reported a mortality rate of 35% among these surgical patients who were COVID-19 positive (7 died/23 COVID-19 positive patients who had surgery for proximal femoral fracture) (Vives et al. JBJS. May 2020). In mid June, the team started arthroplasties and had a plan to increase the number of afternoon surgeries, in order to address the number of arthroplasties in the waiting list by the end of October.

 

In 2019, more than 36,000 surgeries were performed in the hospital, among them 17% were orthopaedic surgeries. Due to the COVID-19 pandemic, 6406 surgeries (920 orthopaedic surgeries) were lost in the first six months in 2020, compared to the equivalent number in 2019. Indeed, the same monthly volume of surgeries (around 500 surgeries in the hospital per month in 2019) had been recovered in early June 2020, despite surgeons having assumed this would happen six months later (January of 2021). The clinicians regarded it as an incredible job.

 

Protocols have been followed to resume elective surgeries:

1) Carried out surgeries progressively and with caution

2) Carefully selected patients eligible for surgery by considering: COVID-19 exposure in 5 categories (Fineberg et al. NEJM. April 2020), age, American Society of Anaesthesiologists (ASA) scores, comorbidities, socio-professional situation, kind of surgery, and length of hospital stay.

3) A strategy for resuming in 4 phases (European Society of Sports Traumatology, Knee (ESSKA) guidelines Surgery & Arthroscopy)

4) Preoperative testing for SARS-CoV-2 is highly recommended 

5) Adapted personal protective equipment

The resuming of elective surgeries might be different in different areas or places in Spain. In Barcelona, hospitals were doing elective surgeries in May, June, and July. Among all patients who went through elective orthopaedic surgeries in Drs. Minguell and Guerra’s hospital, 0.5% of them were COVID-19 positive, and this number had been stable throughout May, June and July.

 

In surgical care, a set of strategies followed which include

1) test every patient for SARS-CoV-2 within 72 hours before a surgery,

2) schedule same day admission surgery, 

3) monitor patients’ symptoms, choose spinal anesthesia, avoid postoperative nausea and vomiting, provide thromboprophylaxis, and 

4) plan for post discharge care.

 

To mitigate impact of the second wave, the hospital followed local and national recommendations and implemented visitor restrictions and areas to maintain physical distance, arranged telematic visits, and organized radiological tests very strictly. Take Dr. Minguell’s schedule on August 6^th as an example, he had both face-to-face and telemedicine visits for his patients. More than 40% of the scheduled 39 morning visits were telematic.

4. Ongoing Health Strategies

Currently, it is recommended not more than 10 people have a gathering or meetings. It is an obligation to wear a mask for everybody. As the number of infected people increases, the restrictions should be stronger in the next few weeks.

 

Border policies are different in different areas, and will change depending on the emerging data on the spread of COVID-19. For example, it is advised to restrict tourists from Germany and England to Catalonia or to Balearic Islands. On the other hand, some European countries advise their citizens not to travel to Spain, and if they travel to Spain, they have to quarantine when they get back to their home countries.

General health recommendations include: 

- Social distancing

- Wearing masks

- Hands washing

- Reinforcing healthcare systems

- Increasing capacity of testing

- Identification and isolation of all infected cases

- Tracing all the people who have had contacts with infected cases

SENSE-MAKING

Drs. Guerra and Minguell shared the three periods of COVID-19 epidemic in Spain: gross pandemic (March and April), stable plateau (May and June) and the second wave (July and August). The second wave is characterized by fewer deaths, mild conditions, and lower rate of hospital and ICU admission. Younger individuals relaxed and are now accounting for the majority of new infections. Based on epidemic data and capacity of the hospital, elective surgeries were resumed in May. Strict protocols are followed to ensure best treatment for patients and protection of healthcare workers.