Journal of Orthopaedic Diseases and Traumatology

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 4  |  Issue : 2  |  Page : 20--25

An online survey to assess preparedness among orthopedic professionals toward resuming practice amid the COVID-19 pandemic


Sudeep Kumar1, Anup Kumar1, K V Charan Teja1, Mohammed Roshen Abdul Razek1, Alapati Hari Venkata Bramesh1, Ravi Kumar2,  
1 Department of Orthopaedics, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Orthopaedics, NMCH, Patna, Bihar, India

Correspondence Address:
Dr. Sudeep Kumar
Additional Professor, Department of Orthopaedics, AIIMS, Patna, Bihar
India

Abstract

As the world has taken a hit in this COVID-19 pandemic started in 2019 and widely recognized and tackled in 2020, we orthopedic surgeons too have faced many challenges and are trying to cope with the new normal. India being a developing country with various geopolitical and economical differences in this country, it was important for us to understand the preparedness of orthopedic surgeons in this part of the world. We wanted to know and understand what are the protective equipment they are looking for before they take any patient, what is the level and frequency of testing (for COVID-19) that they are doing, and how their practice has been modified in anyways.



How to cite this article:
Kumar S, Kumar A, Teja K V, Razek MR, Bramesh AH, Kumar R. An online survey to assess preparedness among orthopedic professionals toward resuming practice amid the COVID-19 pandemic.J Orthop Dis Traumatol 2021;4:20-25


How to cite this URL:
Kumar S, Kumar A, Teja K V, Razek MR, Bramesh AH, Kumar R. An online survey to assess preparedness among orthopedic professionals toward resuming practice amid the COVID-19 pandemic. J Orthop Dis Traumatol [serial online] 2021 [cited 2021 Nov 30 ];4:20-25
Available from: https://www.jodt.org/text.asp?2021/4/2/20/324594


Full Text



 Introduction



COVID-19 pandemic undoubtedly has changed the way medical professionals' practice. Among the surgeons, orthopedic practitioners are known to be notoriously conscious of hand hygiene and sterile surgical techniques in comparison to others. It is to be noted that most of these stringent practices evolved in an effort to protect the patient from infections and focus very little on the safety of the surgeon. Even after COVID-19 being declared as pandemic by the World Health Organization on March 11, 2020[1] and months have passed, there is no clear explanation as to how the virus transmits. Many studies have proven it to be airborne, aerosol borne, and few describe transmission through fomites.[2],[3] As of now, the only effective methods advocated by various authorities for medical professionals are to use personal protective equipment and social distancing.[4] With too many uncertainties and with vaccination drives at a nascent stage the world is trying to restore normalcy and to stay safe, there is a need to modify our prepandemic practices at every step to protect the surgeon and the supportive staff even after vaccination.

Orthopedic practice is riddled with a new set of challenges now as we deal with acute trauma situations which involve predominantly younger population who might be active in the community and have chances of being infected, and there is the old population with multiple comorbidities needing electively planned surgeries for their long-standing ailments such as total joint replacement arthroplasties which will significantly expose them to the chance of getting infected if there are any lapses during their hospital stay. There are numerous other such scenarios that we encounter once we start resuming practice.

To assess how prepared the orthopedic professionals are to face the challenges and how the pandemic has changed their practices, we have made this online form and circulated it among the closed groups of orthopedic surgeons. They were assessed on the basis of how aware they are about the pandemic, what all changes they are expected to do for future practice, and what all changes they have accepted already. Everyone is given an option to stay anonymous and everyone had a section to share about the new techniques, they have adopted and wanted to share with the community for benefit of everyone.

Abbreviations

WHO: World Health Organization; CDC: Centers for Disease Prevention and Control; OPD: out patient department; PPE: Personal Protection Equipment; HCQ: Hydroxychloroquine.

 Materials and Methods



Methodology

Google Forms platform was used to share the questionnaire and the questionnaire had sections for collecting the demographic details, nature of their practice, awareness about transmission, and effective ways of preventing transmission. An additional section was made where they could share their methods which they deem fit and helpful for the community at large when implemented. We also assessed their contributions through studies and case reports during the pandemic.

Study tools

Survey development and sharing

Survey was developed and uploaded to Google Forms and invitation link for filling the survey was shared online through various established groups comprising orthopedic professionals using E-mails, WhatsApp™, Facebook™, etc., Participants could share the link among their personal contacts who were involved in active orthopedic practice at that time.

Data privacy

After the description and informed consent part, all the participants were informed that their data will be anonymous and will be used solely for the purpose of research. No names or contact information of the participants was requested as part of the survey and the responses by the participants were kept confidential in terms with Google's privacy policy (https://policies.google.com/privacy? hl = en).

Questionnaire

the questionnaire shared contained 20 questions covering multiple aspects such as the demography of the participants, screening practices and outpatient department (OPD) setups, procedure they are doing and protection they have implemented for self-employees and fellow employees, their adherence to the guidelines, and prophylaxis and research activities they are working on. Questions were presented without subdivisions for simplicity and ease of filling by participants. A copy of the questionnaire can be found at (https://forms.gle/6fScBwipc6bWJXkp9).

Statistical analysis

Data entered in Google Forms and the responses were exported to Google spreadsheets for analyzing.

 Results



We included the responses obtained by us in the 3-week time after sharing the invite link for the questionnaire and we were able to get 255 complete entries following which the responses were halted for the link. The results were analyzed into the following subsections.

Demography

Gathered responses were mostly from urban areas 84.7% and the remaining were from rural areas 15.3% and majority were from resident doctors 56.9%, private practitioners 18%, faculty 15.3%, and others 9.8%, with most of the participants working in government setup (65.1%), followed by personal clinics (18%), and other places of work (16.9%). Entries represented participants from 21 states and UTs of India with majority from Bihar (40%), West Bengal: 9.8%, and Tamil Nadu: 4.7% [Figure 1].{Figure 1}

Screening and outpatient department setups

When given the choices to pick multiple screening strategies, majority of the participants wanted to do thermal screening of all patients before entry into OPD (59.2%).

Around 51.8% of respondents wanted to assume that every patient to be infective and stay at their guard all the time and the same proportion of doctors wanted to implement questionnaire screening of patients.

Eighteen percent wanted to do rapid antigen testing for all patients before letting entry inside the OPD.

Other measures taken by the participants included implementing social distancing norms by 73.7% and 70.2% had limited the appointments for patients and attendants to decrease the footfall in OPD to curb transmission.

Only 10% had designated donning and doffing areas in OPD setup and 9.4% adopted negative pressure offices in OPD [Figure 2].{Figure 2}

Outpatient department procedures

Most doctors preferred using appropriate screens and drapes for isolation while doing minor procedures in OPD 45.9% and 33.3% preferred to do procedures only if they are absolutely indicated therapeutically.

About 21.2% did not prefer to do diagnostic procedures in OPD which can be confirmed with radiological findings instead, while 19.6% were ready to perform with a recent negative COVID report.

Odds ratio procedures

Majority of the surgeons (46.7%) were ready to do only emergent/trauma cases, while 36.1% were ready to do any surgery. About 7.8% of surgeons preferred doing only planned elective cases with proper screening and negative COVID-19 reports [Figure 3].{Figure 3}

Awareness about aerosols and draping

Awareness regarding aerosol-generating procedures was present in 44.3% of the participants and they had always taken precautions, while 36.5% were aware of the procedures but never took any extra steps in the past and were willing to change the practice in view of COVID-19.

About 14.5% of the surgeons were not aware of the kind of procedures that can generate aerosols before the pandemic.

Draping practice was very diverse before the pandemic with 44.3% using a mixture of disposable sterile drapes and linen reusable drapes. About 14.1% of the participants used all reusable drapes (linen drapes).

About 15.7% had practice of using disposable gowns only for the scrub team, while another 15.3% were using only for the surgeon [Figure 4].{Figure 4}

Personal protection

About one in four (25%) of the participants wanted personal protection equipment (PPE) for every patient contact (27.5%), while about half of them preferred PPE for aerosol-generating procedures only, regardless of the patient infectivity status.

Everyone wanted PPE while managing laboratory-confirmed COVID-19 cases.

The scenario in the operating room was different with about 32.2% wanting full-spectrum Level 3 PPE for all the cases, while half of the participants preferred using Level 2 PPE for COVID-19-negative cases and reserved full Level 3 PPE for confirmed cases.

While operating on COVID-negative patients, few preferred to follow the old methods of draping with surgical masks (5.9%) or with advanced mask N95 (12.9%). About 9% of the surgeons preferred using powered air-purifying respirators for lengthy surgeries. Eleven percent considered double draping to minimize aerosol generation [Figure 5].{Figure 5}

Measures taken for the protection of fellows and employees

Most of the faculty or consultants were ready to allow their residents and fellows in all surgeries with adequate training and appropriate precautions 42.6%. A quarter of them preferred allowing them in only cases with COVID-negative reports. About 26.1% preferred to live relay the surgery or record it for their trainees instead of allowing them in the odds ratio (OR) whenever possible.

In regard to testing of employees and trainees, about half of the respondents were ready to test if exposed to a case of COVID-19 without PPE regardless of symptoms (52.2%), 50.6% were testing only if symptomatic, and 26.3% were letting anyone getting anyone tested on their discretion.

Treatment preference

In case of inadvertently contracting COVID-19 most of the participants (40.4%) would get treated at the government-designated dedicated hospitals treating COVID-19.

The next majority (36.5%) entrusted private setups treating COVID and 17.6% followed employer's protocol.

Only 5.5% preferred telemedicine consultation for self-management [Figure 6].{Figure 6}

Guidelines and prophylaxis

Majority of the participants 69.4% are already taking or willing to take Prophylaxis Hydroxychloroquine (HCQ) as per Indian Council of Medical Research (ICMR) guidelines and among them, 32.9% were concerned about side effect profile and preferred baseline investigations before starting prophylaxis.

About 21.2% of the participants are not in active practice currently due to COVID and will start prophylaxis on resuming work.

About 9.4% did not prefer preexposure prophylaxis and were ready to take only if they get exposed to COVID-19.

With regard to these new changes adopted during COVID times, 40.8% are preferring to continue following them till further government guidelines and 22.7% will follow them till the vaccination program is started. About 27.1% of participants wanted to adhere to these new normal practices till there are no new cases in their state [Figure 7].{Figure 7}

Research work in COVID time

Majority of the participants are not working on any research activities (74.6%), while 13.5% worked on a single project and 6.7% worked on multiple projects. About 4% were in the process of materializing their project ideas which they will start working on eventually.

Only few contributed to literature by publishing their research work, 5.1% published a single work, 6.7% published multiple projects, while 87.7% were unable to publish anything.

 Discussion



Even though research on COVID-19 is very actively undertaken, the relevant information we have obtained is very uncertain and even contradictory from each study. We decided to discuss the published literature relevant to the context of our survey and proven facts which are the need of the hour. COVID as a disease is rapidly evolving and new findings being obtained from studies daily, the guidelines from the World Health Organization (WHO) or other relevant authorities and screening protocols are subjected to change regularly and its imperative to keep ourselves updated with the latest changes.

It is important to understand various practices and methods used by various orthopedic surgeons in the country in these challenging times. In countries with community spread scenarios, there is an increased risk of asymptomatic carriers[5] and these asymptomatic carriers pose the highest risk to the community and the health care as any lapses in following protocols when it comes to these seemingly normal individuals will jeopardize the whole system. The symptoms of COVID-19 have the broadest spectrum and new and odd symptoms are being added on regularly. It is found that loss of smell and taste is one of the earliest features of the disease and should not be taken lightly. In the guidelines of centers for disease prevention and control framed by Patel and Jernigan,[6] they suggested routine testing of all patients before any surgery due to the risk of asymptomatic carriers.

Even though there is no evidence yet that COVID-19 can disseminate through blood, there is convincing evidence that SARS CoV1 particles were identified in blood.[7] And since most orthopedic procedures undertaken will generate aerosols in one form or other carrying blood particles, absolute caution and precautions must be taken to either minimize the aerosols generation or to protect the surgical team from getting exposed. Multiple steps in orthopedic surgery such as electrocautery, osteotomes, powered drills, and saws are known to generate aerosols.[8] Toga system (Gown + hood + positive pressure ventilation) which is essentially used by most orthopedic surgeons during arthroplasty can prevent the passage of small particles and it was used successfully during SARS.[9] The highest level of personal protection comprises powered air-purifying respirator (PAPR)/N95 along with face shield, goggles, isolation gown, gloves, and boot covers. Professionals should be well versed with the fit tests for N95 or other respirators. Persons with excess facial hair, especially over the seal zones of these masks, will fail the fit test, they can instead adopt to shorter trimming or consider using PAPRs which do not depend on the fit.

It was clear from our responses that majority of the respondents will be doing thermal screening which may lead to a deceptive feeling of false security in case of asymptomatic carriers or asymptomatic infections. Although half of our respondents would suspect every patient being treated as a positive case and wound screen and protect themselves and their colleagues accordingly. Wearing PPE is an important aspect in suspected or confirmed cases and it is important for the setup to have a separate donning and doffing area. Just wearing PPE is not enough a proper disposal is also important.[10] Responses from our questionnaires suggest that there are very few (10%) who understand this concept and have a separate designated donning and doffing areas. Our survey suggests that there is definitely a need for this awareness among orthopedic surgeons. Adoption of negative pressure rooms is also lower at 9.4%, it is a type of isolation room with an exhaust system attached to remove more air out of the room than being supplied to it and it essentially removes all the gases or contamination produced in a room outside through the exhaust and does not let anything out thorough the doors or windows. It is helpful in preventing the infection or aerosol originating in the room from spreading outside. Typical operating rooms are designed to operate under positive pressure which is focused more on preventing the outside air from entering inside.

The opinion of the surgeons was divided regarding type of surgeries they would do in this pandemic. Majority of the respondents have no restriction or discretion on the type of procedure (elective or emergency) they would do. They would though go for a negative COVID-19 antigen report before proceeding. The other group preferred postponing the elective surgery and continue doing emergency surgery with negative covid 19 antigen test report.

As per the aerosol-generating procedure and chances of generating aerosol in bone drilling and using cautery and prevention from it was concerned, it is very clear that around 15% respondents had no idea as to what can be aerosol-generating procedure and what could not be. It was also clear that though many (around one third) were aware of the aerosol generation and aerosol-generating procedure, they were not taking any specific precautions for this.

As per draping and gowning of patient and treating team was concerned, it was very diverse. None of the respondents were routinely using all the full spectrum of sterile and disposable drapes and gowns before pandemic. It was a mixture of sterile drapes, gowns only for surgeon, etc., It is important that all sterile and disposable drapes and gowns are used at all the times but especially during these COVID-19 times. It is needed to protect the surgeon and the team and patients from inadvertently acquiring COVID-19. It is also important that when we are using reusable sterile drapes and gowns, we are putting the employees who are involved in cleaning these drapes and gowns under high risk because they are least informed and not properly trained in most of the places in our part of the world.

A quarter of surgeons who responded seems to believe in restriction of entry to their theater area and would replay the surgeries live or record and then play it for their trainees. Another quarter of respondents would allow entry of trainees only in proven COVID-19-negative cases and not in positive cases. Almost 40% of the respondents would let their trained residents in the theater with adequate precautions irrespective of the COVID status. It is important to understand that the training, teaching, and setup of hospitals in our country are very varied. Thus, it is important for the consultant takes up the responsibility and minimize the risk to their trainee and supporting staffs. In this regard, it should be assessed individually about the understanding and level of the training and exposure of the resident before letting them in the theater on assisting in any procedure.

When it comes to getting the staff and trainees tested for COVID-19 after getting exposed unprotected, half of the respondents would get them tested irrespective of symptom present in them or not. While the other half would take a cautious approach and would test their employee and residents only when symptomatic.

In worst-case scenario if one gets infected with COVID-19 infection, majority (around 40%) would prefer a government-designated setup for admission. It seems a logical choice because majority of COVID management setups are government only and very few private setups are designated or are managing COVID patients, although a good 36% of respondents would prefer a private setup. There are some patients who would prefer for home isolation before taking decision for admission This too seems to be a reasonable choice because, at the peak of pandemic, there was a scarcity of COVID beds and asymptomatic patients with no respiratory symptoms can monitor themselves and manage at home with seeking admission only if the condition worsens. This would neither burden the health system unnecessarily nor would lead to a lack of beds for most needy patients in the worst scenarios.

As far as prophylaxis with HCQ was concerned, a vast majority had either taken or were considering taking the drugs as recommended by the ICMR. One third of respondents showed concern about the side effects.[11] Around a quarter of participants would consider taking prophylaxis once they resume active practice. Probably, they are not exposed to any outside world and are maintaining bio-bubble among their family members, and hence, they chose to defer it till they resume public intermingling and interaction once their active practice resumes. Roughly 10% would consider taking prophylaxis if they are accidentally get exposed but before they develop symptoms. It is important to understand the wide variability in this situation arises from no clear consensus in literature as far as prophylaxis of any medication is concerned and their effectiveness. With WHO abandoning the solidarity trials of HCQ in admitted patients created little more uncertainty.[12]

Majority of the orthopedic surgeons have got a time off during this pandemic from their hectic work schedule and like most of the people from the general population orthopods also utilized it in a different way. When asked about publication, we saw two-third of our respondents were not involved in any research work or published any work during this time. Around 10% of respondents were involved in doing some research work. Around same number of respondents have also published their work.

 Conclusion and Future Perspectives



Our survey aimed to understand the perspective of orthopedic surgeons, their understanding about the disease and its dissemination, and the preparedness among them. We found that there is still a lot of scope to spread awareness regarding the spread of infection and its transmission, especially with respect to aerosol-generating procedure. The awareness among respondents was very less as for the matter that bone drilling and cutting with powered tools can spread aerosol containing virus or infective particle up to 6 m × 8 m essentially covering the entire OR space.[8]

There exists a clear lack of knowledge about understanding and importance of a proper designated area for donning and doffing of PPEs and their sequence. A clear confusion is present regarding screening of patients before any surgical procedure, and a nation-wise guideline is a must. Otherwise, patients will be harassed and safety of doctors will compromise in the treatment process.

It is high time that we make an effort to shift gradually from linen drapes and gowns (reusables) to fully disposables ones. Although it seems a costly affair in the beginning but in longer run, it would prove to be beneficial as this not only decreases the rates of surgical site infection but also saves a lot of money in future in terms of antibiotics and secondary procedure, which patients have to undergo after sustaining an infection after any orthopedics procedure. Needless to say that this pandemic era has given us an opportunity to make a change for good.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Listings of WHO's Response to COVID-19. Available from: https://www.who.int/news/item/29-06-2020-COVIDtimeline. [Last accessed on 2020 Dec 10].
2Zhou L, Yao M, Zhang X, Hu B, Li X, Chen H, et al. Breath-, air- and surface-borne SARS-CoV-2 in hospitals. J Aerosol Sci 2021;152:105693.
3Transmission of SARS-CoV-2: Implications for Infection Prevention Precautions. Available from: https://www.who.int/news-room/commentaries/detail/transmission-of-sars-cov-2-implications-for-infection-prevention-precautions. [Last accessed on 2020 Dec 10].
4Durmuş H, Gökler ME, Metintaş S. The effectiveness of community-based social distancing for mitigating the spread of the COVID-19 pandemic in turkey. J Prev Med Public Health 2020;53:397-404.
5Li C, Ji F, Wang L, Wang L, Hao J, Dai M, et al. Asymptomatic and human-to-human transmission of SARS-CoV-2 in a 2-family cluster, Xuzhou, China. Emerg Infect Dis 2020;26:1626-8.
6Patel A, Jernigan DB; 2019-nCoV CDC Response Team. Initial public health response and interim clinical guidance for the 2019 novel coronavirus outbreak – United States, December 31, 2019-February 4, 2020. Morb Mortal Wkly Rep 2020;69:140-6.
7Chang L, Yan Y, Wang L. Coronavirus disease 2019: Coronaviruses and blood safety. Transfus Med Rev 2020;34:75-80.<
8Nogler M, Lass-Flörl C, Wimmer C, Mayr E, Bach C, Ogon M. Contamination during removal of cement in revision hip arthroplasty. A cadaver study using ultrasound and high-speed cutters. J Bone Joint Surg Br 2003;85:436-9.
9Parker R. Summary Report StrykerT4 Surgical Helmet System Filtration Testing. Anonymous. 5-14-2003. StrykerTM Instruments. Available from: http://sars.medtau.org/strykerreport.doc.
10CDC. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention; 2020.Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html. [Last accessed on 2020 Dec 09].
11Dang A, Vallish BN, Dang S. Hydroxychloroquine and Remdesivir in COVID-19: A critical analysis of recent events. Indian J Med Ethics 2020;V: 202-7.
12Coronavirus Disease (COVID-19): Hydroxychloroquine. Available from: https://www.who.int/news-room/q-a-detail/coronavirus-disease-COVID-19-hydroxychloroquine. [Last accessed on 2020 Dec 10].