Recommendations Regarding Safety of Elective Surgery During COVID-19 Pandemic

Ariana Lott, MD and Kenneth L Urish MD, PhD, FAAOS

The COVID-19 pandemic continues to impact the care of orthopaedic patients across the United States. As the pandemic continues, there is an increasing number of patients that are now recovering from COVID-19. As hospitals and physicians continue to adapt, there are questions regarding how to proceed with elective surgery in patients following a prior diagnosis of COVID-19.

Following CDC guidelines, elective surgery should only be considered when your hospital and geographic area have the additional staff, capacity, and resources to support the care of COVID19 patients. Metrics may potentially include staffing availability, COVID-19 admission surges, and bed availability. Postponing elective surgery should be considered when these three metrics are met.

Current evidence suggests that the chance of contracting COVID-19 during admission from an elective procedure remains low with several studies reporting low rates of nosocomial infection. In an analysis of patients following elective procedures who were in COVID-19 units during the peak COVID-19 surge in New York City, the rate of nosocomial COVID-19 infection was 0-2%. Of note, these units were surrounded by COVID-19 units and as reported, there were many PPE shortages during this time2. Furthermore, a study of elective surgical patients during the initial COVID-19 surge in the United Kingdom between April and June 2020 demonstrated that only 1.4% developed COVID-19 positive status within the 30 day post-operative period resulting in a mortality rate of 0.2%3. Current evidence suggests that elective surgery is safe for patients with respect to transmission of COVID-19 when hospitals have existing capacity and resources.

For patients that have an ongoing COVID-19 infection, it is the recommendation of the AAOS that elective surgery is rescheduled. While there is no literature that defines precisely how long individuals should wait after a COVID-19 diagnosis prior to undergoing elective surgery, there are many studies demonstrating the increased morbidity and mortality of patients who undergo surgery while suffering from COVID-19. Several analyses of hip fracture patients highlight significantly greater rates of inpatient mortality in patients with COVID-19 compared to those who did not test positive for COVID-19. Reported a 35% inpatient mortality rate in hip fracture patients with confirmed COVID-19 compared to 7.1% in patients with suspected disease and 0.9% in patients who tested negative4. There was also an observed increase in length of stay, number of inpatient complications, and need for ventilator use. In a series of nearly 500 patients who underwent urgent and emergent surgical procedures, 7.7% tested positive for COVID-19 and had significantly higher perioperative mortality rates (16.7%) compared to those who tested negative (1.4%)5.

Following this logic, elective surgery should be postponed for individuals that have been exposed to COVID-19 via close contact, a positive family member, or a cohabitant. As CDC guidelines recommend self-quarantine and symptomatic monitoring during a period from 48 hours before symptoms onset until that person meets criteria for discontinuing home isolation, elective surgery should be deferred during this time period.

Given this clear increased risk of morbidity and mortality in patients, it remains our recommendation that universal screening of patients who are admitted to the hospital and those who require elective surgery should be considered when testing is available. Screening allows for the detection of asymptomatic patients who are infected for COVID-19 to reduce the risk of transmission and worse outcomes both to the patient in addition to the hospital staff taking care of them. This is important as COVID-19 becomes more endemic in the United States. In an analysis of patients who underwent routine testing for COVID-19 prior to a planned orthopaedic procedure, 12.1% of patients tested positive of which 58.3% were asymptomatic7. In addition, the chance of not identifying an asymptomatic patient with COVID-19 who inadvertently has elective orthopedic surgery is very low (1/7,000) using the specificity/sensitivity rates of the testing in addition to disease prevalence rates6.

There are three strategies, based on CDC recommendations, to determine when positive COVID-19 patients are no longer infectious based on symptoms, time, and testing. For a symptoms-based strategy, there needs to be at least 24 hours without fever, improvement in symptoms, and at least 10 days have passed since symptoms first appeared. In a time-based approach, there needs to be a minimum of at least 10 days since the first positive COVID-19 diagnostic test8,9,10. In a testing-based approach, a negative diagnostic test will confirm recovery from infection. Although an accurate criterion to confirm the absence of infection, many institutions do not use this strategy to clear a COVID-19 patient. PCR COVID-19 tests may remain positive for an extended time period (60 days or more) after a patient has recovered. Time and symptom-based criteria provides an evidence-based approach to safely proceed with surgery.

The COVID-19 pandemic has added an additional layer of risk that needs to be considered for safe elective orthopaedic procedures. Similar to other surgical comorbidities, risk cannot be eliminated, but it can be minimized. As compared to the initial stage of the pandemic, although limited, there is substantially more literature and physician experience at minimizing this risk. Current available evidence and experience suggest that elective surgery can be safe with the proper precautions.

References

  1. Centers for Disease Control. Duration of Isolation and Precautions for Adults with COVID-19. 2020.
    https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
  2. Hastie J, Sutherland L, Takayama H, et al. Low rate of health care-associated transmission of coronovirus disease 2019 (COVID-19) in the epicenter. J Thorac Cardiovasc Surg. 2020 Aug 15. [Epub ahead of print]
  3. Kane A D, Paterson J, Pokhrel S, et al. Peri-operative COVID-19 infection in urgent elective surgery during a pandemic surge period: a retrospective observational cohort study. Anesthesia. 2020 Dec;75(12):1596-1604.
  4. Egol KA, Konda SK, Bird ML, et al. Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective. J Orthop Trauma. 2020 Aug;34(8):395-402.
  5. Knisely A, Zhou Z, Wu J, et al. Perioperative Morbidity and Mortality of Patients With COVID19 Who Undergo Urgent and Emergent Surgical Procedures. Ann Surg. 2020 Oct 14. Online ahead of print.
  6. Kader N, Clement ND, Patel VR, et al. The theoretical mortality risk of an asymptomatic patient with a negative SARS-CoV-2 test developing COVID-19 following elective orthopaedic surgery. Bone Joint J. 2020 Sep;102-B(9):1256-1260.
  7. Gruskay JA, Dvorzhinskiy A, Konnaris MA, et al. Universal Testing for COVID-19 in Essential Orthopaedic Surgery Reveals a High Percentage of Asymptomatic Infections. J Bone Joint Surg Am. 2020 Aug 19;102(16):1379-1388.
  8. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR, et al. Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility. N Engl J Med 2020 May 28;382(22):2081-2090.
  9. Bullard J, Durst K, Funk D, Strong JE, Alexander D, Garnett L et al. Predicting Infectious SARSCoV-2 From Diagnostic Samples. Clin Infect Dis 2020 May 22.
  10. Wölfel R, Corman VM, Guggemos W, Seilmaier M, Zange S, Müller MA, et al. Virological assessment of hospitalized patients with COVID-2019. Nature 2020 May;581(7809):465-469.