|Year : 2021 | Volume
| Issue : 2 | Page : 136-143
Experience of Orthopedic Surgeons Managing COVID Patients at the Peak of Second Wave in a COVID-dedicated Hospital: A Guidance for Future Waves
Sumit Sural, Tarun Suri, Yasim Khan, Pankaj Yadav, Abhay Meena, Rajeev Yadav, Lalit Maini, Vinod Kumar
Department of Orthopaedics Surgery, Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, India
|Date of Submission||02-Jul-2021|
|Date of Decision||02-Aug-2021|
|Date of Acceptance||05-Aug-2021|
|Date of Web Publication||27-Aug-2021|
Dr. Yasim Khan
Department of Orthopaedics Surgery, HN-72 VPO Nangal Thakran, Delhi 110039
Source of Support: None, Conflict of Interest: None
Introduction: The second wave of the severe acute respiratory syndrome coronavirus-2 pandemic in April 2021 had a sudden deluge of moderate to severe patients getting admitted to the orthopedics block, due to scarcity of beds in the medical wards, high dependency and intensive care areas of the hospital. This study is an analysis of these patients managed in the orthopedics block by orthopedic surgeons, which may be useful to formulate guidelines for the management of patients in future waves of the coronavirus disease 2019 (COVID-19) pandemic. Methods: The data of patients were collected by orthopedic residents from the Google sheet which was uploaded daily as part of the hospital data. The data from Google sheet were downloaded and compiled into an excel workbook and analyzed for patient progress, outcome, comorbidities, treatment given, oxygen management, and death analysis. Results: The data of 319 patients admitted from April 17, 2021 to May 20, 2021 in orthopedic block depicted successful recovery and discharge of 160 patients, worsening and transfer to higher wards for 126 patients and 33 deaths. The average age of these patients was 53.43 years with male preponderance (71% male). At the time of admission, 78.05% were reverse transcription polymerase chain reaction/rapid antigen test positive and 21.9% were COVID suspects. The patient’s disease status on arrival was found to be mild in 21.3%, moderate in 43.8%, and severe in 34.7%. The most common comorbidity was hypertension in 39 patients followed by diabetes in 29 patients. The average number of days of hospital stay was 5.48 days. Conclusion: Medical professionals other than critical care medicine can be frontline care providers who can guide the ancillary departments at the peak of pandemic waves. Adherence to the standard operating protocols and interdepartmental coordination need to be effectively managed. This study can be used to formulate guidelines for further improvement in COVID patient care in case of future waves of this pandemic.
Keywords: Coronavirus infection, coronavirus pandemic, COVID-19, orthopedic surgeons, public health
|How to cite this article:|
Sural S, Suri T, Khan Y, Yadav P, Meena A, Yadav R, Maini L, Kumar V. Experience of Orthopedic Surgeons Managing COVID Patients at the Peak of Second Wave in a COVID-dedicated Hospital: A Guidance for Future Waves. MAMC J Med Sci 2021;7:136-43
|How to cite this URL:|
Sural S, Suri T, Khan Y, Yadav P, Meena A, Yadav R, Maini L, Kumar V. Experience of Orthopedic Surgeons Managing COVID Patients at the Peak of Second Wave in a COVID-dedicated Hospital: A Guidance for Future Waves. MAMC J Med Sci [serial online] 2021 [cited 2021 Dec 6];7:136-43. Available from: https://www.mamcjms.in/text.asp?2021/7/2/136/324743
| Introduction|| |
Coronavirus disease 2019 (COVID-19) disease is a global threat to human life. Developing countries are struggling with their health care system on the verge of a break. COVID-19 disease caused by the single-stranded RNA virus, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), had a profound impact on daily lives, with over one-third of the global population in “lockdown” as the world battles to contain the pandemic. As of June 20, 2021, 178,960,779 people were reported to have been affected worldwide with over 3,875,601 reported deaths. All healthcare workers are working in collaboration to deliver the best care to patients. Orthopedic surgeons are also managing these patients to support their hospitals at such a crucial time. Our dedicated COVID tertiary care medical college hospital, the largest of the state government, faced the forefront of the second major COVID-19 wave of the entire national capital region of Delhi. Many challenges like oxygen management, manpower management, hospital beds, and shifting of critically sick patients were faced during this wave. This retrospective analysis of data collected during the second wave is useful to guide and prepare for any forthcoming COVID-19 waves in the near future. A proactive ongoing team effort during this period based on data collection and analysis helped to modify our practice to improve patient care and the overall outcome of our system. The data were presented in a departmental meeting to formulate a standard of practice and guidelines for forthcoming COVID-19 waves. Medical professionals other than critical care medicine can also support other departments of their hospitals to manage patients with COVID during the peak of the pandemic.
| Materials and Methods|| |
Our country went through the first major COVID wave from April 27, 2020 to November 29, 2020. The first wave curve flattened after the maximum number of new cases reached up to 100,000 per day. However, during the second major COVID wave from March 5, 2021 till June, the maximum number of new cases reached up to 400,000 per day. In the second wave, the number of new cases per day spiked within a very short period, which necessitated the involvement of all the resources of the dedicated COVID hospital to work and coordinate at their optimum performance. Our orthopedic block, which was designated for mild cases in the previous wave, started receiving moderate to severe patients with COVID from April 17, 2021 on an urgent basis.
A Google sheet was made to compile the COVID-19 patient data of the whole hospital. This Google sheet was updated on daily basis by the residents of respective wards after rounds. This sheet was shared with the hospital help desk to inform patients’ attendants about the current patient’s status. The data were collected from patients with COVID-19 admitted during the major second wave from April 17, 2021 to May 20, 2021 in the orthopedic block. Orthopedic residents collected the data retrospectively from the Google sheet uploaded by the department of orthopedics for the hospital data. The details of the patients including the vitals and clinical status were uploaded daily on the Google sheet during the pandemic period. We used the version history tab in Google sheet to access the data of backdates (Google sheet>File>Version history>See version history>>version history scrolled date and time-wise) [Figure 1]. The data for this study were selected from the Google sheet data reflected daily at 8.00 pm, for the said period and imported into Microsoft Excel workbook-1. The excel workbook-1 data were entered date-wise in the four wards located in four separate wings on two floors of the orthopedic block. The data were collected on four sheets (four wings), which was then sorted alphabetically name wise over each of the four sheets. This created four excel sheets showing daily data of each patient in subsequent rows of the excel workbook-1. The data from excel workbook-1 were used to fill excel workbook-2 containing data of all patients, with the predefined columns required to generate useful inferences [Figure 2]. The collected data were analyzed for age, gender, reverse transcription polymerase chain reaction (RT-PCR) status, comorbidities, treatment given, SPO2 at time of admission, serial SPO2 during stay and hospital stay duration. Excel workbook-2 was thoroughly analyzed for extracting meaningful inferences to help us improve patient care and outcomes in forthcoming waves of the COVID-19 pandemic in our facility. The patients admitted with orthopedic injuries were also analyzed.
|Figure 1 Image showing Google sheet with used tabs to get the data from back dates.|
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|Figure 2 Flow chart showing the methodology of data collection for the study.|
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The case records of all the patients admitted in the designated COVID orthopedics block who expired from April 17, 2021 to May 20, 2021 had previously been scanned and stored in the form of a PDF document. There were 31 PDF documents available out of the total 33 deaths. These documents were analyzed including the details of their vaccination status. Indian Council of Medical Research (ICMR) guidelines were used to classify patients in mild, moderate, and severe clinical severity of COVID-19 disease. Patients were considered positive if the report of RT-PCR came positive for SARS-CoV-2 RNA. The treatment guidelines were based on the recommendations from the All-India Institute of Medical Sciences Delhi. The patients were discharged as per revised criteria by the ministry of health. To help us in tracking the progress of the patient’s clinical course to guide us in further management, we made a patient progress sheet which also served as a reference while transferring and discharging patients [Figure 3]. The oxygen consumption sheet was made for guiding us, on the oxygen requirement of each wing and of the total block [Figure 4]. This sheet was also useful for detecting and refilling the empty oxygen cylinders in time, since some of the cylinders were getting empty in an erratic time frame. The data collected during this second wave was continuously analyzed on a daily basis to iron out the problem area and the authors are of the opinion that this may be useful to make standard operational protocol and preparations for the next wave of patients with COVID. Informed consent was obtained from patients for publication of data with approval from departmental board.
|Figure 3 Progress sheets used to track patient’s clinical course to guide us in further management and transferring patients to higher wards.|
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|Figure 4 The oxygen consumption sheet used to calculate the oxygen requirement of each wing and the total block.|
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| Results|| |
We managed 319 patients of COVID-19 in the orthopedic block from April 17, 2021 to May 20, 2021. The average age of these patients was 53.43 years (range 14–89 years) with a predominance 227/319 (71%) of male patients. At the time of admission, 249/319 (78.05%) were RT-PCR/rapid antigen test positive and 70/319 (21.9%) were COVID suspects. The average SPO2 at the time of presentation was 91.52%. At the time of admission in the hospital emergency, the COVID severity status was mostly moderate to severe (78.5%) with 140/319 (43.8%) being moderate and 111/319 (34.7%) severe, whereas only 68/319 (21.3%) were mild. As per the hospital protocol, the patients who were not maintaining oxygen saturation above 90% with non-re-breathable mask (NRM) at 15 l/minute of oxygen were transferred to a higher level of care wards having the availability of bilevel positive airway pressure machine or ventilator support. Out of the 319 patients admitted in the orthopedics block, 126 patients (39.5%) were transferred to a higher level of care high dependency units (HDU) and intensive care units (ICUs). A total of 160 patients out of 319 patients (50.15%) were discharged after improvement, as per the guidelines of the ICMR [Figure 5].
|Figure 5 Flow chart showing the clinical status of 319 patients admitted to orthopedic block and their final outcome.|
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The most common comorbidity was hypertension (HTN) in 39/319 (12.2%) patients followed by diabetes (DM) in 29/319 (9%) patients. The most common dual comorbidity was HTN + DM in 31/319 (9.7%) patients [Figure 6]. Patients with mild COVID disease were given Cat-A treatment, whereas patients with moderate to severe clinically were given Cat-B treatment [Figure 7].
|Figure 6 Graph showing the comorbidities of total patients admitted to orthopedic block (n = 319) and comorbidities in mortality group of patients (n = 31).|
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|Figure 7 Treatment categories used for efficient management of patients with coronavirus disease 2019.|
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Oxygen delivery methods available in the orthopedic block were oxygen concentrators and oxygen cylinders with the use of nasal cannula and NRM. At the time of admission in the orthopedics block, 201/319 (63%) patients were kept on oxygen cylinder with different flow rates, 62/319 (19.4%) patients were on oxygen concentrator, whereas only 56/319 (17.5%) patients were maintaining saturation at room air.
Among the patients on oxygen cylinder, 40/201 (20%) were on 5 l/minute, 89/201 (44%) were on 10 l/minute, and 72/201 (36%) were on 15 l/minute at the time of admission in orthopedics block.
The average number of days of hospital stay was 5.48 days.
Death files data subgroup
Out of the 33 deaths during this period, the files of 31 were available for analysis. The average age of these patients was 60.9 years, 19/31(61.2%) patients were more than 60 years of age. The severity of the disease of these patients at the time of admission to the orthopedic block revealed that the majority 27/31 (87%) had severe and the rest 4/31 (13%) had moderate COVID. All of these patients were given the standard treatment of steroids, enoxaparin along with oxygen at 15 l/minute via NRM. The majority of these patients 15/31 (48%) had no known comorbidities, 7/31 (22.5%) patients had HTN + DM [Figure 6]. The progression of desaturation was sudden in 18/31 (58%) patients and gradual in 13/31(41.9%) patients.
Among the deaths, 18/31 (58%) patients expired on the first day of admission, 7/31(22.5%) on the sixth day, 5/31 (16.1%) patients on the fifth day, and 1/31 (3.2%) patient on the second day. The majority of the deaths 28/31 (90.3%) occurred during the period April 17 to 30. Out of these patients, 18/31 (58%) died in the first week from the onset of symptoms and 13/31 (41.9%) died in the second week from the onset of symptoms.
Out of the total death in the orthopedic block, 18/33 (54.5%) died in the first week, 10/33 (30.3%) in the second week, 4/33 (12.1%) in the third week, and 1/33 (3%) in the last 2 weeks. The average SPO2 at the time of admission in orthopedics block was 76% on room air and 87% after giving oxygen at 15 l/minute using NRM.
Orthopedic injuries subgroup
There were only 8/319 (2.5%) patients of COVID-19 disease with an orthopedic ailment during this period and all of them had mild disease. The management of these patients was guided by recommendations of ICMR, Ministry of Health and Family Welfare, GOI and Indian Orthopaedic Association. Only 1/319 (0.3%) patient needed surgical intervention in the form of below-knee amputation in a traumatic crush injury of the leg.
| Discussion|| |
The management of severely ill patients with COVID-19 is a challenge for orthopedic surgeons. During the major second COVID wave, 319 patients were managed in the designated COVID orthopedic block by orthopedic surgeons. During the previous COVID-19 wave of 2020, we managed mild cases with occasional moderate COVID cases. In this second wave of the pandemic, the orthopedics block was prepared for managing mild and moderate patients with COVID-19 to support the designated fully COVID hospital of the state government. Patients were shifted from the main COVID patients receiving area of the emergency department to the orthopedics block after primary stabilization. The hospital protocol was to transfer patients to the orthopedics block only if they were maintaining oxygen saturation of more than 90%, whereas patients with saturation less than 90% with multiple comorbidities were supposed to be admitted to ICU and other higher level of care wards of the hospital. However, there was a deluge of patients thronging the hospital during the peak of the pandemic and this resulted in 140/319 (48.3%) of patients admitted in the orthopedic block being in the moderate, 111/319 (43.8%) to severe category. We made a special sheet to track the progress of the patient’s clinical course to guide us in further management [Figure 3].
The COVID orthopedics block audit revealed that the average age of these patients was 53.43 years (range 14–89 years). Most of the elderly patients with multiple comorbidities were not admitted to the orthopedics block. The majority 227/319 (71%) patients admitted were males. The reason for this was the availability of 77/106 (72.6%) beds for male patients versus only 29/106 (27.3%) beds for female patients distributed in two different wings of two floors of the orthopedics block with only one dedicated wing for female patients. It was decided because of the higher admission rates for male patients in our hospital and literature also., On admission 70/319 (21.9%) patients were COVID-19 suspects, a color coding of files was carried out to identify these patients for sending RT-PCR and subsequent follow-up of their reports detected all of them to be RT-PCR positive.
The orthopedics block was equipped only with oxygen cylinders and the patients were using either nasal cannula or NRM without the facility of high flow. The patients were transferred from the main casualty area on a trolley with nursing orderlies, it takes around 15 minutes to cover this 300-m track. The average SPO2 at presentation was 91.52%, which can be improved if the patients are transported on proper oxygen support with NRM and being cautious about the risk of sudden desaturation of patients while transferring.
Patients were given treatment as per their disease status. Patients with mild symptoms were given Cat-A treatment and patients with moderate to severe disease were given Cat-B treatment. Almost 80% of patients were given Cat-B treatment. Steroids, enoxaparin, and budesonide nebulization were the mainstays for treating moderate patients.
Special drugs like remdesivir were used only in two patients. Although remdesivir was being rampantly used during this wave of the pandemic, the orthopedics department deliberated regarding its administration in the patients admitted in orthopedics block. There was no convincing benefit of this medicine in available literature; moreover, it needed normal hepatic and renal parameters. In view of the large number of patients who would require extra monitoring, it was decided to focus on taking care of sick patients with standard of care treatment in the absence of medicine residents posted in orthopedic block. Later guidelines also recommended against the use of remdesivir for COVID treatment.,,
The HTN and DM were the most commonly associated comorbidities. Patients who were already on hypertensive drugs needed an arrangement of drugs and referrals for adequate blood pressure control. Patients on insulin required special monitoring due to the fluctuating and high blood sugars levels, a result of steroid therapy. Patients having diabetic ketoacidosis were managed with help of telephonic consultation with medicine resident doctors on duty.
Provision of oxygen management was a big challenge in the orthopedic block in the absence of a functional oxygen pipeline central supply. The four wings in the two floors of the orthopedics block were equipped with 88 oxygen concentrators and 105 oxygen cylinders (B type). At the time of admission, 201/319 (63%) patients required oxygen cylinders for maintaining SPO2 with different flow rates delivered by NRM. A high flow rate of 15 l/minute was required in 72/201 (36%), 10 l/minute was required in 89/201 (44%), and 40/201 (20%) required 5 l/minute. To calculate the oxygen demand of the block, we made a sheet of each wing, in which we grouped patients as per oxygen requirement [Figure 4]. Patients on room air and maintaining saturation were considered for discharge. Patients requiring high oxygen flow rates were high-risk patients, which required more attention and the possible need for transfer to higher wards.
On the assessment of the clinical course of these 319 patients [Figure 5], it was observed that the 68 patients who were mild at the time of admission deteriorated to moderate status and among them, two patients died. Out of 140 moderate patients, 68 were discharged, 63 were transferred to ICU or higher level of care wards, and 9 patients passed away in the orthopedic block.
Out of the 111 patients with severe COVID status, 26 were discharged, 63 were transferred to ICU or HDU, and 22 died. Thus, among the moderate and severe group of patients, 126/319 patients could be transferred to a higher level of care wards and ICU having high flow oxygen and ventilatory support, whereas 33/319 patients expired. Most of these patients who expired were in the initial part of this wave of the pandemic. The very first day of admission of patients in the orthopedics block itself had 18 deaths. There were 18 deaths in the first week, 10 deaths in the second week, and 5 deaths in the last 3 weeks. The increasing number of deaths in the first 2 weeks was a reflection of the overcrowding in the designated COVID hospital and absence of beds in the ICU and wards with facilities of high and low oxygen, though many of these patients with severe COVID may have succumbed in the ICU due to their comorbidities. The higher mortality in the first 2 weeks also coincides with the peak of the second COVID wave which jolted our healthcare system. The in-hospital mortality rate was 22/111 (19.8%) in severe patients admitted to our orthopedic block which is lower than the reported rate of 241/800 (30.1%) by Martinez et al., where the severe patients were managed by specialist doctors.
Out of 33, 18 patients had sudden desaturation with no response time for help from higher wards. Management of these patients was a challenge for us. For any future forthcoming COVID-19 waves, the department of orthopedics recommends the provision of an oxygen pipeline and the creation of HDUs and ICU in the orthopedics block. There is also a need for the availability of a multispecialty team consisting of anesthesiology and critical care specialist and medicine specialist to care for the severe COVID cases and the other patients whose disease status worsen from moderate to severe.
The authors thank every healthcare member of the orthopedics block and the Lok Nayak Hospital for the management of the patients with COVID. The authors acknowledge the help of Dr Lokesh, Dr Sagar, Dr Saurabh Arora, and Dr Saurabh Garhia for collecting the data from the Google sheet to the Excel workbook-1.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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