|Year : 2021 | Volume
| Issue : 2 | Page : 27-32
Changing practices of delivering orthopedic and coronavirus disease 2019 care: Outcome of a pan-India survey
Kumar Keshav1, Pulak Sharma1, Amit Kumar1, Anurag Baghel1, Kumar Kaustubh2, Najmul Huda3, Prabhaker Mishra4
1 Department of Orthopedics, Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
2 Department of Anesthesiology, Lady Hardinge Medical College, New Delhi, India
3 Department of Pediatric Orthopedics, King George's Medical University, Lucknow, India
4 Department of Biostatistics and Health Informatics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
|Date of Submission||22-May-2021|
|Date of Decision||02-Jun-2021|
|Date of Acceptance||19-Jun-2021|
|Date of Web Publication||02-Aug-2021|
Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Vrindavan Yojna, Lucknow - 226 029, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Purpose: Coronavirus disease 2019 (COVID-19) pandemic has caused severe disruption of services for other health-related ailments. This study was done to assess change in practices of orthopedic surgeons, availability of proper training and personal protective equipment (PPEs), and changes in hospital setup/preparedness for the management of COVID-19 patients. Materials and Methods: A pan-India online survey was done among practicing orthopedic surgeons. Orthopedicians not practicing in India, trainees, and those who had left their practice before the pandemic were excluded from the study. Survey MonkeyR questionnaire and Google FormsR were sent to 10,055 orthopedicians, during the 7th week of nationwide lockdown in the month of May, 2020. Complete responses were received from 407 participants who were included in the final analysis. Results: Only a quarter (n = 100/407, 24.6%) of the doctors were visiting hospitals at a frequency similar to that before the pandemic. Onus of orthopedic care among COVID-19 suspected/diagnosed cases and routine COVID-19 patients were mainly borne by the government sector. Only 38.8% (n = 158/407) doctors felt that they received adequate training while 64.9% (n = 264/407) of the doctors had adequate supply of PPE kits. “Designation of specific areas of their hospitals exclusively for COVID-19 patients” was opined by 43.7% (n = 178/407), urgent diagnostic facilities by 52.8% (n = 215/407), and exclusive operation theaters by only 28.3% (n = 115/407) of the respondents. Conclusion: This study has shown a drastic fall in the frequency of hospital visits by orthopedic surgeons, predominant involvement of government sector orthopedicians, inadequate training of doctors and inadequate availability of PPE kits, lack of proper designated areas, operation theaters, and urgent diagnostic facilities for the management of COVID-19 patients.
Keywords: Coronavirus disease 2019, orthopedic care, orthopedics, pandemic, practices
|How to cite this article:|
Keshav K, Sharma P, Kumar A, Baghel A, Kaustubh K, Huda N, Mishra P. Changing practices of delivering orthopedic and coronavirus disease 2019 care: Outcome of a pan-India survey. J Bone Joint Dis 2021;36:27-32
|How to cite this URL:|
Keshav K, Sharma P, Kumar A, Baghel A, Kaustubh K, Huda N, Mishra P. Changing practices of delivering orthopedic and coronavirus disease 2019 care: Outcome of a pan-India survey. J Bone Joint Dis [serial online] 2021 [cited 2021 Oct 28];36:27-32. Available from: http://www.jbjd.org/text.asp?2021/36/2/27/322946
| Introduction|| |
Coronavirus disease 2019 (COVID-19) has affected nearly all the countries of the world, and the outbreak was declared a Public Health Emergency of International Concern on January 30, 2020, by the World Health Organization (WHO). Most of the health-care resources have been channelized toward the containment of COVID-19. This has caused severe disruption of services for other health-related ailments. The WHO, in a survey of 155 countries, found that there was severe disruption of prevention and treatment services for noncommunicable diseases (NCDs). In 94% of the countries who responded in the survey, staffs working in the care of patients of NCDs were partially or fully reassigned to support COVID-19.
Orthopedic surgery (including trauma) also come under the domain of NCDs. All major orthopedic associations of the world have issued their own guidelines and so has the Indian Orthopaedic Association.,,, Issuing guidelines are one thing and implementation and execution of these guidelines are an entirely different thing. When the pandemic had just started in India, there were some growing concerns among the Indian orthopedic fraternity, which has been enumerated in [Table 1].
|Table 1: Some genuine concerns among the orthopedic community related to coronavirus disease 2019 pandemic|
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Government in different countries, and also in our country India, in an effort to contain the disease, has taken bold steps like nationwide lockdown.,, This allowed the government to upgrade its services for COVID-19. Designated COVID hospitals were created out of the existing ones. Even at many premier institutes in our country, trauma centers which were away from the main hospital campuses were converted to COVID hospitals. This had an unavoidable repercussion on orthopedic and trauma services.
The present study was conducted as an online survey with an aim to assess the change in practices of orthopedic surgeons in terms of their hospital visits, involvement in the management of suspected/confirmed COVID-19 orthopedic patients as well as routine COVID-19 patients having no orthopedic issues, availability of adequate training and personal protective equipments (PPEs) and change in hospital setup/preparedness for the management of COVID-19 patients in terms of exclusive designation of specific areas of hospitals, urgent diagnostic facilities, and separate operation theaters.
| Materials and Methods|| |
To achieve the above-mentioned aims, we conducted a pan-India survey as a part of the project titled “Impact of COVID-19 pandemic on Orthopedic practice in India: An online survey” at our institute. The contents of the questionnaire were validated by eight faculty members. We also assessed the internal consistency of the questionnaire by using Cronbach's alpha which showed good correlation among the questions (0.83) with most of them showing correlation with each other. After getting clearance from our Institutional Review Board (IEC Code: 2020-133-IMP-EXP-20) and email ids and mobile numbers of practicing orthopedic surgeons from Indian Orthopaedic Association, we sent the questionnaire through email and WhatsAppR. Orthopedicians not practicing in India, trainees (residents/fellows), and those who had left their practice before the onset of pandemic were excluded from the study. We used two tools – Survey MonkeyR Questionnaire and Google FormsR to conduct the survey. Questionnaire was sent to 10,055 orthopaedicians, during the 7th week of nationwide lockdown in the month of May, 2020, out of which there were 533 who satisfied our inclusion/exclusion criteria and consented to participate in our study. Among these, complete responses were received from 407 participants and only these were included in the final analysis.
For the purpose of statistical analysis, continuous variables were presented in median with range whereas categorical variables in frequency (%). To test the association between hospital setting (government, private, and both) with other variables related to orthopedic practices, Chi-square test was used (when each cell had at least 5 expected frequency). P < 0.05 has been considered as statistically significant. Graphs were prepared in Microsoft Word 365.RStatistical package for the social sciences version-23 (SPSS-23, IBM, Chicago, USA) R was used for data analysis.
| Results|| |
In this study, 407 orthopedic doctors (government sector: n = 76, 18.7%, private sector: n = 296, 72.7%, and mixed/both sector: n = 35, 8.6%) from all over India who completed the questionnaires have been included. Median (range) age of the study participants was 41 years with range of 27–65 years. Most of the doctors (n = 270, 66.3%) belonged to 30–50-year age group. For assessment of the impact of COVID-19 on change of orthopedic practices, orthopedic surgeons were enquired about their frequency of hospital visits, involvement in management (operative/conservative) of orthopedic patients with suspected/confirmed COVID-19 patients, involvement in the clinical management of routine COVID-19 patients without orthopedic issues, adequacy of training, availability of PPE kits, and changes in the hospital setup and preparedness for managing COVID-19 patients.
Results showed that there was drastic fall in the frequency of hospital visits by orthopedic consultants. Only around a quarter (24.6%, n = 100) of doctors were going to hospitals at a frequency that matched before the onset of pandemic. Another 30% were either those not going at all (n = 20, 4.9%) or at a significantly lesser frequency (n = 104, 25.6%). 17.2% (n = 70) had decreased their frequency slightly whereas 27.8% (n = 113) decreased their hospital visits to around half. Government sector had higher proportion of doctors visiting hospital such as prepandemic times (32.9% vs. 23.3% vs. 17.1%, P > 0.05) and lower proportion of doctors who had either stopped (2.6% vs. 6.1% vs. 0%, P > 0.05) or significantly decreased (9.2% vs. 30.1% vs. 22.9%, P < 0.05) their frequency as compared to private and mixed sectors [Figure 1] and [Table 2].
|Figure 1: Graph showing the frequency of hospital visits by practicing orthopedic surgeons during the coronavirus disease 2019 pandemic|
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|Table 2: Various parameters of orthopedic and coronavirus disease 2019 care and its distribution among the different sectors - government, private, and both|
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We asked doctors regarding their involvement in orthopedic management of COVID-19 suspected/diagnosed patients and of routine COVID-19 patients without orthopedic issues. 85% doctors (n = 346/407) had not managed any orthopedic patient with suspected/undiagnosed COVID-19 status. Out of the rest 15% (n = 61/407), 8.6% (n = 35/407) (government: 17.1% vs. private: 6.8% vs. mixed: 5.7%, P = 0.013) had done only conservative management while just 5.7% (n = 23/407) (government: 10.5% vs. private: 4.1% vs. mixed: 8.6%, P < 0.001) doctors had done some form of operative interventions as well. Among both of them, involvement of government sector was more. There were only few (n = 3/407) (government: 0% vs. private: 0.7% vs. Mixed: 2.9%) who had done only surgical management and not conservative. 31.4% (n = 128/407) doctors were involved in clinical management of routine COVID-19 patients and they were again higher in government sector (government: 63.2% vs. private: 22.3% vs. mixed: 40%, P < 0.001). With regard to training, only 38.8% (n = 158/407) orthopedic surgeons felt that they actually received adequate training to handle COVID-19 suspected/diagnosed patients (government: 69.7% vs. private: 29.4% vs. mixed: 51.4%, P < 0.001) [Figure 2] and [Table 2].
|Figure 2: Involvement of orthopedic surgeons in the management of suspected/confirmed coronavirus disease 2019 patients (for orthopedic problems) and in the management of routine coronavirus disease 2019 patients (without orthopedic issues), adequacy of training and availability of PPE kits|
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As far as COVID-19 pandemic is concerned, vaccine and proper treatment guidelines are still being developed. During the patient's care, avoiding infection in treatment providers is possible only by using appropriate preventive measures including wearing PPE and N-95 masks. When we asked doctors regarding its supply/availability at their hospital, 64.9% (n = 264/407) doctors were receiving adequate PPE kits at their hospitals, whereas 12.8% (n = 52/407) received it inadequately and 20.1% (n = 82) were not receiving at all. The supply was comparatively better in government sector (government: 72.4% vs. private: 62.8% vs. mixed: 65.7%, P > 0.05) [Figure 2] and [Table 2].
COVID patients, due to the nature of the disease and its transmission, have to be managed separately. 43.7% (n = 178/407) of the doctors said that a part of their hospital had been converted/designated exclusively for COVID-19 patients. (government: 77.6% vs. private: 33.4% vs. mixed: 57.1%, P < 0.001). However, there were only 32.9% (n = 134/407) of the doctors (government: 72.4% vs. private: 20.6% vs. mixed: 51.4%, P < 0.001) wherein the hospitals had actually admitted COVID-19 patients till the day of our survey. Orthopedic doctors were asked regarding availability of urgent diagnostic facilities and operation theaters in their hospitals exclusively for COVID-19 patients. Urgent diagnostic facilities were available in hospitals of 52.8% (n = 215/407) doctors (government: 72.3% vs. private: 47.6% vs. mixed: 54.3%, P < 0.05). 28.3% (n = 115) doctors said that they had exclusive operation theaters for suspected or diagnosed COVID patients (government: 47.4% vs. private: 22.6% vs. mixed: 34.3%, P < 0.001) [Figure 3] and [Table 2].
|Figure 3: Graph showing percentage of respondents in whose hospitals' separate area was designated for coronavirus disease 2019 patients, where coronavirus disease 2019 patients were actually being admitted, availability of urgent diagnostic facilities, and availability of separate operation theaters|
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| Discussion|| |
COVID-19 has completely changed the dynamics of health-care industry. In our country, government took the extreme but rightful step of nationwide lockdown on March 24, 2020.,, Most of the services were disrupted except few essential ones such as health care, police, administration, and sanitation. Orthopedic surgeons face the risk of getting infected, especially from the substantial number of COVID-19 patients who are asymptomatic or in the incubation period. A survey conducted in Wuhan to identify the orthopedic surgeons who were infected with COVID-19 showed that out of 26 who were infected, suspected sites of exposure were general wards (79.2%), public places at the hospital (20.8%), operating rooms (12.5%), the intensive care unit (ICU) (4.2%), and the outpatient clinic (4.2%). In India also, there were few orthopedic surgeons who succumbed to COVID-19., All these coupled with inadequate availability of PPE kits led to a sense of fear among the orthopedic surgeons, and hence, they started avoiding going to hospitals. However, with time, when things started becoming clear regarding mortality due to the disease and availability of PPE kits began to improve, a lot of the fear psychosis started to fade away. This, along with pressure from the government or employer on the practicing doctors, gradually resulted in more and more doctors coming back to their duties. If we look at our data, we can clearly observe that people in private sector were visiting their hospitals far less as compared to government employees. This may be due to the nature of the employment as the government employees are more bound by the rules and could not avoid their duties. As the private practitioners have shut down their clinics, the patients are usually referred to higher tertiary centers, most of which are government ones.
The number of orthopedic patients, both elective and emergency ones, has decreased significantly during this time. This has been due to several reasons such as nationwide lockdown, fear psychosis among the general public, decreased road traffic injuries, and inability of patients to reach hospitals due to lack of transportation facilities., Hence, it is not quite surprising to see only 6.4% of the doctors actually getting involved in orthopedic patient's management who were not confirmed COVID negative at the time of admission. In times like these, there is always going to be dearth of doctors and other health-care staff. COVID-19 is a disease mainly involving the respiratory system. Doctors who have been trained in critical care medicine, anesthesiology, and pulmonology are mainly the ones who have adequate expertise to handle these patients once they require life-saving interventions. Out of around 9 lakh doctors in India, <20,000 are actually trained in these disciplines. This led the government in some states to mandate doctors from other specialties to treat COVID patients. Few states such as Maharashtra had to take some extreme steps such as ordering municipal commissioners and district collectors of the Mumbai Metropolitan Region to take charge of 80% of beds in private hospitals while capping treatment costs till 31st August. Similar steps have been taken in Delhi where private hospitals have been advised to reserve 20% of their beds for COVID-19 patients. Hence, it is quite obvious to send the orthopedic surgeons also for care of routine COVID-19 patients. However, they do not feel themselves competent enough to handle these patients. In our study, orthopedicians who saw themselves competent enough to handle ICU patients (requiring procedures such as intubation) and nonserious isolation ward patients of COVID-19 were 5.5% (n = 7/128) and 44.5% (n = 57/128), respectively. Our orthopedic training in India is such that we do not get much experience to do procedures such as intubation. Hence, in our opinion, they are at best suited for triage or isolation ward duties. This also highlights the importance of improving the standards of clinical training during the internship of the MBBS curriculum so that during such instances in future, all the medical graduates could be roped in for providing their services.
Considering the fact that reverse transcription-polymerase chain reaction (RT-PCR) for COVID-19 testing has got a false-negative rate of 20%–38% among symptomatic patients depending upon the stage of disease, all proper precautions must be taken., PPE kits should always be worn, irrespective of COVID-19 status, in the current scenario, while giving any treatment which requires prolonged and close contact with the patients like performing any procedure or surgical intervention on them. Ignorance leads to fear and anxiety, and hence, the doctors and other health-care workers (HCWs) must receive proper training in regard to donning and doffing of PPE kits and basic knowledge about nature of the virus, disease COVID-19, and its transmission. A cross-sectional study of 1457 HCWs in China emphasized the importance of correct removal of protective equipment. In their study, they found that careful removal of protective equipment was positively associated with a higher education level and negatively with median work experience. Hence, they advised for targeting novices and HCWs with lower educational attainment for giving proper training of removal of protective equipment. Our view of giving adequate training to not only the doctors but also the entire health-care staff resonates with their experience.
Many of the guidelines have categorically stressed on the creation of separate hospitals for suspected and diagnosed COVID-19 patients.,,, Our data clearly show that the onus has been taken over mainly by the government sector as creation of such separate entity in a short span of time requires a lot of money which may be beyond the reach of private hospital owners. However, with the recent government orders, things may change especially in areas where the number of cases has gone beyond what the government undertakings can cater to., There have been many reports wherein the patients were admitted in the routine wards with other patients, and later, the patient came out to be COVID-19 positive, which resulted in subsequent sealing of the hospitals and subjecting all its staff to quarantine, thereby further jeopardizing the health-care system. In view of this, it is really important to have specific separate designated areas in the hospitals and separate teams of health-care workers so that we can admit and manage patients exclusively based on their COVID status – uncertain COVID-19 status, positive and negative virological status. In case of requirement of emergency surgery, all efforts must be done to give the primary management like splintage in case of fractures and defer the surgery till COVID-19 status is known. Once the report comes, the patient may be shifted to specific wards designated for positive and negative patients. If the surgery cannot be deferred, the patient should be considered positive and operated in the OT complex designated for positive patients., For the successful running of this system, there is a need to have urgent diagnostic facilities (RT-PCR) as well. This will not only help in giving early definitive care to the patient but also in reducing the duration of hospital stay and thereby increasing the turnover. All efforts must be done to maximize the use of telemedicine facilities and decrease length of hospital stay of the patients.
Nevertheless, our study had some limitations. First, the regional differences should be taken in consideration. India is a vast country with quite remarkable regional variations in the COVID-19 scenario. Second, the questionnaire was circulated and responses collected during the 7th week of nationwide lockdown, and hence, the findings may be representative of lockdown period and not once the lockdown is lifted up in near future. Third, the number of participants who responded was 533. However, as we only analyzed fully filled questionnaire, we ended up having 407. Although this seems to be a small number considering the vast country like India, if we look at the published literatures that included not only orthopedic surgeons but also those which included all health-care individuals, most of them had similar numbers.,
| Conclusion|| |
The present study, one of the first done in India, has shown a drastic fall in the frequency of hospital visits by orthopedic surgeons, predominant involvement of government sector orthopedicians, inadequate training of doctors and other HCWs, inadequate availability of PPE kits, lack of proper designated areas, operation theaters, and urgent diagnostic facilities for COVID-19 patients. Strong steps need to be taken which include proper and adequate training, especially with regard to donning and doffing of PPE kits and management of COVID-19 patients, adequate supply of PPE kits and infrastructural changes like creation of separate hospitals/blocks and operation theaters for suspected and diagnosed COVID-19 patients, blocking the possibility of mixing up of COVID positive and negative patients, availability of urgent diagnostic facilities, and maximizing the use of telemedicine facilities.
This research project was approved by Institutional Ethics Committee, SGPGIMS, Lucknow, U.P., India (IEC Code-2020-133-IMP-EXP-20).
Consent to participate/publish
Informed consent was taken from all the study participants.
Availability of data and material
We are having the master chart of all the 407 respondents, which may be made available if required.
Statistical package for the social sciences version-23 (SPSS-23, IBM, Chicago, USA) was used for data analysis (License available with us).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]