key: cord-274782-yymo9i6r authors: Şahbat, Yavuz; Buyuktopcu, Omer; Topkar, Osman Mert; Erol, Bulent title: Management of orthopedic oncology patients during coronavirus pandemic date: 2020-07-02 journal: J Surg Oncol DOI: 10.1002/jso.26092 sha: doc_id: 274782 cord_uid: yymo9i6r The new measures implemented in hospitals also altered the operation of orthopedics and traumatology departments. The main purpose of this article is to discuss how orthopedic oncology clinics should be organized during the pandemic and to present the process management scheme for patients requiring orthopedic surgery, including trauma surgery, from diagnosis to treatment, together with our experiences. Instead of thinking about the global emergence of the epidemic, it is time to act decisively. At first glance, the coronavirus disease 2019 (COVID‐19) pandemic and orthopedics may seem to be unrelated disciplines, but the provision of healthcare services to patients who require them proves that these two fields are parts of the same whole. Our experiences in treating neutropenic, lymphocytopenic, and chemotherapy patients seem to have proven beneficial during this process. We operated on 10 biopsy patients, 15 primary bone sarcomas, 9 soft tissue sarcomas, and 82 trauma patients within this time frame. Only three patients were suspected to have COVID‐19 before admission. The early identification, strict isolation, and effective treatment of these patients prevented any nosocomial infections and disease‐related comorbidities. This success is the result of the multidisciplinary cooperation of the Ministry of Health, our hospital, and our clinic. The novel coronavirus was first reported as a zoonotic agent in hand hygiene with soap and water or by alcohol based hand rub, avoiding touching eyes, nose and mouth, wearing face masks, and practicing respiratory hygiene by coughing or sneezing into a bent elbow or tissue and then immediately disposing of the tissue, maintaining social distance (minimum of 1 m). 3 All health workers have to use personal protective equipment (PPE) during procedures of COVID-19 suspected or diagnosed patients. In addition to these measures, people who had been in close contact with newly diagnosed cases, including medical personnel, were traced and put under a 14-day house quarantine. The consensus opinion issued by the Turkish Society of Orthopedics and Traumatology (TOTBID) indicated that authorized clinics in public hospitals should continue trauma and tumor surgeries. 4 The new measures implemented in hospitals also altered the operation of orthopedics and traumatology departments. The main purpose of this article is to discuss how orthopedic oncology clinics should be organized during the pandemic and to present the process management scheme for patients requiring orthopedic surgery, including trauma surgery, from diagnosis to treatment, together with our experiences. Instead of thinking about the global emergence of the epidemic, it is time to act decisively. We searched for the keywords "coronavirus" and "hospital management scheme" in the PubMed advanced search engine. We determined the statements published by the Turkish Ministry of Health and TOTBID as the bases of the patient management scheme. We obtained data from the hospital information system regarding all oncologic orthopedics and trauma surgery patients operated on and followed between 11 March 2020, the date of the first confirmed case of coronavirus in Turkey, and 11 May 2020. As per the World Health Organization's pathogen screening system, patients were questioned regarding their symptoms and their contacts. The patients who were operated previously or who have been followed conservatively were continued following in outpatients clinics with precautions for coronavirus. All preoperative patients were questioned and examined for signs and symptoms related to COVID-19. Besides routine pre- During this process, we contacted patients with benign bone lesions and soft tissue masses that required surgery and postponed their operations. We continued to perform the surgeries of patients with primary bone sarcomas, metastatic lesions with impending or eventuated pathological fractures, and malignant soft tissue masses, after taking the adequate precautions for health care workers from getting infected. We recommended and performed biopsies for patients whose medical history and physical and radiological examinations indicated a high risk of malignancy. The 10 patients who required biopsy (four males and six females, aged 7-84 years) were scheduled for outpatient surgery. They were asked to come to the hospital in the morning ready for surgery and were sent home after the nerve block or general anesthesia wore off. The patients were not hospitalized overnight. This outpatient surgery approach allowed the patients to remain in the hospital for less than 24 hours and helped avoid nosocomial infections. One patient with soft tissue sarcoma who was being followed for surgical wound care was determined to have a fever, cough, fatigue, and pancytopenia in the preadmission screening. The blood test results of this patient were as follows: hemoglobin, 6.8 g/dL; white blood cells, 0.1 × 10 3 /µL; platelets, 65 × 10 3 /µL; lymphocytes, 0.1 × 10 3 /µL; procalcitonin, 1.43 µg/L; C-reactive protein, 220 mg/L; D-dimer, 1.74 mg/L; ferritin, 2023 µg/L; and fibrinogen, 752 mg/dL. The CT scan results of the patient revealed ground-glass opacities in both lungs and the patient was tested for COVID-19 by real time RT-PCR, which came back negative (Figure 4 ). In the meantime, the patient was isolated and treated (plaquenil + azithromycin) in a different ward as per the recommendation of the infectious diseases department. All medical staff were screened for fever the morning of the operation. All staff were also screened for fever during entry to and exit from the hospital. Only healthcare workers were allowed in the clinic to reduce the risk of nosocomial infections originating from other people. All medical staff were provided with online COVID-10 training in accordance with the directives of the Ministry of Health. All patients were screened for fever twice a day and lymphocyte counts were evaluated daily. Parallel to the measures taken by the medical staff, certain rules were introduced for the patients. The patient's relatives were provided with information on COVID-19 before the patient being admitted to the clinic. Wearing masks was made mandatory and daily fever screenings were implemented. We evaluated all patients that were scheduled for biopsy and surgery both preoperatively and postoperatively at weekly orthopedic oncology committee meetings that included a pediatric oncologist, a medical oncologist, a radiation oncologist, a radiologist, an orthopedic surgeon, and a pathologist. To reduce contact, we reduced the number of physicians on the committee from three specialists per branch to one. A seating plan was organized in which the members of the committee would be at least 1.5 m apart. Also use of mask was encouraged during those meetings. We thus ensured that the treatment of orthopedic oncology patients that required a multidisciplinary approach would not be disrupted. The patients were operated by an experienced surgical team. Entrance to and exit from the operating room were kept to minimum. The operating room ventilation system should minimize the presence of airborne pathogens. The ventilation system in our operating room provided at least 20 air changes per hour. We reduced the amount of equipment in the operating room and only kept the essentials for the surgical procedure. We minimized the number of people in the operating room, especially during the intubation or extubation of the patient. We applied tranexamic acid to every patient unless contraindicated to reduce complications related to perioperative and postoperative bleeding ( Figure 5 ). Visitors were not allowed after the operation. We administered standard postoperative antibiotic and anticoagulant prophylaxis since there is no evidence suggesting the preferred postoperative In our clinic, we primarily decided to reduce all forms of contact. We halted general orthopedic and nonurgent specialty outpatient services (foot and ankle surgery, sports surgery, deformity surgery, arthroplasty, hand and wrist surgery, pediatric orthopedic surgery). We aimed to reduce both the healthcare workers' contact with patients and the patients' contact with other patients while coming to and from the hospital. We reduced the number of actively working outpatient clinics from seven to two, where we followed up only early postoperative patients, patients followed for conservative treatments or casts, and tumor patients. We created a separate outpatient service for tumor patients and prevented any contact with other patients during follow-ups. We determined early postoperative patients who were operated on before the COVID-19 outbreak through the hospital information system and used teleconferencing for consultations. We only called in patients who were deemed necessary to come into the hospital for assessment. During teleconference con- Our patients were asked to arrive in the morning ready for surgery and were sent back home after nerve block or general anesthesia wore off. The patients were not hospitalized overnight. The outpatient surgery approach allowed the patients to remain in the hospital for less than 24 hours and helped avoid nosocomial infections. 5 Considering the possibility that the fight against the COVID-19 outbreak may be long-term, it is crucial to ensure the safety of healthcare workers and the rational use of medical resources. For this reason, like all healthcare workers, the orthopedic team was instructed to regularly wash their hands and to wear surgical masks during clinical practice. The infectious diseases clinic and ward were isolated and separated as a follow-up and treatment zone for patients with COVID-19. Two healthcare workers who worked in the orthopedics clinic had recently returned from abroad and were put under 14 days of home quarantine. Four staff working in the outpatient clinic during the outbreak presented with fever and flu-like symptoms and tested positive by real time RT-PCR. They were subsequently put under 14 days of home quarantine and were treated at home as per the suggestion of the infectious diseases clinic. These six workers returned to active duty after two consecutive real time RT-PCR test results came back negative. One employee of the hospital had lymphocytopenia (lymphocyte count of <500) due to using immunosuppressive drugs for multiple sclerosis and was removed from active duty and quarantined. Healthcare workers' safety is one of the key goals. 5, 14 One of the key strategies here is to reduce the number of surgeries and elective operations in the entire hospital. 15 At first glance, the COVID-19 pandemic and orthopedics may seem to be unrelated disciplines, but the provision of healthcare services to patients who require them proves that these two fields are parts of the same whole. Our orthopedics and traumatology clinic was This success is the result of the multidisciplinary cooperation of the Ministry of Health, our hospital, and our clinic. 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Management of orthopedic oncology patients during coronavirus pandemic The authors did not receive any outside funding for their research or preparation of this work. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.