key: cord-1038863-zpcgriq6 authors: Athey, Alexander G.; Cao, Li; Okazaki, Ken; Zagra, Luigi; Castelli, Claudio; Kendoff, Daniel; Kerr, Joshua; Yates, Adolph J.; Stambough, Jeffrey B.; Sierra, Rafael J. title: Survey of AAHKS International Members on the Impact of COVID-19 on Hip and Knee Arthroplasty Practices date: 2020-04-24 journal: J Arthroplasty DOI: 10.1016/j.arth.2020.04.053 sha: 5332588287c2d2d9d4ca37f0f95f4b10e84811da doc_id: 1038863 cord_uid: zpcgriq6 Abstract Coronavirus disease 2019 (COVID-19) pandemic poses an important risk to global health. This study surveyed 370 international orthopaedic surgeons affiliated with the American Association of Hip and Knee Surgeons to help identify the global impact of the COVID-19 pandemic on patient care. A total of 99 surgeons (27% of those surveyed) completed the questionnaire representing 32 different countries. Except for surgeons in Japan, all respondents noted that their practice had been affected to some degree and 70% of the surgeons have cancelled elective procedures. More than a third of the surgeons have had to close their practices altogether and the remaining open practices were estimated to be sustainable for 7 weeks on average given their current situation. The COVID-19 pandemic has resulted in marked changes to the majority of international arthroplasty practices. In December 2019, coronavirus disease 2019 broke out in Wuhan, 15 Hubei Province, the People's Republic of China. Since that time, the disease has spread 16 worldwide to an extent not seen in decades and poses an important global health threat [1] . It is 17 now known that COVID-19 is a highly contagious disease caused by the SARS-CoV-2 virus 18 which produces symptoms that are much more severe than the seasonal flu, with fatality rates 19 around 1.4% [2] . The virus is transmitted person-to-person and health-care professionals may 20 serve as a mechanism for hospital associated transmission and outbreaks [3] . Healthcare 21 providers are at risk of propagating this disease and this risk is not exclusive to those healthcare 22 workers at the 'front lines' of the pandemic (e.g. emergency department, isolation wards, etc.). In 23 one recent report, upwards of 78% of health-care workers infected were outside of these front 24 line areas, allowing infection to spread [4] . As such, measures to slow the spread of infection 25 have been witnessed worldwide in targeting all departments within hospitals. 26 The need to slow the rate of transmission and accountability of proper stewardship of 27 medical resources is of utmost importance. The acute spike in sick patients with COVID-19 in 28 Italy and Spain, for example, showed that hospitals could quickly become depleted of necessary 29 medical equipment to protect patients and staff. A similar situation has been seen in U.S. based 30 hospitals where we have seen key shortages in ventilators, personal protective equipment (PPE), 31 and blood products [5] [6] [7] . In response, early recommendations were made by the American The responses were anonymous and tabulated and reported in aggregate form. Descriptive statistics including mean, standard deviation, and median values were reported for all 65 continuous variables. Percentiles and sample size were reported for categorical variables. The survey questions are shown in Table 2 through 4. (19), or performing more administrative work (26). Ten respondents noted 79 that they were providing more non-orthopaedic patient care. Twenty-two respondents report that In general, survey results from the international hip and knee arthroplasty societies from 102 Japan, Germany, China, and Italy were similar to the results from AAHKS poll. There were 103 some notable differences between societies. Japan had the highest number of respondents still performing arthroplasty cases, while Italy had the lowest. As expected, telemedicine was adopted 105 by many societies, and most Italian surgeons are performing some form of telemedicine. We 106 were surprised to see that very few surgeons across societies practice safe intubation/extubation 107 guidelines and wear an N-95 respirator mask during operative procedures (Table 5) . COVID-19. Thus, they recommend routine wear of the respirator at all times to prevent infection and spread both in the OR and while rounding on the floor. In our study, it was found that 67 151 surgeons reported using an N-95 respirator to some capacity in the OR, with 32 wearing them in 152 the OR for every surgical procedure. However, over half of responders (58) reported not using an 153 N-95 mask during any inpatient rounding duties. Based on the data available from the Wuhan 154 study, it would seem reasonable to recommend using an N-95 respirator mask at all times; 155 limited access to N-95 respirators may have played a role in the reported numbers in our survey. Perhaps the most alarming finding of our study was that more than one third of 157 international arthroplasty surgeons (37/99) have been forced to close their practice altogether. Department of Health and Human Services have also announced relaxation of HIPAA requirements and provided waivers for the use of telemedicine during the pandemic in order to 174 ensure care for COVID-19 and non-COVID patients is continued [15] . As gleaned from the 175 survey, a number of international members are using some form of telemedicine to communicate 176 with patients. Maintaining contact with our patients is of paramount importance during this 177 crisis, as practices will need to be reinvigorated once the pandemic resolves. In our study, 44 respondents have had their wages stopped to limit costs and support 191 This study has several limitations mainly due to its survey design. First, it is possible that 192 the population who chose to complete the survey represents a small subset of the orthopaedic 193 arthroplasty community and is not indicative of the larger group as a whole. However, given the 194 large cohort of arthroplasty surgeons encompassed in the AAHKS this may not be accurate. Another limitation is the overall response rate of 27%, which raises the potential for non-responder bias. However, we extended the survey to include additional individuals from different 197 arthroplasty societies and these results were found to be generally similar. Perhaps those that are 198 continuing their practices did not have time to respond, falsely skewing the data collected. 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CARES Act Provider Relief Fund Access Date Notification of Enforcement Discretion 236 for Telehealth Remote Communications During the COVID-19 Nationwide Public Health 237 Emergency. 2020. Access Date 16