Key words
COVID-19 - Centre for Geriatric Trauma - Trauma Centre - IMPACT-Study - proximal femur
fracture
Introduction
On 11 March 2020 the World Health Organization declared a pandemic caused by the novel
Coronavirus-2 (COVID-19) [1]. The COVID-19 pandemic represents a major challenge for all healthcare systems worldwide.
The lockdown in Germany from 13 March to 19 April meant massive restrictions on both
public life and routine clinical operations. Federal Health Minister Spahn declared
that, starting on 16 March 2020, all hospitalisations and surgeries without medical
urgency were to be postponed. It was not until a further government statement was
issued on 27 April 2020 that some of the available hospital capacity could once again
be used for elective surgeries. As a result, a current study based on data from the
Initiative for Quality Medicine (IQM) showed a pronounced reduction in numbers of
hospital treatments for certain diagnoses [2]. Orthopaedic medicine in particular, with therapies and surgeries that are for the
most part
elective, registered a sharp reduction in these procedures. During this period,
78.3% fewer hip arthroplasties and 83.5% fewer knee arthroplasties were implanted.
Trauma surgeries also showed a downturn. 34% fewer polytraumata, 24.1% fewer femur
neck fractures and 18.9% fewer pertrochanteric femur fractures were treated [2]. In a current survey, all members of the University Orthopaedic and Trauma Surgery
Professors Convention were asked for their assessment of the impact of the COVID-19
pandemic. The replies reported a reduction of hospital bed capacities by 45.3 ± 20.1%,
a reduction of surgical capacities by 49.4 ± 20.4% and fewer emergency patients by
72.0 ± 21.1%. In the university clinical departments, 14.7 ± 17.2% of the medical
employees were reassigned to other departments. The average financial loss of the
departments was reported as 29.3 ± 17.9% [3].
Within the framework of the international study “International Multicentric Project
Auditing COVID-19 in Trauma & Orthopaedics (IMPACT)”, initiated by the Scottish Orthopaedic
Research Trust into Trauma, the Scottish Hip Fracture Audit and the Scottish Government,
the study initiators contacted the Trauma Surgery Academy (AUC) so as to involve Germany
in the study. A cooperation was agreed on within a partial study, the IMPACT Services
Survey. The aim of this partial study was to evaluate the impact of the COVID-19 pandemic
on elective treatments in orthopaedics and trauma surgery, the impact on treatment
of proximal femur fractures, the strategies aimed at containing the pandemic and the
subsequent normalisation phase. To this end, the English questionnaire was translated
into German and supplemented with specific questions. This constituted a restriction
on free formulation of the survey questionnaire on our part so as to comply with the
parameters of the
international study. Publication of the international survey results is planned
by the IMPACT study initiators.
The aim of this study, besides cooperation with the efforts of the IMPACT study, was
to determine the impact of the COVID-19 pandemic on trauma surgery in Germany at all
medical care levels.
Material and Methods
The initiators of the international IMPACT study provided the questionnaire used in
the survey to the AUC [4]. The authors translated the questionnaire into German and supplemented it with additional
questions so as to obtain further details on levels of care and therapy of other diagnoses.
The questionnaire comprised a total of 24 questions. The first two questions concerned
the organisational structure of the clinic, which German State it was located in and
the TraumaZentrum DGU (TZ) (Trauma Centre) classification (local/regional/supraregional)
or whether certification as an AltersTraumaZentrum DGU (ATZ) (Geriatric Trauma Centre)
had been issued. The next five questions referred to the general and organisational
impact of the COVID-19 pandemic.
The following 14 questions addressed the impact of the COVID-19 pandemic on treatment
of special diagnoses. Specifically, effects on fractures close to the hip joint, distal
radius fractures, proximal humerus fractures and on the treatment of polytraumatised
patients were addressed. Replies were subgrouped in each case by month for March,
April and May 2020 and participants were asked to draw comparisons with the same monthly
periods in the previous year.
The next question referred to the recovery phase and expected long-term impacts of
the COVID-19 pandemic. The last two questions were designed to determine whether the
figures provided were estimates or concrete data and whether the participants had
any further comments on the COVID-19 pandemic.
It was left up to the participants whether they wished to fill out the questionnaire
anonymously or enter their personal data for possible citation in the study group
of the IMPACT study.
The AUC passed on the survey in the form of an online questionnaire to the TZ and
ATZ contacts as listed, whereby several questions were labelled as mandatory, i.e.
the form could not be completed unless these questions were answered.
The web-based survey started on 20 June 2020 and concluded on 10 July 2020. The feasible
survey period was short as stipulated by the IMPACT study initiators.
The replies from the participating clinics were then evaluated using the program Microsoft
Excel. The results formulations were purely descriptive, with only mean values and
categories reported.
Results
72 centres of the total of 692 queried participated in the survey, a response rate
of 10.4%. 76.4% of these respondents were combined orthopaedic and trauma surgery
clinics and 23.6% were trauma surgery facilities only. [Fig. 1] shows the distribution among the individual Federal German States.
Fig. 1 Comparison of regional distribution of TraumaZentren DGU with location of clinics
of the survey respondents. No reports from Bremen, Thuringia and Saarland; BaWü: Baden-Württemberg;
MV: Mecklenburg-Vorpommern; NRW: North Rhine-Westphalia.
In terms of care level classification 45.8% of the participating clinics were certified
as local TZs, 30.6% as regional TZs and 19.4% as supraregional TZs, reflecting the
distribution in the TraumaNetzwerk DGU (Trauma Network) (49.7%/32.9%/17.5%). 33.3%
of the participating clinics were certified as ATZs ([Fig. 2]).
Fig. 2 Percentile distribution of the different levels of care in TraumaNetzwerk DGU and
among the survey respondents. The distribution is comparable in the two groups.
58.3% of respondents reported a qualitative downturn in trauma surgery/orthopaedic
medical care due to the COVID-19 pandemic. 38.9% saw no impact. Only 19.4% had access
to full surgical capacity during the lockdown phase. 43.1% of respondents had access
to 50% of normal capacity ([Table 1]). Notwithstanding, 59.7% had already registered a normalisation of capacities. A
total of 84.7% of the clinics reported reduced numbers of surgeries.
Table 1 Measures taken and reallocations of personnel and infrastructure resources.
|
Question
|
Response choices: Percentiles
|
|
n: number of responding clinics; response choices were indicated in addition to percentile
distribution
|
|
Capacity:
Availability of surgical theatres until normalisation (n = 72)
|
> 100%
|
100%
|
75%
|
50%
|
≤ 25%
|
|
4.2%
|
19.4%
|
27.8%
|
43.1%
|
5.5%
|
–
|
|
Normalisation in (n = 42)
|
1st half of April
|
2nd half of April
|
1st half of May
|
2nd half of May
|
1st half of June
|
2nd half of June
|
|
4.9%
|
0.0%
|
19.5%
|
19.5%
|
53.7%
|
2.4%
|
|
Reassigned personnel (n = 49)
|
Medical specialists
|
Medical assistants
|
Students in probationary year
|
Qualified nurses
Surgical/technical assistants
|
Orthogeriatric employees
|
Assistant nursing personnel
|
|
38.8%
|
79.6%
|
18.4%
|
79.6%
|
14.3%
|
71.4%
|
|
Reallocated areas (n = 55)
|
Entire ward
|
Ward sections
|
Surgical theatres
|
Examination rooms
|
Emergency admissions
|
–
|
|
7.3%
|
80.0%
|
27.3%
|
34.5%
|
47.3%
|
|
Covid-19 measures taken (n = 66)
|
Symptom questionnaire
|
Obligatory laboratory test
|
Laboratory test in case of conspicuous history
|
Other
|
Unknown
|
–
|
|
74.2%
|
48.5%
|
54.5%
|
6.1%
|
0.0%
|
Personnel had to be reassigned to support pandemic measures in about 70% of the responding
clinics, with areas reallocated for these reasons in 76.4% ([Table 1]).
In March 2020, 40.3% of the clinics registered a decrease in proximal femur fractures
by an average of 35% per clinic compared to March 2019. 54.2% of clinics reported
no change. The number of clinics reporting a decrease was still 33.3% for April 2020
(with 61.1% reporting no change). Further normalisation was then reported for May
2020 with 18.1% still showing reduced case numbers compared to the previous year (and
no changed reported in 75%). These clinics did, however, report a mean decrease by
38% ([Table 2]).
Table 2 Percentile distribution of data reported by clinics for changes in case numbers for
the diagnoses surveyed and compared to the same month in the previous year.
|
Hip fracture
|
Polytrauma
|
Distal radius fracture
|
Humerus head fracture
|
|
March 2020
|
|
|
|
|
|
|
40.3%
|
48.6%
|
40.3%
|
34.7%
|
|
|
35%
|
39%
|
31%
|
39%
|
|
|
54.2%
|
50.0%
|
54.0%
|
63.9%
|
|
|
5.5%
|
1.4%
|
5.7%
|
1.4%
|
|
April 2020
|
|
|
|
|
|
|
33.3%
|
47.2%
|
45.8%
|
34.7%
|
|
|
39%
|
39%
|
32%
|
43%
|
|
|
61.1%
|
48.6%
|
48.6%
|
62.5%
|
|
|
5.6%
|
4.2%
|
5.6%
|
2.8%
|
|
May 2020
|
|
|
|
|
|
|
18.1%
|
30.6%
|
33.3%
|
29.2%
|
|
|
38%
|
45%
|
17%
|
37%
|
|
|
75.0%
|
61.1%
|
59.7%
|
70.8%
|
|
|
6.9%
|
8.3%
|
7.0%
|
0.0%
|
The incidence of patients with proximal femur fractures who tested positive for COVID-19
was mainly within the range of 0 – 4% ([Fig. 3]).
Fig. 3 Percentile of patients who tested positive for COVID-19 in the total collective of
fractures close to the hip joint.
Regarding indications for surgical therapy, 94% of the participating facilities reported
no shift towards more conservative therapy.
Regarding elective orthopaedic/trauma surgery therapy, 68.1% reported that it had
been completely discontinued and the rest continued to perform only urgent elective
therapies, including those potentially involving surgery. 83.3% reported no impact
on therapy of tumour diseases due to discontinuation or reduction of the elective
programme, but even this therapeutic indication saw reduced treatment in 16.7% of
these facilities. At any rate, discontinuation of the elective programme did result
in a pronounced reduction in admissions, especially to orthopaedic/trauma surgery
wards. 84.7% reported this situation. Several respondents remarked in the freely formulated
responses that the compensation payments passed by the Federal Government would not
cover the resulting losses. In 94.4% of the clinics, the elective programme had already
been reinstated. 90.3% also reported that this situation was not worrisome.
With regard to therapy of polytraumatised patients with Injury Severity Scores ≥ 16,
the data from March and April 2020 showed a comparable decrease compared to the same
period in the previous year in about 50% of the clinics. In May 2020, the responding
clinics still reported a decrease in case numbers of 30.6% ([Table 2]).
The same tendency was observed in the numbers of treated cases of distal radius fracture.
A decrease was still reported for March and April by 40 – 45% of the clinics, which
figure was still at 33.3% in May 2020 ([Table 2]). An interesting aspect was that in 16.7% of the clinics the indication for surgical
therapy was revised, i.e. more patients then received conservative therapy in these
clinics. This was often justified as requested by patients due to a fear of COVID-19
infection.
The decrease for proximal humerus fractures was somewhat less pronounced. In this
category, 34.7% of clinics reported a decrease for March and April 2020, with 29.2%
still reporting this for May 2020 ([Table 2]). As regards the diagnosis of a proximal humerus fracture, 93.1% reported no change
regarding indications for surgical therapy. Only a small number of clinics reported
having treated a larger portion of humerus fractures conservatively.
In their replies regarding the questions on the recovery phase and long-term effects
of the COVID-19 pandemic, many clinics stated that they did not expect any more serious
impacts. A total of 30 clinics feared financial losses, 9 expanded organisational
demands, 4 personnel cuts and 2 reductions in advanced training programmes. The reported
potentially positive effects were improved hygienic standards (3 clinics), reduction
in overtime hours worked (6 clinics), procedural improvements (9 clinics) and remuneration
for empty-bed capacities (2 clinics). The numeric data reported in the survey were
based on estimates in 80.6% of respondents and on actual concrete information in the
rest.
Discussion
Our survey reflects the development of orthopaedic and trauma surgery medical practice
in Germany as impacted by the COVID-19 pandemic in all care level classifications.
The analysis was based on categorisation of the trauma centres as local/regional or
supraregional. Regarding elective procedures in particular, the decrease was dramatic.
About 70% of the clinics discontinued their elective programmes completely, while
the remainder continued to perform only urgent elective therapies. This result was
confirmed by the analysis of the IQM data done by Kuhlen et al., describing a decrease
in arthroplasties by more than 80% and in spinal procedures by nearly 55% [2]. The Diagnosis Related Groups (DRG) browser of the Hospital Remuneration System
Institute (InEK) also recorded a decrease in elective knee endoprosthetic procedures
by 52.5% (DRG I44C) and in hip endoprosthetic procedures by 48% (DRG I47C) [5]. These effects,
especially on elective orthopaedics and trauma surgery, had also been described
at the international level [6], [7].
Our survey also revealed that trauma surgery therapies decreased during the COVID-19
lockdown as well. Nearly 50% of the clinics reported having treated fewer cases of
proximal femur fractures during the lockdown. The literature, however, reports that
in particular the numbers of fragility-related proximal femur fractures had remained
constant, even during the pandemic [8], [9], [10]. These international results were not confirmed for Germany, either by our survey
or by the IQM data, with a reduction of femur neck fractures by about 24% and of trochanteric
femur fractures by about 19% [2]. Data from the InEK DRG browser revealed a reduction from 41,975 proximal femur
fractures during the period from 01 March 2019 to 31 May 2019 to 33,753 cases, a reduction
by about 20% [5]. This could reflect differences in German, Spanish and English data
for unknown reasons. The first part of the IMPACT study, a multicentre, retrospective
evaluation of 30-day mortality post femur fracture close to the hip joint and COVID-19
infection, also reported no reduction in incidence of femur fractures close to the
hip joint during the pandemic [11]. An interesting aspect of the first results from the IMPACT study was the proportion
of COVID-19-positive patients, which was 8.5% of all patients treated during the study
period [10]. In our survey, the percentage of COVID-19-positives from March to May 2020 was
0 – 4% in about 90% of the clinics. A possible explanation for the divergent data
could be that all patients in the IMPACT study were tested and only 26% of the patients
showed relevant symptoms upon admission [10].
As to developments in polytraumata, distal radius fractures and proximal humerus fractures,
international publications report a similar picture. A monocentric epidemiological
study at a U. K. hospital also determined a clear reduction of polytraumata and fractures
of the upper extremity [12]. This is explained in particular by massive restrictions on public life in the lockdown,
resulting in pronounced reduction of injuries, particularly those due to sporting
activities, alcohol abuse and traffic accidents [13]. According to the Federal Office of Statistics, traffic accidents decreased during
the period from January to April 2020 by 18.4% compared to the same period in the
previous year. The rate dropped by 35% in April alone [14]. A pronounced reduction by 10.3% was also reported for reportable occupational and
commuting accidents by the Transport and Traffic Professional Association for
the 1st quarter of 2020 [15]. On the other hand, the Professional Association of the Construction Industry expressed
concern about increased death rates due to construction site accidents during the
COVID-19 pandemic [16]. One clinic in our survey reported a significant reduction in patient numbers from
a German holiday resort area due to the drop-off in tourism. Reports from North America
also mentioned lower incidence levels for polytraumata and other injuries, which was,
however, paralleled by a rise in penetrating wounds caused by firearms [17]. The InEK DRG browser revealed a decrease from 15 273 proximal humerus fractures
in 2019 to 12 145 cases, a reduction by 20.5%. Case numbers for polytraumata decreased
from 1919 to 1485 cases (reduction by 20.6%). Distal radius fracture treatments dropped
from 18 527 cases to 16 797 (reduction by 9.3%). The period from 01 March 2019 to
31 May 2019
was compared to the period from 01 March 2020 to 31 May 2020 in each category
[5]. On the whole, the reductions in case numbers observed by the responding clinics
were comparable to the data provided to the InEK by all German clinics.
A considerable share of the personnel and infrastructure resources of the clinics
was used in the fight to contain the pandemic. Compared to results of the survey of
the members of the University Orthopaedic and Trauma Surgery Professors Convention,
the share would appear to be even higher. In the study by Haffer et al., the initially
somewhat low quota was explained by the fact that university departments are responsible
for research and teaching tasks in addition to patient treatments [3]. However, the respondents to the present survey were for the most part clinics without
university affiliation.
84.7% of the clinics reported palpable drops in clinic revenues due to the COVID-19
pandemic, this despite the compensation payments passed by the Federal government
[18]. This was confirmed in a retrospective study at a Germany University Clinic for
Orthopaedics and Trauma Surgery. In addition to the clear reduction in case numbers,
this study showed a loss of financial revenues of about 57% after all compensations
were included. These medical facilities calculated a mean shortfall, despite correction
for material costs, of 567 € per case. This study compared the period from 16 March
2020 to 17 April 2020 with the exact same period in the previous year [19].
The most important limitation of our study is certainly the low response rate, which
entails a high risk of bias. However, the percentile distribution of care levels in
the trauma centres is comparable to the actual distribution in Germany and can thus
presumably give a realistic picture. In addition, most of the estimates were made
by senior physicians in the respective clinics. Estimation of the figures used here
must also be mentioned as a clear limitation.
Nonetheless, the results of our survey did demonstrate that German orthopaedic and
trauma surgery clinics responded at all care levels to the political call to discontinue
nearly the entire elective programme during the lockdown. In addition to this, orthopaedic
and trauma surgery clinics provided resources and reassigned personnel successfully
in support of the effort to contain the COVID-19 pandemic.
Conclusion
Our survey revealed a significant impact of the COVID-19 pandemic on the TraumaZentren
DGU and AltersTraumaZentren DGU. Besides the clear reduction of elective patient therapies,
this fact is also reflected in many clinics in decreases in the numbers of trauma
surgery patients with fractures. This can be explained by the lockdown and its restrictions
on public life. It also explains the fear of economic sacrifices felt by most of the
responding clinics.
