Universal Testing for COVID-19 in Essential Orthopaedic Surgery Reveals a High Percentage of Asymptomatic Infections

Abstract

Background: The long incubation period and asymptomatic spread of COVID-19 present considerable challenges for health-care institutions. The identification of infected individuals is vital to prevent the spread of illness to staff and other patients as well as to identify those who may be at risk for disease-related complications. This is particularly relevant with the resumption of elective orthopaedic surgery around the world. We report the results of a universal testing protocol for COVID-19 in patients undergoing orthopaedic surgery during the coronavirus pandemic and to describe the postoperative course of asymptomatic patients who were positive for COVID-19. Methods: A retrospective review of adult operative cases between March 25, 2020, and April 24, 2020, at an orthopaedic specialty hospital in New York City was performed. Initially, a screening questionnaire consisting of relevant signs and symptoms (e.g., fever, cough, shortness of breath) or exposure dictated the need for nasopharyngeal swab real-time quantitative polymerase chain reaction (RT-PCR) testing for all admitted patients. An institutional policy change occurred on April 5, 2020, that indicated nasopharyngeal swab RT-PCR testing for all orthopaedic admissions. Screening and testing data for COVID-19 as well as relevant imaging, laboratory values, and postoperative complications were reviewed for all patients. Results: From April 5, 2020, to April 24, 2020, 99 patients underwent routine nasopharyngeal swab testing for COVID-19 prior to their planned orthopaedic surgical procedure. Of the 12.1% of patients who tested positive for COVID-19, 58.3% were asymptomatic. Three asymptomatic patients developed postoperative hypoxia, with 2 requiring intubation. The negative predictive value of using the signs and symptoms of disease to predict a negative test result was 91.4% (95% confidence interval [CI], 81.0% to 97.1%). Including a positive chest radiographic finding as a screening criterion did not improve the negative predictive value of screening (92.5% [95% CI, 81.8% to 97.9%]). Conclusions: A protocol for universal testing of all orthopaedic surgery admissions at 1 hospital in New York City during a 3-week period revealed a high rate of COVID-19 infections. Importantly, the majority of these patients were asymptomatic. Using chest radiography did not significantly improve the negative predictive value of screening. These results have important implications as hospitals anticipate the resumption of elective surgical procedures. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of a comprehensive pre-procedural screening protocol for COVID-19 in times of a high SARS CoV-2 prevalence: a prospective cross-sectional study

“…The risk of COVID-19 hospital-associated transmission not only endangers the health of hospitalised patients (who may be already weakened by their underlying medical conditions) and healthcare providers but may also lead to further loss of working force. As transmission from asymptomatic or pre-symptomatic carriers or people with mild or atypical symptoms has been documented [6] and universal screening for SARS-CoV-2 in patients admitted to hospital revealed a high percentage of asymptomatic infections [7,8], screening on the basis of symptoms only seemed unwise.…”

Hip fracture care and mortality among patients treated in dedicated COVID-19 and non-COVID-19 circuits

“…All patients admitted to hospital, regardless of diagnosis, were screened for COVID-19 form March 14th on; other authors only tested clinically suspicious cases and it is likely that they may have not detected several asymptomatic cases, as was the case for over one-third of our RT-PCR(+) patients. A study from New York reported a 12% positive rate for SARS-CoV-2 once the universal screening was adopted during the first pandemic wave, with over half of the detected cases asymptomatic at the time of admission [39], and 11% of the patients that tested positive at admission in a multicentric series from London were asymptomatic [40]. Consequently, other authors may have a selection bias that could overestimate mortality.…”

Self-quarantine programme and pre-operative SARS-CoV-2 PCR screening for orthopaedic elective surgery: experience from Japan

“…[11]. Universal screening for essential orthopaedic surgery in New York in April 2020 showed a 12.1% COVID-19 positive rate, which included 58.3% asymptomatic patients [12]. Computed tomography (CT) screening for urgent elective surgery in the United Kingdom reported findings suggestive of COVID-19 in 13/156 (8%) patients, and COVID-19 was confirmed in two of these patients with an additional PCR test [13].…”