What is a Coronavirus?

A Coronavirus is a type of virus that is roughly ball shaped with a halo of protruding spikes (its corona). 

Which Coronavirus is causing the current pandemic?

The current pandemic is being caused by the SARS-CoV-2 coronavirus.

What happens to people infected by SARS-CoV-2 virus and what is COVID-19 disease?

Approximately one in five people infected by the SARS-CoV-2 virus will experience no symptoms. Such people are asymptomatic. Nevertheless, the virus is still using the person’s body to replicate itself and the infected individual will be able to pass the virus to others until their immune system has developed antibodies to eradicate the virus from their body.  A second group develop mild symptoms that settle after a week or two.  These people generally feel better once they develop antibodies and are able to clear the virus from their bodies. Nevertheless, some post-viral symptoms may persist for several weeks or months.  The third scenario is that the infected person develops more serious symptoms and becomes very ill.  This is known as COVID-19 disease and such people may need to be admitted to hospital or even die.  

What percentage of people catching SARS-CoV-2 virus go on to develop COVID-19 disease? 

This is a particularly difficult question to answer because the virus affects different groups in different ways. Very few children and young adults suffer a serious illness. More men than women develop COVID-19 disease. Older people are also more likely to be severely affected. The figures from different studies also vary due to the different circumstances in which people have been tested.  Overall, it seems that about one on five infected people never notice any symptoms, and about one in five infected people develop symptoms that would be classified as COVID-19 disease.  In countries, such as Germany, where extensive testing was initiated early, it appears that about one in every 150 infected people will die from the disease.

How long does it take between catching the SARS-CoV-2 virus and developing symptoms?

This interval varies from person to person. 

·      The middle of this range is around 5 days.

·      97.5% of people will exhibit symptoms by 11.5 days

·      99% of people will exhibit symptoms by 14 days. 

These figures explain why people are instructed to self-isolate for fourteen days after being exposed to individuals with the infection or before returning to work or coming into hospital for an investigation or treatment.

What are the symptoms caused by SARS-CoV-2 virus infection?

The primary symptom are shortness of breath or difficulty breathing, cough (this is usually non-productive).

The secondary symptoms are fever, chills, rigors, muscle pains, fatigue, headache, sore throat, new loss of smell or taste in the previous 2 weeks.

How is the SARS-CoV-2 pandemic being managed in UK hospitals?

Throughout the first wave of the pandemic most COVID-19 patients have been cared for in the original NHS estate and almost all of the private hospitals have been maintained as SARS-CoV-2 free facilities to undertake urgent and emergency NHS surgery.  The private hospitals have also been able to continue a small amount of their normal work but, only for cases where a committee of experts have deemed that an intervention was time critical and could not be delayed.

How are patients being prioritised for operations in the NHS and private sectors?

On 11 April the four Royal Colleges of Surgery (England, Ireland, Edinburgh and Glasgow) issued guidance describing levels of surgical priority, covering all surgical specialties with the exception of obstetrics and gynaecology and ophthalmology for patients requiring surgery during the COVID-19 crisis. The guidance recommended that patients should be classified in the following groups: 

Priority level 1a Emergency - operation needed within 24 hours 

Priority level 1b Urgent - operation needed within 72 hours

Priority level 2 Surgery that can be deferred for up to 4 weeks 

Priority level 3 Surgery that can be delayed for up to 3 months 

Priority level 4 Surgery that can be delayed for more than 3 months 

This guidance has been adopted for both the NHS and private sectors. At present, only cases in categories 1 and 2 are being undertaken and only after approval from multidisciplinary teams assessing the validity of requests from surgeons to undertake the procedures.  Recent advice suggests that Priority level 3 patients will be considered for surgery from the middle of June.

Are there any other factors that will be considered when deciding which operations can be undertaken?

In addition to the 4 levels of surgical priority, all patients will be assessed according to a traffic light system to take into account their current health and whether they are less or more likely to suffer COVID-19 disease if they catch the SARS-CoV-2 virus.  The traffic light system will be used to assess patients as shown below:

 *https://www.boa.ac.uk/uploads/assets/9383a53f-36d8-4782-8fe264c691b39b15/BOA-Guidance-for-restart-full-doc-final2-v11.pdf

How will normal hospital services be restored?

As the first wave of the SARS-CoV-2 pandemic recedes, staff in NHS and private hospitals are working to formulate plans that will enable them to address the backlog of work that has accumulated over the past few months.  The current contract between the NHS and the private healthcare providers is due to end on 28 June but it remains unclear what will happen thereafter.  Recent advice suggests that all hospitals will be allowed to start treating level 3 cases during the latter part of June with the private hospitals being allowed to start treating their patients in parallel with the NHS facilities. However, it is possible that the NHS will invoke an extension of their contract with the private providers so the private hospitals can be used until the NHS backlog is more manageable.   Whatever is agreed, there will be additional challenges due to depleted supplies of certain drugs and PPE equipment.  Furthermore, treatment pathways will be more complicated and patients will need to be properly informed regarding the relative risks of delaying treatment against proceeding during a period when they may run the risk of SARS-CoV-2 infection and the potential associated complications that could ensue. 

What are the risks of having hospital treatment during the SARS-CoV-2 pandemic?

Under normal circumstances, the great majority of patients enjoy a smooth recovery from surgery and only a small percentage experience any kind of complication.  In normal times, Orthopaedic surgeons are able to provide their patients with fairly robust statistics regarding the chances of different complications occurring.  Sadly, the SARS-CoV-2 pandemic has introduced a number of new factors that make it impossible to quantify these risks and it is much harder to provide our patients with accurate information to consider.  We do know from a paper, written by the surgeons working in Wuhan, that when they inadvertently undertook surgery on people who had, or were developing the SARS-CoV-2 infection, approximately 20% died.  This is a frightening figure and it does seem to be consistent with data from a more recent, multinational study organised by a team in Birmingham. 

However, these studies do not tell us the risk of such complications if steps are taken to avoid operating on patients who have been appropriately isolated and tested for SARS-CoV-2 in advance of their operation.  Encouragingly, more than a thousand planned operations have been undertaken in the HCA hospitals in London over the last few months. Thus far, the HCA pathway has resulted in none of these patients catching the SARS-CoV-2 virus during their hospital admission.  Other private hospital groups have implemented similar precautions and all providers are closely monitoring the effectiveness of their pathways.   

What factors do you need to consider before deciding whether to go ahead with investigations or treatment in a hospital?

If you decide to go ahead with investigations and treatment before a vaccine is available, there are SARS-CoV-2 risks that you need to consider:

1)    You could be carrying the SARS-CoV-2 virus, despite not having any symptoms when you come into hospital for your investigation or treatment.

2)    You could catch the SARS-CoV-2 virus from one of the hospital staff or other patients, who are unknowingly carrying the virus.

3)    If you are carrying SARS-CoV-2 virus when your treatment is undertaken or if you develop COVID-19 symptoms, soon after an intervention, your recovery could be prolonged and there is a risk of developing serious illness, possibly leading to admission to intensive care or even death.

4)    If your treatment involves a steroid injection, this can normally be undertaken as an out-patient procedure.  However, even though your exposure to the hospital environment will be minimised, precautions will still be necessary and there is continuing uncertainty whether steroid injections may make you more vulnerable to more serious symptoms if you catch the SARS-CoV-2 virus in the succeeding few weeks.  

5)    If your treatment involves an operation, your recovery from surgery could be compromised if you catch the SARS-CoV-2 virus in the first few months after the procedure and you may require readmission to hospital.

What precautions can we take to minimise the risks of you having SARS-CoV-2 infection before, during or after hospital treatment? 

Precautions being put into place include:

 1)    As part of the work-up for any in-patient admission, a pre-admission assessment will be undertaken and your health will be assessed in relation to the risk factors outlined above. Following the assessment, you will be advised, in writing, on which risk category you fall into.  If your surgery is deemed high risk, your operation may have to be postponed.  

 2)     All the hospitals in which we work are following strict protocols to minimise the risk of anyone with active SARS-CoV-2 infection being admitted to the hospital.  Assuming your pre-admission assessment does not identify any reason to delay your operation, you will need follow a strict pre-admission pathway.  Firstly, you will need to self-isolate yourself for two weeks before your admission.  Secondly, you must be confident that neither you, nor anyone living with you, has had any SARS-CoV-2 symptoms in the two weeks preceding your admission. Lastly, a swab test will obtained in the 48-72 hours before your admission and this must be negative.

3)    The hospital will undertake regular checks on all the staff looking after you, to screen them for SARS-CoV-2 infection.

4)    To keep you and our staff safe, you will not be allowed any visitors whilst you are in hospital.

5)    We will not keep you in hospital any longer than necessary.

6)    You will need to self-isolate for two weeks after your discharge from hospital.  This can be with your family or carers. This also means that you will not be able to see a physiotherapist while you are self-isolating. To minimise the effect of this restriction, we will provide you with instructions for the exercises that you should undertake and provide you with telephone and/or online support from our physiotherapy team.

We will monitor your progress through regular telephone calls and ask you to use a smartphone App that will help you with guidance and feedback on your progress. 

How does this advice change if you have already had and recovered from a SARS-CoV-2 infection?

The new antibody tests claim to be up to 99% accurate in telling us whether an individual has already been infected with the SARS-CoV-2 coronavirus and developed antibodies against the virus.  However, these claims are widely questioned. While it is anticipated that people with antibodies to the SARS-CoV-2 virus will be immune to a second infection, it is possible that there may be some exceptions and it will be some months before we can be completely confident on this question.  We also know that people who have suffered COVID-19 can have post viral symptoms for a number months and such individuals may find it more challenging to recover from an operation.

Would it be better to postpone your operation? 

Even if you would qualify for surgery, the final decision on when to go ahead is up to you.  If you have not already had a SARS-CoV-2 infection and decide to wait to be vaccinated, you will be following the least risky option.  However, this needs to be weighed against the degree to which your symptoms are compromising your life, your ability to maintain your general fitness and the risk of your problem worsening while you wait.  Please be reassured that if you do decide to wait, we will do our best to support you until you feel ready to proceed.