Effectiveness of patient triage at the orthopedic hospital and the hygiene concept in a professional handball team in the first year of the SARS-CoV-2 pandemic

In Germany, the first severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patient was isolated in a clinic in Munich on 27 January 2020 [5]. A few weeks later, all German hospitals reduced their capacities in the sector of elective surgery by up to 49% [1, 19]. Orthopedic surgery was one of the most affected branches. The number of total knee arthroplasty operations decreased by 80% in April 2020 [1]. During the first pandemic wave in spring 2020 there were neither vaccines against the virus nor specific treatment options for the coronavirus disease 2019 (COVID-19). For the vulnerable group of patients (immunocompromised tumor patients, patients with rheumatic disease, older multimorbid patients etc.) visiting clinic meant a significant risk of infection. Also, a higher mortality rate among COVID-19 patients undergoing elective surgery [13] made the protection of the orthopedic ward from virus outbreak a prioritized task. To proceed with the treatment of orthopedic patients and to protect the vulnerable group, mitigation strategies were necessary. In the outpatient clinic of the orthopedic department a standardized triage procedure was implemented to identify cases with suspected SARS-CoV‑2 infections.

In March 2020 all sporting events and competitions were called off or postponed due to the first national lockdown [10]. To restart the activities, also in professional sports, hygiene concepts had to be established. For the professional handball team of the Sport Club Magdeburg (SCM), such a concept was developed in cooperation with the Department of Orthopedics at the University Hospital Magdeburg and implemented in August 2020. The hygiene concept included strict mitigation measures and a PCR test regime to protect the team and the staff taking part in national and international matches.

Persons who demonstrated acute respiratory symptoms (or exacerbation of chronic disease, such as cough, fever, shortness of breathing, sore throat), travelled to COVID-19 hot spot regions in the last 14 days or contacted people known to be infected with SARS-CoV‑2 were categorized as suspected COVID-19 patients. This group was redirected to the fever center. All negative cases were allowed to proceed to their destination clinics.

A second triage system in the outpatient clinic at the Department of Orthopedics involved medical staff using a similar triage questionnaire (Fig. 2) and collecting information about residence in national hot spots or abroad during the last 14 days, acute COVID-19 symptoms and contacts with SARS-CoV‑2 infected cases. The selection of negative cases at the first triage led to a low number of positive cases at the second triage. Non-contact temperature measurement with a cut-off value of 37.5 °C, according to the WHO recommendation [3], was a part of the triage process. During the second pandemic wave in autumn 2020 and increasing infection rates, especially national hot spots had to be considered during triage process. The districts our patients were coming from were noted down on the triage questionnaire beginning with calendar week number 45 (2 November 2020). Districts with 7‑day incidence rates over 200 per 100,000 population were defined as national hot spots.

We reviewed 15,739 triage questionnaires of our patients and visitors in the orthopedic outpatient department of the Orthopedic University Clinic Magdeburg in a 12-month period from 1 March 2020 to 28 February 2021. Persons categorized as suspected COVID-19 cases could enter the facility only in cases of emergency. All symptomatic cases were redirected to the fever center or general practitioner. Persons travelling abroad during the last 14 days were allowed to enter the clinic with a negative PCR test result not older than 48 hours. For patients who contacted SARS-CoV‑2 infected persons, a 14-day quarantine was required, based on the official health department´s recommendation. After the self-quarantine period a negative PCR test result not older than 48 hours had to be presented at the triage.

We also reviewed PCR test results of suspected COVID-19 cases among orthopedic patients which were performed in our outpatient department, orthopedic ward and fever center. Part of the suspected cases were tested externally after the triage and not at the University Hospital Magdeburg.

The Corona virus was responsible for two pandemics during the 21st century [4]. The SARS-CoV‑1 pandemic caused in November 2003 more than 8000 infections with a high mortality rate of nearly 10% [14, 18]. Infection rates among health care workers of up to 30% were also very high [14]. There were neither vaccines against the virus nor specific treatment for severe acute respiratory syndrome (SARS), with its incompletely known pathogenesis [18]. The German health care system was confronted with comparable circumstances at the beginning of the SARS-CoV‑2 pandemic in March 2020. Infection rates among health care workers were three times higher than the federal average [22, 25]. The Robert Koch Institute informed weekly about the increasing number of SARS-CoV‑2 outbreaks in German hospitals [20]. Significant higher mortality rates were reported for patients undergoing emergency and elective surgery [6, 7, 13, 17]. In the absence of vaccines and specific treatment for the COVID-19 disease, preventive strategies had to be implemented to protect our patients, especially the vulnerable groups. Patient triage, together with a specific testing strategy, increased patient safety and prevented a SARS-CoV‑2 outbreak in orthopedic department of a maximum-care hospital. During the study period, 8 cases of SARS-CoV‑2 infection in total were detected among: medical staff (1), inpatients (4; N = 2328) and outpatients (3; N = 15,739). Patient triage by medical staff before entering the clinic can be an effective tool for preventing mass infection.

Up to 35% of German and Austrian professional athletes were quarantined and 0.5% hospitalized during the first pandemic year in Germany [2]. Despite the fact that professional athletes rarely develop severe clinical COVID-19 symptoms [9, 15, 21], a severe illness can lead to longer rehabilitation and affect eligibility [21]. Key factors for safety during professional sports events are the reduction of transmission risk by strict mitigation measures and the identification of positive cases by regular PCR testing [11, 23, 24]. To restart training and competition for the professional athletes of the Sport Club Magdeburg during the SARS-CoV‑2 pandemic, a hygiene concept was implemented in August 2020. The PCR testing strategy, as an important part of this concept, was realized by the medical staff of our outpatient department with 1428 PCR tests for 25 team members during the first and second pandemic waves in Germany (March 2020–February 2021). The PCR test regime referring to a 7‑day incidence rate together with strict hygiene concept protected the athletes from any SARS-CoV‑2 infection during the study period.