International Orthopaedics https://doi.org/10.1007/s00264-020-04798-1 ORIGINAL PAPER Nosocomial infection with SARS-CoV-2 and main outcomes after surgery within an orthopaedic surgery department in a tertiary trauma centre in Spain Kushal Lakhani 1,2 & Joan Minguell 1,2 & Ernesto Guerra-Farfán 1,2 & Yuri Lara 1,2 & Unai Jambrina 1,2 & Joan Pijoan 1,2 & Jorge H. Núñez 1,2 Received: 2 July 2020 / Accepted: 1 September 2020 # SICOT aisbl 2020 Abstract Aims The purpose of the present study is to analyse clinical data of a series of cases who developed nosocomial infection with SARS-CoV-2 in an orthopaedic and traumatology department. Patients and methods In this non-interventional retrospective study, carried out at a tertiary hospital within the Spanish National Health System, all adult patients who were admitted in the Orthopaedic Surgery and Traumatology Department between March 9th and May 4th, 2020, were included. Clinical, biological and radiological data, as well as mortality rates, were collected from hospital medical records. Results A total of 293 periods of hospitalization were analysed in 288 patients. Mean age was 66.1 years old and 57.3% were females. Nineteen patients (6.48%) met the inclusion criteria to be categorized as a nosocomial infection with SARS-CoV-2. In a comparison between patients with and without nosocomial infection, age, mortality and hospital length of stay were statistically significant (p < 0.05). The median time from admission to diagnosis of SARS-CoV-2 infection in our cohort was 16 days (6– 86 days). No statistically significant differences were found in sex, living situation, reason of admission or period of admission (even if we observed that most of the nosocomial infections (78.9%) occurred in March). Conclusion We have found a 6.48% of nosocomial infection with SARS-CoV-2, but with an important reduction of it after undergoing preventing protocols that included screening RT-PCR test for COVID-19. Age and hospital length stay were statistically significant risk factors for nosocomial infection with SARS-CoV-2. For the progressive restoration of the surgical activity, we recommend to correctly select the patients in elective surgery and to encourage fast-track programs and early discharge of patients with fractures. Keywords Nosocomial infection . SARS-CoV-2 . Coronavirus . COVID-19 . Surgery . Orthopaedic Introduction (COVID-19) was classified as a pandemic on March 11th, 2020. Spain was one of the first European countries to deal On January 20th, 2020, the World Health Organization with this virus outbreak, declaring the State of Alarm on (WHO) declared a public health emergency due to a new March 14th, 2020. This State of Alarm had several conse- coronavirus disease: severe acute respiratory syndrome coro- quences on the Spanish population, imposing restrictions navirus 2 (SARS-CoV-2). This coronavirus disease 2019 mainly in the free circulation of people and educational activ- ity. People were allowed to move around public spaces only in very specific cases, like buying food or medicines, and all * Kushal Lakhani klakhani@vhebron.net; kushallakhani@hotmail.com educational activities were cancelled [1]. Hospitals were forced to adapt their sources to face the im- 1 pact of the virus, reducing the surgical activity to the minimum. Department of Traumatology and Orthopedic Surgery, University Hospital of Vall d’Hebron, Passeig de la Vall d’Hebron, 119-129 In our hospital, all elective-surgical activity was suspended 08035 Barcelona Spain from March 16th, 2020, and only traumatic and non- 2 Universitat Autónoma de Barcelona, Passeig de la Vall d’Hebron, delayable septic or oncological surgery was taken. However, 119-129 08035 Barcelona Spain as one of the trauma care centre referrals in Spain, covering a International Orthopaedics (SICOT) catchment area of more than 550,000 inhabitants, medical as- Table 1 Description of characteristics of all patients analysed (from March 9th to May 4th, 2020) sistance was needed to supply to a considerable number of patients in this period. Special measures were adopted to min- Characteristics Periods of hospitalization (n = 293) imize the risk of infection with COVID-19 for patients as well as for health professionals. Notwithstanding protective mea- Age (years) sures, the risk of contracting the virus during hospitalization Mean (SD) 66.1 (20.8) period (or immediate outpatient care) did not appear to be un- Gender % (n) important, and the main clinical outcomes of the patients, such Male 42.7 (125) as early mortality, seemed to be magnified. Female 57.3 (168) Very few data about nosocomial infection with SARS- Residency % (n) CoV-2 is available in the literature [2]. This parameter seems Family home 91.1 (267) to be a key factor for the progressive restoration of normal Nursing home 5.4 (16) surgical activity in hospitals. Thus, the purpose of the present Transfer from other hospital 3.4 (10) study is to analyse clinical data of a series of cases who de- Status before surgery % (n) veloped nosocomial infection with SARS-CoV-2 in an ortho- Hospitalized 61.8 (181) paedic and traumatology department. Non-hospitalized 38.2 (112) Emergency surgeries % (n) 4.9 (14) Hospital length of stay (days) Patients and methods Median (interquartile range) 8 (3–15) COVID-19 screening test % (n) Study design and participants Positive 3.4 (10) Negative 31.4 (92) This is a non-interventional retrospective study, carried out at a Not performed 65.2 (191) tertiary hospital within the Spanish National Health System. All Mortality % (n) adult patients who were admitted in the Orthopaedic Surgery No 90.1 (264) and Traumatology Department between March 9th and Yes 9.9 (29) May 4th, 2020, were included. This period was selected as it included the immediately preceding week of the first patient % percentage, n: number, SD: standard deviation diagnosed with SARS-CoV-2 in our department, which took place on March 15th, 2020. Exclusion criteria included patients under the age of 16, as these patients were admitted in a differ- Nosocomial infection with SARS-CoV-2 ent building of our hospital. From March 9th, 2020, to May 4th, 2020, a total of 293 periods of hospitalization were analysed in Definition of nosocomial infection with SARS-CoV-2 was 288 patients. Mean age was 66.1 years old, standard deviation based on current studies that have tried to investigate the (SD) 20.8; 57.3% were females. Characteristics of the patients length of the incubation period of COVID-19 [3, 4]. Lauer are reported on Table 1. Reason for admission in our depart- et al. estimated the median incubation period to be 5.1 days ment is reported in Fig. 1, and all orthopaedic procedures done (CI 4.5–5.8) and underlined that after 14 days, it is highly are analysed in Fig. 2. unlike that further symptomatic infections would be undetect- Data about age, gender, living situation, diagnosis, date of ed among high-risk individuals, as is the case of recent admission and discharge, dates and types of surgery per- formed, status of COVID-19’s screening, data of ulterior pos- itive test and early mortality were collected from hospital medical records. If the same patient was hospitalized twice, each hospitalization was counted as a different period. Likewise, for patient who developed nosocomial infection with SARS-CoV-2, data about comorbidities, nutritional sta- tus, diagnose contextualization, clinical course and medical and surgical complications were further investigated. Clinical outcomes for all patients were monitored up to May 18th, 2020. At the moment of recollecting data, eight patients were still hospitalized. Ethical approval for this study was obtained from the Research Ethics Committee of our institution (PR(AG)336/2020). Fig. 1 Reason for admission of all patients International Orthopaedics (SICOT) Statistical analysis Categorical variables were presented with their absolute values and percentages and quantitative variables were expressed as mean (standard deviation, SD). Continuous var- iables were compared using Student’s t test or Mann-Whitney U test, whereas categorical variables were compared using the χ2 test or Fisher’s exact test, as appropriate. The most relevant risk factors associated with nosocomial SARS-Cov-2 infec- tion were selected in the bivariate logistic regression analysis. Variables with a p value < 0.05 in the bivariate logistic regres- sion analysis were included in the final multivariate logistic regression analysis. A p value < 0.05 was considered statisti- Fig. 2 Orthopaedic procedures of all patients. Other procedures (12%) cally significant. SPSS software (version 23.0; IBM) was used mainly included hardware removal, peripheral nerve revision surgery, for statistical analysis of collected data. closed reduction and cast application, joint infiltration (hip and thoracic and lumbar facet joint injection) and correction surgery of various foot deformities Results During this period, from the 52 staff members and 26 residents hospitalized patients [4]. Thus, in our study, nosocomial in- of the Orthopaedic Team, eight members (4 staff members fection with SARS-CoV-2 was defined by meeting these and 4 residents) were diagnosed with COVID-19 infection. requirements: Nineteen patients (6.48%) met the inclusion criteria to be cat- egorized as a nosocomial infection with SARS-CoV-2 – Not having a positive test screening at admission or clin- (Table 2). Statistically significant differences were found in ical symptoms suggestive of SARS-CoV-2 infection. age, sex, residence, reasons for admission, mortality, period of – Developing COVID-19 infection during the hospitaliza- admission and length of hospital stay (p < 0.05) between pa- tion period or during the first 14 days after discharge. tients not infected with COVID-19, patients with nosocomial infection and patients infected at the time of admission If screening test was not performed, patient was catego- (Table 3). From the patients who had a positive test result at rized as developing nosocomial infection with SARS-CoV-2 admission, mean age was higher comparing with the other two if the diagnosis was done after the fourth day of hospitaliza- groups (mean age 83.3 years old; SD 6.7). Furthermore, 100% tion, according Lauer et al. investigations [4]. of these patients were women, percentage who lived in nurs- ing home was higher (40%) and mortality was also superior Protective measures (50%). Analysing the reason for admission of the nineteen patients External consultations were converted to telematics phone- who developed nosocomial infection with SARS-CoV-2 ac- call consultation whereas possible. Additionally, systematic cording to our definition, incidence in each subgroup of pa- screening with thorax X-Ray, nasopharyngeal swabs and a tients susceptible to develop it was calculated. A total of 11% quantitative PCR test to detect SARS-CoV-2 infection of of the susceptible patients with a proximal femoral fracture patients upon admission into our department was implanted acquired it, as the 7% of the patients with a lower extremity on March 30th, 2020. Until then, the test was performed fracture and the 13.8% of the patients with an infection-related only in case of suggestive symptoms or recent contact with process developed it too. None of the 26 patients hospitalized a COVID-19+ patient. Droplets and contact isolation pre- during the study period who underwent a THR or TKR devel- cautions were adopted in all patients having a positive PCR oped a nosocomial infection with SARS-CoV-2. test, until negative result. All chest X-Ray were reviewed Evaluating the medical and surgical complications after and evaluated by a radiologist. Emergency department was surgery of the 19 mentioned patients, only two patients were also divided into two different circuits to separate COVID- registered with no complications. Eight patients developed 19+ patients and non-COVID-19 patients. Social distancing severe anaemia according to WHO classification (Hb < was applied among healthcare workers when possible, in- 8.0 g/dL), seven suffered acute respiratory failure (one of them cluding common spaces as dining halls, lifts and work due to an acute pulmonary oedema) and six developed cardiac spaces. Additionally, family visits were also prohibited failure (2 of them due to a new onset of atrial fibrillation). from March 16th, 2020, onward. Additionally, two patients developed urinary tract infection International Orthopaedics (SICOT) Table 2 Description of all characteristics, including laboratory data at the time of diagnosis, of the patients developing nosocomial infection with COVID-19 Clinical characteristics Patients developing nosocomial infection with COVID-19 (n = 19) Age (years) Mean (SD) 78.3 (19.9) Gender % (n) Male 47.4 (9) Female 52.6 (10) Residency % (n) Family home 84.1 (16) Nurse home 10.6 (2) Transfer from other hospital 5.3 (1) Comorbidities % (n) Smoking history 31.6 (6) Hypertension 68.4 (13) COPD 5.3 (1) Asthma 15.8 (3) Cerebrovascular accident 21.1 (4) Ischemic cardiopathy 21.1 (4) Dyslipidaemia 26.3 (5) Chronic renal failure 15.8 (3) Cancer history 26.3 (5) Reason for admission % (n) Proximal femoral fracture 52.6 (10) Fracture of lower extremity 15.8 (3) Infection 21.1 (4) Polytrauma 5.3 (1) Non-traumatic spine lesion 5.3 (1) Hospital length of stay before COVID-19 diagnosis (days) Median (range) 16 (6–86) COVID-19 screening test % (n) Negative 36.8 (7) Not performed 63.2 (12) Moment of COVID-19 diagnosis % (n) During hospitalization 84.2 (16) After hospital discharge 15.8 (3) Do-Not-Resuscitate status before COVID-19 diagnosis % (n) 52.6 (10) Signs and symptoms at the time of diagnosis % (n) Cough 63.2 (12) Fever 47.4 (9) Dyspnoea 21 (4) Diarrhoea 0 (0) Oxygen saturation on room air at the time of diagnosis % (range) 95 (82–99) Most aggressive ventilation mode applied % (n) Room air 47.4 (9) Nasal cannulae 5.3 (1) High-concentration oxygen mask 42.1 (8) Tracheostomy 5.3 (1) Albumin (g/dL) Mean (SD) 2.85 (0.41) International Orthopaedics (SICOT) Table 2 (continued) Clinical characteristics Patients developing nosocomial infection with COVID-19 (n = 19) Leukocytes count (109/L)* 7.22 (3.02–14.86) Neutrophils (109/L)* 5.2 (1.6–13) Lymphocytes (109/L)* 1 (0.1–2.7) C-reactive protein (mg/L)* 6.2 (1.87–18.7) Interleukin-6* 37.06 (1.89–1196) Ferritin* 770 (352–3118) D-dimer* 1335 (300–11,000) Mortality % (n) No 63.2 (12) Yes 36.8 (7) % percentage, n number, SD standard deviation, COPD chronic obstructive pulmonary disease *Values are given as the median (range) with Escherichia coli; one patient suffered of a deep venous with patients without COVID-19 infection (6.4%). The prin- thrombosis of the upper extremity. Only one surgical compli- cipal findings of our study were that age (OR 16.5; 95% CI: cation was registered: a wound infection after spinal fusion in 68.9–87.5 years; p < 0.007) and hospital length of stay (OR a 44-year-old polytrauma patient, who required a surgical 7.6; 95% CI: 23.5–39.7 days; p < 0.001) were statistically sig- debridement. nificant risk factor for developing nosocomial infection with In a comparison between patients with and without noso- SARS-CoV-2. comial infection, only age, mortality and hospital length of Minimizing nosocomial transmission of COVID-19 re- stay were statistically significant (p < 0.05). No statistically mains a challenge, given the wide spectrum of respiratory significant differences were found in sex (p = 0.77), living syndromes and mild respiratory symptoms at presentation situation (p = 0.31), reason of admission (p = 0.19) or period [5, 6]. Nosocomial transmission has emerged as a significant of admission (p = 0.15) (Table 4). Using the bivariate and concern; in Wuhan, almost one-third of an initial cohort of multivariate logistic regression to assess risk factors of noso- COVID-19 patients were healthcare workers (HCWs) and comial COVID-19 infections, age (Odds ratio (OR) 16.5; 95% hospitalized patients [7]. To our knowledge, only two studies confident interval (CI): 68.9–87.5 years; p < 0.007) and hos- have reported the rate of nosocomial infection with SARS- pital length of stay (OR 7.6; 95% CI: 23.5–39.7 days; CoV-2 between patients. Luong-Nguyen et al. reported a p < 0.001) were statistically significant (Table 5). 4.9% (15/305) of nosocomial infection with SARS-CoV-2 Additionally, all nosocomial COVID-19 infections occurred in three different department of digestive surgery [2]. when there were admitted more than 450 patients with Vanhems et al. reported an infection rate of 20% among pa- COVID-19 infection in our institution. However, there was tients in a French geriatric unit [8]. Differences of these rates no statistical significance on this issue (p = 0.99) (Fig. 3). On may be explained by the mean age of the patients analysed. April 1st, 2020, over 800 patients were hospitalized in our Protective measures applied and early PCR test screening in- institution with COVID-19 infection. Our hospital was classi- stauration may have also played an essential role to decrease fied thereby as the hospital in Catalonia that attended the nosocomial infection with COVID-19. In Luong-Nguyen highest amount of patients with COVID-19 infection during et al., mean age of patients with COVID-19 nosocomial infec- the outbreak (over 2000 patients). tion was 62 years old; meanwhile, in our study, the mean age was 78.3 years old. Vanhems et al. reported that the index case had 97 years old. Discussion We found that age was a statistically significant risk factor for nosocomial infection with SARS-CoV-2 The risk of nosocomial infection with SARS-CoV-2 seems to (p < 0.007). In our study, the mean age of all patients be a key factor for the progressive restoration of normal sur- was 66.1 years old (range 16–101). This high mean age gical activity in hospitals. In our study, we had a 6.48% (19/ may be explained because of the demographics of Spain, 293) of nosocomial infection with SARS-CoV-2. There was a as the 18.15% of the Spanish population are 65 years old higher mortality in patients admitted with COVID-19 (50%) or older. Spain is currently expected to be the country and patients with nosocomial infection (36.8%) comparing with the most elderly population in the world by 2040 International Orthopaedics (SICOT) [9]. As it has been already reported, despite the contin- looking after the protection of health workers, the protocol gency plans and lockdown measures, the incidence of was improved. All patients admitted wore surgical mask osteoporotic hip fractures seemed to remain stable during and underwent an RT-PCR test for COVID-19. The positive the State of Emergency (implementation of stringent lock- effects of these measures were studied with the bivariate down measures for the population) [10, 11]. In the present regression analyses, which did not find statistically signifi- study, proximal femoral fracture was the most common cant differences between the patients hospitalized with reason for admission (33.8%). As the increase in the se- COVID-19 in our institution and the risk of developing nos- verity of COVID-19 with age is clearly studied [12], pro- ocomial SARS-CoV-2 infection in our department (OR 1.0; tective measurements were applied universally in our de- 95% CI: 0.998–1.002; p = 0.80). partment, but with special emphasis in elderlies. The median time from admission to diagnosis of SARS- We observed that most of the nosocomial infections oc- CoV-2 infection in our cohort was 16 days (range of 6– curred in March (78.9%), when the outbreak was higher. 86 days). Hospital length of stay was a statistically significant Until March 31st, at admission, an RT-PCR for COVID- risk factor for nosocomial infection with SARS-CoV-2 (p < 19 was only requested if the patients had symptoms or had 0.001). Luong-Nguyen et al. reported a median time from a pathological chest X-ray evaluated by a radiologist admission to diagnosis of SARS-CoV-2 infection of 34 days (Fig. 4). Due to the increase of pandemic outbreak and (5–61 days). In their study, 12 patients (80%) were diagnosed Table 3 Description of general characteristics of patients (analysed by groups, depending on the COVID-19 infection status) COVID-19 infection Non-infected (n = 264) Nosocomial infection (n = 19) Infected at admission (n = 10) p value Age (years) Mean (SD) 64.5 (20.7) 78.3 (19.6) 83.3 (6.8) < 0.05 Gender % (n) Male 43.9 (116) 47.4 (9) 0 (0) 0.02 Female 56.1 (148) 52.6 (10) 100 (10) Residency % (n) Family home 93.2 (246) 84.1 (16) 50 (5) 0.001 Nursing home 3.8 (10) 10.6 (2) 40 (4) Transfer from other hospital 3.0 (8) 5.3 (1) 10 (1) Reason for admission % (n) Proximal femoral fracture 30.7 (81) 52.6 (10) 80 (8) 0.001 Fracture of lower extremity* 15.2 (40) 15.8 (3) 10 (1) Fracture of upper extremity 11.0 (29) 0 (0) 0 (0) Infections 9.5 (25) 21.1 (4) 10 (1) Others 33.6 (89) 10.5 (2) 0 (0) Hospital length of stay (days) Mean (SD) 11.2 (16.9) 31.7 (28.9) 17.7 (12.8) < 0.05 Mortality % (n) No 93.6 (247) 63.2 (12) 50.0 (5) 0.001 Yes 6.4 (17) 36.8 (7) 50.0 (5) Period of admission % (n) Before 1st March 10.6 (28) 21.1 (4) 0 (0) 0.002 Between 1st and 15th March 45.1 (119) 36.8 (7) 0 (0) Between 16th and 31st March 14.0 (37) 31.6 (6) 0 (0) Between 1st and 15th April 13.3 (35) 5.3 (1) 60 (6) Between 16th and 30th April 16.7 (44) 5.3 (1) 30 (3) After 30th April 0.3 (1) 0 (0) 10 (1) % percentage, n number, SD standard deviation *Does not include proximal femoral fractures International Orthopaedics (SICOT) Table 4 Description of general characteristics of patients (analysed by groups, depending on the COVID-19 infection status and excluding patients with COVID-19 infection at admission) Nosocomial COVID-19 infection No (n = 264) Yes (n = 19) p value Age (years) Mean (SD) 64.5 (20.7) 78.3 (19.6) < 0.05 Gender % (n) Male 43.9 (116) 47.4 (9) 0.85 Female 56.1 (148) 52.6 (10) Residency % (n) Family home 93.2 (246) 84.1 (16) 0.31 Nursing home 3.8 (10) 10.6 (2) Transfer from other hospital 3.0 (8) 5.3 (1) Reason for Admission % (n) Proximal femoral fracture 30.7 (81) 52.6 (10) 0.19 Fracture of lower extremity* 15.2 (40) 15.8 (3) Fracture of upper extremity 11.0 (29) 0 (0) Infections 9.5 (25) 21.1 (4) Others 33.6 (89) 10.5 (2) Hospital length of stay (days) Mean (SD) 11.2 (16.9) 31.7 (28.9) < 0.05 Mortality % (n) No 93.6 (247) 63.2 (12) 0.001 Yes 6.4 (17) 36.8 (7) Period of admission % (n) Before 1st March 10.6 (28) 21.1 (4) 0.15 Between 1st and 15th March 45.1 (119) 36.8 (7) Between 16th and 31st March 14.0 (37) 31.6 (6) Between 1st and 15th April 13.3 (35) 5.3 (1) Between 16th and 30th April 16.7 (44) 5.3 (1) After 30th April 0.3 (1) 0 (0) % percentage, n number, SD standard deviation *Does not include proximal femoral fractures after a hospital length of stay greater than 14 days [2]. optimization of patients is more essential than ever [13]. However, they only made a descriptive analysis of patients Modifiable variables and correct selection of patients, as well with nosocomial SARS-CoV-2 infection, with no comparison as preventing protocols to restrict increases of hospital length [2]. Due to the imminent restoration of the surgical activity, to stay, should be carefully evaluated. In a systematic review and understand modifiable risk factors of nosocomial SARS-CoV- meta-analysis of 21,494,459 patients undergoing a knee 2 infection becomes crucial for all surgery departments. As arthroplasty, Shah et al. found that a pre-operative most of orthopaedic surgery is elective, pre-operative haemoglobin < 13.0 g/dL (95% CI = 0.34 to 0.98; p < 0.001) Table 5 Bivariate and multivariate analysis of the risk Bivariate Multivariate factors for nosocomial COVID- 19 infection OR (95% CI) p value OR (95% CI) p value Age 1.06 (1.02–1.10) p = 0.02 16.5 (68.9–87.5) p = 0.007 Hospital length of stay 1.04 (1.02–1.16) p = 0.001 7.6 (23.5–39.7) p = 0.001 OR odds ratio, CI confidence interval International Orthopaedics (SICOT) Fig. 3 Relation between number of COVID-19+ patients in our institution, number of patients hospitalized at our department and nosocomial COVID- 19 infection was a risk factor for an increased hospital length of stay [14]. Our study has the limitations and weaknesses of retro- In a prospective study, Piuzzi et al. concluded that increased spective designs, and the fact that RT-PCR test for age, higher body mass index and greater Charlson COVID-19 was not performed to all patients prior to hos- Comorbidity Index were predictors of a longer hospital length pital discharge may be reducing the rate of nosocomial of stay (p < 0.001) [15]. Notwithstanding, most studies have infection by this way. However, a follow-up of 14 days found that early discharge is not an independent risk factor for after discharge to all patients was made, and all suspicious major complications or readmissions following arthroplasty cases were tested with a RT-PCR for COVID-19. Three [16, 17]. As well, programs for a rapid return to home in patients were added to our cohort of patients with noso- elderly patients who have undergone surgery for fractures comial infection in the first 14 days after hospital dis- have already demonstrated better results in terms of readmis- charge, maybe overestimating the rate of nosocomial in- sion rates, mobility and autonomy [18, 19]. fection. To our knowledge, this is the first study to Fig. 4 a Thorax X-ray at admis- sion of an 82-year-old patient ad- mitted in our hospital. b Thorax X-ray of the same patient after 27 days of hospitalization, pre- senting multifocal and bilateral reticular interstitial opacities with lower lobes predominance and alveolar opacity in the right upper lobe. Right lower lobe atelectasis. No pleural effusion International Orthopaedics (SICOT) analyse risk factors of nosocomial infection with SARS- 6. Mavrogenis AF, Quaile A, Scarlat MM (2020) The virus crisis affects orthopaedic surgery and scientific activities worldwide. CoV-2 within an orthopaedic surgery department. International Orthopaedics (SICOT) 44:813–817 To conclude, we have found in our study a 6.48% of nos- 7. Huang C, Wang Y, Li X et al (2020) Clinical features of patients ocomial infection with SARS-CoV-2 between March 9th, infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020, and May 4th, 2020, but with an important reduction 395(10223):497–506 8. Vanhems P (2020) Fast nosocomial spread of SARS-CoV2 in a of it after undergoing preventing protocols that included French geriatric unit Lyon Study Group on Covid-19 infection. screening RT-PCR test for COVID-19. Age and hospital Infect Control Hosp Epidemiol. https://doi.org/10.1017/ice.2020. length stay were statistically significant risk factors for noso- 99 comial infection with SARS-CoV-2. For the progressive res- 9. Foreman KJ, Marquez N, Dolgert A et al (2018) Forecasting life expectancy, years of life lost, and all-cause and cause-specific mor- toration of the surgical activity, we recommend to correctly tality for 250 causes of death : reference and alternative scenarios select the patients in elective surgery and to encourage fast- for 2016–40 for 195 countries and territories. Lancet. 392(10159): track programs and early discharge of patients with fractures. 2052–2090 10. Núñez JH, Sallent A, Lakhani K et al (2020) Impact of the COVID- Acknowledgments We would like to thank Dr. Magda Campíns-Martí, 19 pandemic on an emergency traumatology service: experience at Head of Service of the Preventive Medicine and Public Health a tertiary trauma centre in Spain. Injury. 51(7):1414–1418 Department of the Hospital Universitari Vall d’Hebron (Barcelona, 11. Meng Y, Leng K, Shan L et al (2020) A clinical pathway for pre- Spain), for her valuable work undertaken during the coronavirus outbreak operative screening of COVID-19 and its influence on clinical out- and for the epidemiological assessment in conducting the present study. come in patients with traumatic fractures. International Orthopaedics (SICOT) 44:1549–1555 12. Verity R, Okell LC, Dorigatti I, Winskill P, Whittaker C, Imai N, Funding This research did not receive any specific grant from funding Cuomo-Dannenburg G, Thompson H et al (2020) Estimates of the agencies in the public, commercial or not-for-profit sectors. severity of coronavirus disease 2019: a model-based analysis. Lancet Infect Dis 20(6):669–677 Compliance with ethical standards 13. Parvizi J, Gehrke T, Krueger CA et al (2020) Resuming elective orthopaedic surgery during the COVID-19 pandemic. 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