Getting it right in time

by Alex Trompeter 

Published 30 March 2020

Today, 30th March, is my birthday. As always, birthdays are a time for reflection and looking back over the past year to consider achievements, good results, near misses, what ifs, and downright disasters. As I sit here in isolation with my family (my wife and I both had symptoms of COVID-19) I realise that reflection and perhaps more importantly, foresight are increasingly relevant at this time.

The spread of COVID-19 is happening rapidly. The surge is upon us. We cannot be complacent and wait to embark on a period of rumination after this is all over, wondering what if…. We need to act now.  As orthopaedic surgeons, we are not the vanguard in this war. That role falls to our intensive care, anaesthetic, medical and nursing colleagues, not to mention the huge number of allied healthcare professionals supporting them. So, what is it that we, as an orthopaedic community, should be doing?

Our experience in London is perhaps slightly ahead of the rest of the country. We have seen a huge number of cases already. Our hospital, St George’s, is filling rapidly, and the numbers are startling. We can tell you from our own limited experience at this time, that if you have not planned for things already, at the worst-case scenario, you are too late. Leaving the bigger pictures to one side, such as number of ventilated beds, zoning of wards and wings to COVID-19 positive and negative, and so on, what should an orthopaedic department be considering right now?

Firstly, workforce planning. You need to accept your juniors will be seconded to medical specialties within the next few days. Your rotas need to consider a consultant delivered service of all aspects of care – wards, on call, trauma lists, clinics and so forth. We have developed a 3-team based rota system, 3 days on and 6 days off. That will drop to two teams as staff become ill or isolate, and then eventually just one team. Your solutions need to include the doomsday scenario of just a few of you left working in the department, sustaining a skeleton service with a skeleton staff. Does your consultant body know how to electronically prescribe, book a CEPOD case, recognise and manage a deteriorating medical patient, and write a discharge summary?

Clinic activity will need to be reduced massively. Plans need to include the loss of administrative and nursing staff – so how will you manage letters/documentation/booking follow ups? Elective clinics are now all virtual, fracture clinic sees only the most urgent, and the majority of people are followed up via telephone. Clinic can even be run from home, so have you got all your consultants with remote access and NHS card readers or equivalent at home?

Orthopaedic and plastic surgery teams may well find themselves running the A+E minor injuries units. Are they familiar with the different computer systems that many EDs use compared to the rest of the hospital? Do you have new SOPs for certain injury groups – wounds and lacerations, dislocations, casting of injuries?

Surgery – many difficult decisions will need to be made over the next few weeks. The NHSE and emergency BOAST documentation around this provide a lot of support. Offering non operative management wherever possible and accepting late reconstruction as a consequence will become the norm, as will discussions on ceilings of care. The burden on one individual to make some of these challenging decisions may be too much – we have introduced a daily triumvirate of 3 wise heads to take the responsibility of any difficult decision away from the consultant on call. Your surgical capacity will become significantly limited if not already – at St George’s, we are down to sharing CEPOD lists with other specialties and have made provisions in our rotas for night-time operating. Are your staff all trained in PPE donning and doffing? Do you have a daily meeting between all surgical specialties prioritising case mix? Have you explored sending ambulatory trauma to the private sector?

Communication – perhaps of all the things to have in place early on, a functional communication platform is essential. Virtual meetings work well in this era of social distancing. Microsoft Teams has been our choice tool for running the trauma meeting – no need for 30 people to be in a room. More beneficial is an evening consultant online meeting every day. An agenda set out to discuss all aspects of our service, with a strict one-hour time limit. It is not compulsory, but everyone dials in – the pace of change here is so fast, that a daily catch up has proven to be hugely valuable.

Finally, your trauma network should have considered the redistribution of case mix already. Triage of the majority of trauma cases to the trauma units is likely to happen. Have you considered the implications of this? What is the skill mix in the peripheral units, how can the major trauma centres offer support, and how can the trauma units get rapid assistance when needed? We have a daily network trauma meeting, running directly after our own in the MTC, offering an opportunity for each TU to discuss any cases they need support with, not just fractures, but all aspects of major trauma.

There is a huge amount of work to be done in getting your trauma service prepared for the next few weeks. There is no doubt the majority of units have got plans in place, but our experience is that by the time your plans are circulated they will need to change again. You need the next 2 or 3 iterations of planning ready to go at the drop of a hat. Until a couple of months ago, ‘Getting it Right First Time’ was a mantra well appreciated in orthopaedics. With the COVID-19 pandemic we may not get it perfectly right as there are too many unknowns, but we have to have plans in place – Getting it Right In Time is perhaps the more appropriate mantra now. We have to have processes and systems that allow us to move forward at the pace the virus dictates, not how we would like to work. These plans may not be perfect, and need to be flexible, but something is better than nothing.

We have provided a compilation of some of our documentation and planning processes from St George’s, with permission to share. I am extremely grateful to the extraordinary work of our clinical directors for orthopaedics and the whole of surgery, Mr Yemi Pearse and Miss Shami Umarji. Their foresight is impressive, and rightly so - once this is all over, you do not want to be the ones sat reflecting and wondering ‘what if’…

Alex Trompeter

BOA Trauma Committee
Consultant Orthopaedic Trauma Surgeon, St George’s University Hospital, London
Honorary Reader in Orthopaedic Surgery, St George’s University of London

Alex is happy to be contacted by anyone wanting more information: alex_trompeter@hotmail.com