Orthopaedic care during COVID-19: An overhaul of services in the West of Ireland

By McCabe P, Fitzgerald E, O’Neill B and Kelly J

Department of Trauma & Orthopaedic Surgery, Sligo University Hospital, Sligo, Ireland

Corresponding author email: patrickmccabe@rcsi.ie

Published 01 July 2020

Introduction

The unprecedented speed at which COVID-19 swept across western Europe imposed a sudden and profound strain our health service. In spite of a national lock-down and 'stay at home' order, orthopaedic units at the frontline of healthcare, had to maintain full functionality due to the relentless and unpredictable nature of trauma and the urgency required in the management of same. With international guidelines recommending the implementation of strict social distancing, a review of methods by which we currently provide outpatient services was necessary, in order to protect both our staff and our patients. A large cohort of patients attending for orthopaedic injuries are also in the so called 'high-risk' category, primarily due to age and associated comorbidities, highlighting the importance of safe practice in orthopaedics specifically. The British Orthopaedic Association (BOA) released new, Standards for Trauma and Orthopaedics (BOAST) in response to the COVID-19 pandemic, these were compiled in conjunction with the following bodies; Orthopaedic Trauma Society (OTS), British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), British Society for Surgery of the Hand (BSSH), The British Association of Hand Therapists (BAHT) and the British Society for Children’s Orthopaedic Surgery (BCOS)1. In which it highlighted the need for orthopaedic departments to remain functional while providing principles in how to adopt a specific management algorithm in order to protect both the staff and patients alike by utilising the outpatient department to is maximum potential. These guidelines entitled 'Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic' identified 6 key areas for consideration with specific recommendations within each area:

  1. General management considerations
  2. Outpatient management of traumatic and urgent orthopaedic conditions
  3. Inpatient management of traumatic and urgent orthopaedic conditions
  4. Management of patients with hand injuries
  5. Management of children with orthopaedic trauma
  6. Management of children with non-traumatic orthopaedic conditions.

We describe here the rapid and fundamental overhaul of Trauma and Orthopaedic services in a level 3 hospital in the west of Ireland in accordance with the BOAST COVID-19 guidelines1.

Methods

A retrospective review of practice protocols and procedures was undertaken to assess the one month period prior to implementation of the new BOAST guidelines (February 2020). For comparison with those in an analogous one month period following implementation of same (April 2020), allowing a sufficient time period for application of said recommendations. The main area of focus was specifically 'Recommendation 2' of the BOAST guidelines 'Management of patient with traumatic injuries and urgent orthopaedic conditions treated as outpatients during the coronavirus pandemic' which outlines 16 principles. We assessed the performance of our unit based on compliance with same, and notably we describe the innovative methods deployed in this particularly novel scenario in order to achieve compliance.

Results

In February 2020 our department treated 936 outpatients of which 587 were trauma patients and 349 were elective patients. Meanwhile in April 2020 total patients treated in the hospital numbered 756 with 415 trauma and 341 elective patients, (see Table 1). Significantly in April however, following the implementation of the virtual clinic a new subset of patients numbering 309 were facilitated without the need to physically attend the hospital. Notably 62% of all new referrals from the ED during April were deemed suitable for virtual clinic follow-up, thus significantly reducing the number of attendances at the fracture clinic. Furthermore, following chart review of the upcoming clinics, a further cohort of patients were identified and deemed for eligible virtual follow up resulting in a 30% reduction in review patients attending clinic. This resulted in another marked reduction in physical attendances, significantly reducing risk to both patients and staff and also allowing for adequate spacing of clinic appointments to avoid unnecessary crowding in the waiting room and clinical areas.

Table 1: Monthly comparison of No. of patients treated

Month

Trauma Outpatients

Elective Outpatients

Total Outpatients

Virtual Outpatients

February 2020

587

349

936

0

April 2020

415

341

756

309

 
Table 2: Means of achieving compliance with BOAST recommendations

 

BOAST recommendation

Achieved

Means of achieving compliance

1

Consultant delivered definitive decision making at first attendance.

Yes

SIILO referral from ED with consultant review over all referrals.

2

Orthopaedic management of minor injuries presenting to Emergency department as 7-day service.

No

Continued primary management by ED with 24/7 senior orthopaedic input via SIILO.

3

Safely-spaced waiting areas, assessment and treatment cubicles with space for PPE storage, donning and doffing.

Yes

Social distancing, spacing in waiting room, alternating cubicles used, Face masks in clinic, Yellow bins in all areas with PPE info-graphics displayed.

4

Patients who potentially need immediate management that requires sedation facilities, such as those with dislocations, may need to remain in the ED, but T&O teams should aim to manage these patients.

Yes

Continued primary management by ED with 24/7 senior orthopaedic assistance via SIILO.

Plaster technician engagement via SIILO during routine hours.

5

GPs and Minor Injury Units (MIU) should have direct telephone access to senior T&O advice to minimise the need for patients to attend the Trauma Clinic. The risk of hospital attendance may outweigh the potential benefit of intervention, particularly for patients in vulnerable groups.

Yes

Direct contact with on-call Registrar for minor queries, else standard ED referral pathway.

6

Impact on radiology services should be minimised. Imaging should be requested after the patient has been assessed in the Trauma Clinic to minimise requests and avoid repeat imaging. Avoid use of multiple imaging modalities and consider immediate use of the modality most likely to give a definitive diagnosis. Arrange for use of a mini C-arm in the Trauma Clinic if possible. CT scanning should be minimised as this is the investigation of choice for coronavirus pneumonitis.

Yes

Senior orthopaedic chart review prior to selection of image modality of choice, if required.

7

Use of removable casts or splints should be maximised to reduce follow-up requirements.

Yes

Plaster technicians utilised for application of non-routine bracing, splints and casts directly in the ED via SIILO during routine hours.

8

Patient-initiated follow-up should be the default, with booked appointments only where this is unavoidable. Junior doctors should not arrange follow-up without senior agreement.

Yes

TAC patient information sheets containing contact number & 24/7 answering machine. Follow-up diary reviewed by consultant on call with senior team members daily.

9

Follow-up appointments should be delivered by telephone or video call if at all possible. Existing appointments should be cancelled, postponed or conducted remotely.

Yes

Introduction of TAC clinic, with virtual follow-up as appropriate.

All patients contacted by senior orthopaedic team member.

10

Follow-up imaging should only be performed when there is likely to be a significant change in management. There is no role

for imaging to check for fracture union in most injuries.

Yes

Senior orthopaedic chart review prior to selection of image modality of choice, if required.

11

Rehabilitation services are likely to be very limited. Alternative resources such as written and web-based information should be maximised.

 

Yes

Tele-physiotherapy arranged for patients. YouTube channel created with simple rehabilitation information and exercises. Written physiotherapy exercises posted to patients’ post- virtual consultation.

12

Dislocations of native and replaced joints should be reduced in the ED, MIU or Trauma Clinic wherever possible. If the joint is stable after reduction, the patient should be discharged with appropriate follow-up.

Yes

Introduction of TAC clinic, with virtual follow-up as appropriate.

13

Most upper limb fractures, including clavicle, humeral and wrist fractures, have high rates of union and may be managed non-operatively, recognising that some patients may require late reconstruction.

Yes

Introduction of TAC clinic, with virtual follow-up as appropriate.

14

Ligamentous injuries of the knee may be managed with bracing in preference to early ligament reconstruction.

Yes

Introduction of TAC clinic, with virtual follow-up as appropriate.

Contemporaneous appropriate bracing by Plaster Technicians via SIILO, during routine hours.

15

Penetrating injuries (stab wounds) to the limbs that are not contaminated and have no neurological or vascular deficit may be sutured in the ED, MIU or Trauma Clinic.

No

 

Continued primary management by ED with 24/7 senior orthopaedic input via SIILO.

 

16

Abscesses in patients without systemic sepsis may be incised and drained under local anaesthetic in the ED, MIU or Trauma Clinic.

No

Continued primary management by ED with 24/7 senior orthopaedic input via SIILO.

Discussion

The overhaul of our service in response to this pandemic, in an attempt to comply with the BOAST best practice guidelines can be surmised under 2 succinct headings:

  1. The modification of the referral process from the Emergency Department to the Orthopaedic team by means of the expedited implementation of a Trauma Assessment Clinic (TAC) type protocol combined with the exclusive use of an electronic referral pathway.
  2. Restructuring of the outpatient clinical environment in order to comply with social distancing guidelines.

Trauma assessment clinics are in place in numerous departments throughout the UK and Republic of Ireland with positive, known and validated outcomes2. It is a topic that had previously been broached in our department but due to various constraints, had hitherto not been acted upon. The restrictions imposed by the COVID-19 pandemic however presented an ideal scenario to deploy this valuable asset.

Thus, a modified version of the trauma assessment model was employed under the guidance of senior orthopaedic personnel. This was coupled with a newly implemented electronic referral platform 'SIILO'3 for all cases in the emergency department warranting an orthopaedic input. This encrypted and validated application available on various smartphone platforms allows for referral of cases from the emergency department to the orthopaedic team on-call. All members of the hospital’s Emergency Medicine Department, Consultants, NCHD’s & ANP’s were involved along with all members of the Orthopaedic Surgery Department including Plaster Technicians. This process allowed for contemporaneous referral of patients to the team on-call, the ability for one or multiple of these team members to provide input on case specific management and make pivotal, time sensitive decisions on whether the patient would be suitable to follow one of the 3 defined pathways: i) Admission to hospital; ii) Follow up in Virtual Trauma Assessment Clinic or; iii) Follow up in Orthopaedic Fracture Clinic. This senior input removed any layer of ambiguity that may have been present. Virtual referral pathways have been shown to be efficacious when combined with virtual fracture clinics in previous studies4.

The addition of other allied healthcare professionals, namely plaster technicians, to the pathway allowed for the application of optimal immobilisation at an early stage post injury. This was pivotal in light of the modified BOAST guidelines, highlighting a more conservative approach in fracture management and definitive management at the earliest opportunity. Application of specifically moulded casts at an early stage would aid in ensuring the best possible outcome in the conservatively managed patient, if other patient and injury specific factors allowed for same. It afforded the opportunity for a single definitive management interaction, which could last the duration of a patient’s treatment, thus negating the need for another journey to the hospital with the inherent risks associated with same, especially amongst vulnerable patient cohorts.

The patients selected as being suitable for virtual follow up, in accordance with virtual fracture clinic guidelines employed in other units2,5, were advised on the day of their injury to expect a telephone follow up from the orthopaedic team at specific time interval. The relevant orthopaedic registrar then performed the virtual consultation addressing any concerns that the patient may have and further virtual or physical clinical encounter were necessary. This single element dramatically reduced the volume of patients warranting physical attendance at the fracture clinic by 55% and thus reducing the overall risk profile to both patients and staff.

In combination with the details outlined above all patients scheduled to attend the clinic underwent a chart review by a senior member of the orthopaedic team in the preceding days. Patients were stratified into multiplicators;

  1. Those definitively requiring attendance at clinic e.g. post-operative patients warranting wound review, patients requiring Cast or K-Wire removal or in pathologies where clinical examination was unavoidable.
  2. Those deemed suitable for a virtual consultation, following which these patients were subsequently allocated to
    1. Attend the clinic as initially planned                          
    2. Rescheduled for further physical or virtual clinic
    3. Discharged directly to community services (Physio / GP) where appropriate.

Patients warranting attendance at clinic had a provisional management plan drafted prior to same which allowed for efficient scheduling of their attendance and an expedited transit through the department. Patients were scheduled to attend at 15-minute intervals in order aid compliance with governmental social distancing guidelines.

We also engaged the services of our dedicated musculoskeletal physiotherapists employing novel methods of providing virtual physiotherapy care or where necessary scheduling patients for one-on-one sessions in a safe environment, particularly important for those patients in vulnerable cohorts and those who had been placed in virtual clinics to negate the need for multiple hospital attendances.

With regards the areas of 'non-compliance' as outlined in Table 2, there were in fact other protocols in place negating the need for implementation of same and thus, there was no negative impact on patient care as a result. For example, regarding '7-day orthopaedic management of trauma patients in the ED'. This was not required as our Emergency Medicine Department underwent a significant restructuring, allowing for continued management of said patients in the ED with 24/7 orthopaedic input available via electronic referral as outlined above. Furthermore, the necessity for management of complex wounds and abscesses (point 15 and 16 respectively) in the ED was not relevant as our theatre capacity, access and location was not impacted to such a degree to warrant same.

Conclusion

Orthopaedic trauma will continue to be one of the largest burdens on hospital services and emergency departments and our experience throughout the pandemic reinforces this fact. The emergence of COVID-19 was the catalyst to force the rapid uptake of these various measures in our hospital, which will undoubtedly aid in streamlining our service and boosting efficiency, however not all of these methods are viable options in the long-term functionality of the unit. Thus, audit of effectiveness and employment of specific strategies that will have long term robustness will be necessary.

References

  1. British Orthopaedic Association (2020) BOAST - Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. Available at: https://www.boa.ac.uk/resources/covid-19-boasts-combined.html.
  2. O'Reilly M, Breathnach O, Conlon B, Kiernan C, Sheehan E. Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland. Injury. 2019;50(4):898-902.
  3. van Mameren V. WhatsApp Doc? The alternative. Available at: https://mastersofmedia.hum.uva.nl/blog/2018/09/23/whatsapp-doc-the-alternative/.
  4. Breathnach O, O'Reilly M, Morrissey K, Conlon B, Sheehan E. Electronic referrals for virtual fracture clinic service using the National Integrated Medical Imaging System (NIMIS). Ir J Med Sci. 2019;188(2):371-7.
  5. Kelly M, O'Keeffe N, Francis A, Moran C, Gantley K, Doyle F, et al. Connolly Hospital Trauma Assessment Clinic (TAC): a virtual solution to patient flow. Ir J Med Sci. 2020;189(2):425-9.