Trauma and Orthopaedic services during COVID-19 lockdown: The Stoke response to Coronavirus pandemic

By Kahlan Al Kaisi, Damian McClelland, Ian Dos Remedios, Maria Belen Carsi and Akshay Malhotra

The University Hospitals of North Midlands NHS Trust

Corresponding author e-mail: kahlan.alkaisi@nhs.net

Published 23 June 2020

Background

In January 2020, health systems of the entire world were struck by one of the biggest challenges in modern history. The World Health Organisation (WHO) declared corona virus a pandemic on 11th March 20201. In early March 2020, COVID-19 cases started to steadily rise in the UK2. In an attempt to reduce the number of cases; the UK government introduced social distancing measures and a lockdown procedure in the country on the 23rd March3. Despite these measures, the pandemic continued to spread, which put the NHS under pressure. The system responded rapidly by focussing its resources and undergoing major reconfiguration of services in order to save the lives of those infected with COVID-19. Across the country, strategic planning and service reconfiguration in medical and surgical specialities were carried out.

This article discusses the response of the Trauma and Orthopaedics (T&O) department at University Hospitals of North Midlands NHS Trust (UHNM) to the pandemic. The Department aimed to continue providing urgent and essential surgery during the crisis.

More than two months have passed since the UK underwent a lockdown in response to the COVID-19 outbreak. This would be a good time to reflect on the situation and explore the changes within our department, which enabled us to adapt to the COVID-19 pandemic. Through this document we would like to share our experience of what went well and what could have ben improved, with other medical organisations so that we could all learn from these unprecedented times.

Before the COVID-19 lockdown

University Hospitals of North Midlands NHS Trust has two sites; Royal Stoke University Hospital (RSUH) located in Stoke-on-Trent, and County Hospital (CH), located in Stafford. From these sites the organization provides a full range of acute hospital services for approximately 1.1 million people living in and around Staffordshire and beyond4. Moreover, the RSUH site is a tertiary referral hospital for Trauma and Orthopaedics, spine and neurosurgery, cardiothoracic and plastic surgery. The RSUH is also a Major Trauma Centre (MTC), providing specialist trauma service to almost three million people in a wider area, including neighbouring counties and North Wales. RSUH has approximately 1,157 beds while CH has 350 beds.

The Accident & Emergency (A&E) department at RSUH is open 24 hours a day, seven days a week. The A&E department at CH open every day from 8 AM to 10 PM while the minor injury unit at CH open from 8 AM to 6 PM.

The Musculoskeletal services in the trust, work across two sites (RSUH) and (CH). The unit comprises of 23 Trauma and Orthopaedic consultants and eight Spine Consultants supported by a team of 28 registrars and 17 junior doctors.

The elective orthopaedic and spine services both inpatient and day case are carried out at both sites. This is accomplished using three theatres and a 28 bedded ward at RSUH along with a 29 bedded Elective Orthopaedic Unit (EOU) and three theatre facility situated at CH.

For acute trauma, there is a dedicated fracture neck of femur ward and an additional three wards for acute and general trauma admission. Each ward has 29-30 beds. The hospital routinely operates almost 45 trauma theatres sessions a week including the weekends.

COVID-19 crisis

In preparation for the COVID-19 crisis, the national plan was to try and increase the ventilator capacity. Locally, decision was taken to convert majority of the theatre and recovery complex, at RSUH, into additional intensive care beds increasing our capacity to nearly 116 critical care beds. This would leave four theatres functioning 24x7 to provide a variety of acute emergency services.

On 30th March 2020, the T&O service moved into a 24/7 full shift system. The aim was to continue to provide acute and emergency services including being a Major trauma. All elective work was suspended and staff from CH was re-organised to support the critical care, theatre and recovery areas.

Rota

  • Consultants:
    • The consultant body was divided into five teams, 5-6 in each team, with a proportional skill mix of T&O subspecialties. On a daily basis there would be two teams present. The red team would cover the on call, acute admissions, major trauma and ward rounds. The black team would cover fracture clinic, virtual clinics and support the red team in case of emergencies, if required. The red team would cover a 24-hour period while the black team 12 hours (0730-2000). One consultant in each team was assigned as a team leader in a rotational manner. The team leaders would allocate duties to other consultants and registrars/junior doctors on day by day basis. There would be a minimum of three consultants available in each team during the day and one resident consultant at night, (see Table 1).
    • Five consultants were not included in the above two teams. This team covered minor injury unit, fracture clinic, and ward rounds on EOU at CH. They also ran a minor injury unit at Haywood Community Hospital.
  • Registrars:
    • To accommodate for absence due to isolation, the registrars work pattern changed into a long day shift 07:30 to 20:00 and nights shifts 20:00 to 08:00. This ran in a pattern of three days on followed by three days off. During the day, one registrar would be on call to provide T&O emergency care and one registrar to cover the on call for spine emergencies. A minimum of two registrars allocated to theatres and two registrars to ward rounds. A further two registrars along with two consultants would cover fracture clinic and minor injury units at CH and Haywood Hospital, (see Table 2).
    • Consultant-Registrar pairing for training purposes was postponed.
  • Junior Doctors:
    • Core Surgical Trainees were redeployed to A&E.
    • Foundation doctors and Trust grade junior doctors: three doctors at F1 level to cover the wards and seven doctors at F2/Trust Grade level to cover ward as well as second on call duties for T&O, (see Table 3).
  • Care was taken to keep the average weekly working hours in line with the national working time regulations.
  • Work force availability and back up teams was arranged to accommodate for self-isolation, sick leave, and exhaustion.
  • Changes to rota and allocations was advertised and circulated via email and online platforms e.g. WhatsApp® on daily basis, (see Table 4).
Table 1: Consultants teams work pattern in an average week during COVID-19 lockdown

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Team 1 (Red)

Team 3 (Red)

Team 2 (Red)

Team 4 (Red)

Team 5 (Red)

Team 1 (Red)

Team 3 (Red)

Team 2 (Black)

Team 4 (Black)

Team 5 (Black)

Team 1 (Black)

Team 3 (Black)

Team 2 (Black)

Team 4 (Black)

Table 2: Registrars duties in an average week during COVID-19 lockdown
Duties Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
Theatre 2 2 2 2 2 3 3
On call T&O 1 1 1 1 1 1 1
On Call-Spines 1 1 1 1 1 1 1
Haywood-Minors 1 1 1 1 1 1 1
County-Minors 1 1 1 1 1 0 0
Nights 3 3 3 3 3 3 3
Table 3: Junior Doctors work pattern on an average week
Duties Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7
On call Junior T&O Dr 1 1 1 1 1 1 1
Ward cover RSUH 2 2 2 2 2 0 0
Ward cover CH 1 1 1 1 1 1 1
Ward cover - Spines 1 1 1 1 1 1 1
Nights 1 1 1 1 1 1 1
Table 4: Clinicians present/attending different duties on an average week day

Duty

Red Team (consultants

Black Team (consultants)

Day Registrars

Day On call T&O registrar

Day On call T&O Junior Dr

Theatre Registrars

Night Shift Registrars

Night On call T&O Junior Dr

Trauma meeting

X

X

X

X

X

X

X

X

Theatres

X

 

 

 

 

X

X

 

Fracture clinic

 

X

X

 

 

 

 

 

Ward round

X

 

X

X

X

 

X

 

A&E/Minors

X

 

 

X

X

 

X

X

On call

X

 

 

X

 

 

X

X

Trauma meetings

  • A large area in fracture clinic waiting area was prepared to host the morning Trauma meeting and evening handover (to ensure social distancing measures). The Trauma meeting was held face-to-face by all teams on duty on that day and linked via Microsoft Teams to consultants and registrars at home (to provide as much consensus decision for each case).
  • The morning Trauma meeting started at 07:30 and evening handover at 20:00. Acute admissions recorded on Excel Spread sheet handover as before COVID-19. New fields added to the patient’s history (Clinical Frailty Score & COVID-19 status) to aid decision making.
  • Clinical decisions for each case followed the NHS England speciality guidelines and British Orthopaedic Association Standards for Trauma5,6.

Theatres

  • Due to emergency response by anaesthetic and theatre departments, only four theatres were made available to serve Emergency, Trauma, Urgent, & Cancer demand. Priority was given to life and limb threating emergencies. The trust also planned for further theatre capacity for Cancer surgery in the private sector. Moreover, the health board has taken the decision to treat all operative cases as a potentially COVID-19 positive. Each theatre was allocated a double number of staff and all personnel wearing full Personal Protective Equipment (PPE) during the operation including FFP3 masks7. A pause of 11-18 minutes after intubation and extubation to reduce risk of aerosol spread. These control measures made each operation take longer to perform because of the COVID-19 protocols required.
  • To accommodate for reduced capacity, all surgical specialties attended a theatre morning meeting at 08:00 to discuss planned operations for the day. Each operation was assessed on its urgency and relevance by the Lead Anaesthetic Consultant (Gatekeeper). Each case will be allocated a priority code:
    • E1 – within the hour
    • E2 – within 6 hours
    • E3 – within 12 hours
    • E4 – within 24 hours
  • The T&O Consultant Team Leader for the day attended the above meeting to discuss the planned trauma cases for that day. If accepted by the (Gatekeeper) entered onto a formal theatre list.

Wards

  • T&O in-patients were cared for by junior and foundation doctors along with registrars on day duty. This was supervised by the on call T&O consultant.
  • A maximum of three clinicians to present during patients review at ward round (to reduce the risk of COVID-19 contact and transmission).
  • Ward rounds started after trauma and morning theatre meetings once daily duties were allocated.

Emergency Care

  • A&E was divided into red area for COVID-19 suspected or proved and green areas for non-infected cases.
  • T&O department continued to provide major trauma and acute admission care at RSUH as before the lockdown.
  • The minor injury unit at CH and a walk in centre at Haywood Hospital were supported by one T&O consultant and one T&O registrar seven days a week on site. These two units were designed to care for walking wounded patients.
  • Urgent minor procedures and manipulations under local anaesthetics carried out at fracture clinic at RSUH during the hours 08:00-17:00.

Trauma Network

The department also provides service for pelvic and spine surgery in a regional network. This is carried out through online communication pathway (Refer a Patient). In response to the crisis, some changes applied to the pathway:

  • No patient to be transferred unless life or limb threatening disorder OR cannot be treated conservatively.
  • No COVID-19 suspicious or positive patient to be transferred unless consultant in critical care informed and agrees.
  • All patients for transfer must be fit and ready and willing for surgery.
  • No transfer if on irreversible anticoagulants unless life or limb threatening.
  • No patient to be transferred for diagnostic investigations.

Response to planned Elective work

New Clinics

  • All elective face-to-face (F2F) clinics for routine referral cancelled.
  • All elective routine adult referrals cancelled (choose and book closed).
  • All urgent adult and paediatric referrals to be triaged by respective sub specialty consultant for discharge, routine, urgent virtual or urgent F2F appointment.
  • Urgent F2F appointment to be booked into fracture clinic.

Follow-up clinics

  • All consultants triaged their follow up lists to determine urgent F2F or virtual appointments.
  • Consultants organised virtual or F2F follow up clinics with their secretaries.

Discussion

The T&O department at UHNM responded rapidly to the pandemic. There was a well planned reconfiguration in its structure, enabling it to continue to provide specialist trauma care for the regions. The elective T&O ward at the RSUH site became a COVID-19 ward. The EOU at CH became an intermediate care facility for post-operative Trauma patient e.g. hip fractures. The new rota allowed a senior clinical treatment in minor injury and A&E by front line T&O consultants. This, along with the move into telephonic consultations reduced the requirement for new and follow-up fracture clinic appointments. Secure virtual daily trauma meetings to discuss all trauma cases has enhanced decision making. We think that the COVID-19 restructuring of Trauma service would be a good way for hospitals to plan long-term cost savings. However, this was balanced against the cancellation of elective work and suspension of non-urgent musculoskeletal surgery. The department’s appropriate use of resources represents a model for resource adjustments to cope with a National and international medical emergency.

We believe that COVID-19 pandemic will affect T&O clinical outcomes and this need to be measured. Further work on the impact on clinical workload and patient outcome is underway.

Compared to other centres in the region8,9, we do not think that the changes implemented by our department caused a major disruption in orthopaedic registrar training. This is predominantly true when it comes to general and major trauma experience. Most trainees continued to participate in trauma theatre on regular basis, particularly during night duties. On the other hand, the new structure offered prospects for registrar to participate in research and audit projects, and to demonstrate leadership skills. These traits are important when a trainee become a consultant.

Conclusion

The COVID-19 pandemic initiated a well-structured response by our department. Strong departmental leadership along with a team working spirit have been crucial. The use of modern media platform has been utilised to minimize the number of face to face hospital appointments. This has reduced the risk of virus transmission for both patients and health care professionals. The registrar training and involvement in major trauma did not stop during the pandemic. Our experience in emergency response could be used by other MTCs. Moreover, more research is needed to evaluate the impact of the pandemic on service provision and training.

References

  1. World Health Organisation (2020). WHO Director-General's opening remarks at the media briefing on COVID-19 - 11 March 2020. Available at: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.
  2. World Health Organisation (2020). Rolling updates on Coronavirus disease (COVID-19) [Cited June 2020]. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen.
  3. GOV.UK (2020). PM address to the nation on coronavirus: 23 March 2020. Available at: https://www.gov.uk/government/speeches/pm-address-to-the-nation-on-coronavirus-23-march-2020.
  4. NHS England (2020). Staffordshire and Stoke on Trent STP. Available at: https://www.england.nhs.uk/integratedcare/stps/view-stps/staffordshire-and-stoke-on-trent.
  5. NHS England (2020). Coronavirus, Specialty guides for patient management. Available at: https://www.england.nhs.uk/coronavirus/publication/specialty-guides.
  6. British Orthopaedic Association (2020). Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. Available at: https://www.boa.ac.uk/uploads/assets/ee39d8a8-9457-4533-9774e973c835246d/4e3170c2-d85f-4162-a32500f54b1e3b1f/COVID-19-BOASTs-Combined-FINAL.pdf.
  7. Public Health England (2020). Reducing the risk of transmission of COVID-19 in the hospital setting. Available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/reducing-the-risk-of-transmission-of-covid-19-in-the-hospital-setting.
  8. Govilkar S, Dover C, Dass D, Rhind J-H, Ramhamadany E, D Ford, et al. From Elective Orthopaedic Centre to a COVID-19 Trauma Unit: Rapid transformation. The Transient Journal of Trauma, Orthopaedics and the Coronavirus. June 2020. Available at: https://www.boa.ac.uk/policy-engagement/journal-of-trauma-orthopaedics/journal-of-trauma-orthopaedics-and-coronavirus/from-elective-orthopaedic-centre-to-a-covid-19.html.
  9. Mackay N, Shivji F, Langley C, David M, Syed F, Chapman A, et al. The Provision of Trauma and Orthopaedic Care During COVID-19: The Coventry Approach. The Transient Journal of Trauma, Orthopaedics and the Coronavirus. June 2020. Available at: https://www.boa.ac.uk/policy-engagement/journal-of-trauma-orthopaedics/journal-of-trauma-orthopaedics-and-coronavirus/the-provision-of-trauma-and-orthopaedic-care.html.