By Yasser F Aljabi, Kiran Divani and Pinak S Ray
Department of Trauma & Orthopaedic Surgery, Barnet Hospital (Royal Free London Trust), London, UK
Corresponding author email: [email protected]
Published 01 June 2020
The Coronavirus Disease 2019 (COVID-19) pandemic is an evolving challenge that has affected many health care systems worldwide1,2. Specifically, Trauma & Orthopaedics have continued to remain an important part of the health service despite restrictions to elective operating1,3-5. At the heart of this service are the Trauma and Orthopaedic trainees with varying level of seniority – from senior speciality / peri-CCT registrars to foundation doctors.
We report on our experience with managing the Orthopaedic trainees’ roster in Barnet hospital, a district general hospital in North London with a busy Trauma & Orthopaedics unit. The roster has 14 registrars and seven foundation doctors and core trainees. Speciality registrars were of various training levels varying from ST3 to ST8 / peri-CCT and had come from five different rotations – namely the Royal National Orthopaedic Hospital (Stanmore), University College London Hospital, Potts-Percival, Royal London and Imperial (North West Thames) rotations. The roster is managed by a senior trainee and overseen by the clinical lead of the department.
Several factors had to be dealt with during the surge of the COVID-19 pandemic; for instance, the redeployment of foundation doctors and core trainees to a COVID-19 rota, the anxiety shared amongst trainees of either catching COVID-19 or passing it to members of their household, yet equally, the burning desire to upskill and be an integral part of caring for patients in the Intensive Care Unit (ICU). Other changes also included having the registrars do resident night shifts with no junior support, the significant reduction in operating and training opportunities and the gaps created within the rota due to registrars self-isolating due to symptoms.
Due to the unpredictable nature of the COVID-19 pandemic and the uncertainty regarding the magnitude of the strain that would be put on the National Health Service (NHS), we had devised three formats of the roster – Firstly, a roster with all trainees involved, secondly a reduced staff rota due to redeployment and finally and contingency rota with a very limited number of senior trainees and consultants should there be a significant redeployment of trainees to the COVID-19 roster. All rosters were constantly updated and available to allow for a dynamic transition as required. The roster was written by the senior trainee managing the rota (YA) and overseen by the clinical lead (PR). The rota was done on Allocate© application which is available for the registrars to view both on desktop and mobile phone versions. Roster was constantly checked to ensure it was European Working Time Directive (EWTD) compliant and was available at least two weeks in advance.
To help with the workload of the emergency department in our hospital, we developed a pathway involving a dedicated oncall registrar present daily fom 8am to 8pm dealing directly with ‘COVID-19-free’ walk-in injuries, bypassing the triaging system in the emergency department and having patients routed directly to our fracture clinic where care was provided. This pathway was designed following a meeting that had happened early during the COVID-19 crisis between our clinical lead (PR), senior consultants and the main stakeholders in the emergency department. We felt that this had created a sense of harmony and elevated levels of mutual respect between our department and the emergency department in our hospital and had taken some of the burden encountered by the emergency department to allow them to care for patients with COVID-19.
Furthermore, to help our colleagues in the Intensive Care unit (ICU), the roster had a daily registrar allocated along with a consultant to support our anaesthetic colleagues and nurses in the ICU – it gave us immense pleasure to be the first service in the trust in to provide regular staff to support the activities of the ICU department. Regular training sessions had been organised by the trust to allow for upskilling of our staff members.
As a result of redeployment of the house officers and foundation doctors to COVID-19 wards, the speciality registrars’ rota had to be restructured – this had happened in an open forum by means of a teleconference and opinions of trainees of various levels were taken onboard with the emphasis of making this a valuable learning and personal development opportunity for all.
To deal with gaps in the rota due to self-isolation / unforeseen circumstances, we had a standby registrar of the week who would be rostered for no routine duties and would be resting off-site and asked to cover any gaps shall there be any. We found that this had worked well as a safety net.
To help alleviate some of the junior trainees’ anxiety created by the COVID-19 pandemic, we have designed a mentorship program led by the senior registrars and divided the cohort of trainees into groups of 4-5 with a dedicated senior registrar who is accessible by the juniors for pastoral care. Each senior registrar would take the initiative of contacting their allocated mentees on a regular basis to ensure their well-being and allow them to express any concerns or seek advice as needed. The senior registrars would then meet collectively on a regular basis to discuss any outstanding issues and work on finding solutions as necessary. Other initiatives that we had in place to help with supporting the trainees included inviting a British Airways pilot to our department to provide our trainees with tips on how to deal with fatigue related to night shifts and irregular sleeping patterns.
For an orthopaedic trainee, building and maintaining a knowledge base is paramount. It is with a sound understanding of common concepts and conditions that trainees base their decision making and management plans. With fellowship examinations postponed, revision courses cancelled and trauma meetings and multi-disciplinary meetings restructured the common forums in which a lot of orthopaedic teaching and learning occurs has been impaired. We recognised the impact this would have on training and subsequent career progression and with the initiative of registrars and fellows in the department a remote teaching timetable was structured.
In addition to our weekly Trust departmental meetings to discuss current affairs, bi-weekly video meetings were arranged using various video conference software to hold our own departmental webinars ensuring topics of the orthopaedic curriculum continued to be covered in a systematic way, via didactic lecturing, case presentations and journal club meetings6. This initiative received favourable feedback and it is something that trainees will be able to use to demonstrate continued learning and development to their training programme directors at annual competency progression review meetings during times of COVID-19. Details of this initiative was discussed by Al-Obaedi and Subramanian in an earlier publication in this journal7.
Our learning points from managing the roster for Orthopaedic trainees in a busy Trauma & Orthopaedic unit is to always involve them in the decision-making process of the roster. We found that this had helped alleviate anxieties caused by the COVID-19 situation. Furthermore, keeping the trainees informed of the development of the current situation and future planning had also helped. Staff safety is paramount, and the roster had to be dynamic to accommodate trainees with special circumstances such as failing FFP3 mask testing or having issues with Personal Protective Equipment (PPE).
- Velavan TP, Meyer CG. The COVID-19 epidemic. Trop Med Int Health. 2020;25(3):278-80.
- Liebensteiner M, Khosravi I, Hirschmann MT, Heuber P, Board AGA, Thaler M. Massive cutback in orthopaedic health- care services due to the COVID-19 pandemic. Knee Surg Sports Traumatol Arthrosc. 2020;28(6):1705-11.
- Iacobucci G. Covid-19: all non-urgent elective surgery is suspended for at least three months in England. BMJ. 2020;368:m1106.
- NHS England (2020). Clinical guide for the management of trauma and orthopaedic patients during the coronavirus pandemic. Available at: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0274-Specialty-guide-Orthopaedic-trauma-v2-14-April.pdf.
- Hirschmann MT, Hart A, Henckel J, Sadoghi P, Seil R, Mouton C. COVID-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon. Knee Surg Sports Traumatol Arthrosc. 2020 Apr 27. (Epub ahead of print].
- Lipomi DJ. Video for active and remote learning. Trends Chem. 2020;2(6):483-5.
- Al-Obadei O, Subramanian P. ‘Distant learning’: A glimpse into the future and beyond. The Transient Journal. April 2020. Available at: https://www.boa.ac.uk/resources/distant-learning-a-glimpse-into-the-future-and-beyond.html.