Campbell M1, Hughes AJ1, Daly B1, Hanahoe A1, Moloney DP1, Sheehan E1,2, Merghani K1,2
1Department of Trauma and Orthopaedic Surgery, Midlands Regional Hospital Tullamore
2Medical School, University of Limerick
Corresponding e-mail: [email protected]
Published 30 March 2020
Editors Note: The excellent article from Tullamore describes their response as a unit to COVID-19. I am hoping that we will have more sharing of local practices to prevent others from having to re-invent solutions. In the future it would be advantageous to distinguish more clearly between an "article" be it a balanced discussion or diatribe which would best be in TJTO&C and an unadorned shared local policy which goes better in the local guideline repository where it is ripe for plagiarism. As with everything in this current crisis we wanted to save time. Therefore with this particular article the simplest solution was to put it in both places; that is not the long term plan.
The COVID-19 pandemic has posed unprecedented challenges to health systems, both globally and domestically, and within the Irish healthcare system itself. Since the WHO declared the COVID-19 pandemic on March 11th 2020, the Trauma and Orthopaedic Surgery Department in Midlands Regional Hospital Tullamore, Co Offaly, has introduced practice changes so as to ensure a safe working environment, whilst maintaining care standards for our patients and the wider community.
Service provision has been streamlined, in order to limit footfall within the hospital and reduce exposures for our patients, most of whom fall within the “vulnerable” category. In line with the WHO guidelines for infection prevention and control of pandemic-prone acute respiratory infections (2007), all elective orthopaedic surgeries and elective outpatient department sessions have been cancelled1. Traditional trauma clinics have been “virtualised” via the Trauma Assessment Clinic, or virtual fracture clinic, a pathway that exists between the three Midlands Hospitals2. Inclusion criteria have been expanded to include all trauma cases. Patients requiring clinical review are seen later that same afternoon. The weekly trauma conference has taken the form of a teleconference, with all consultants and NCHD’s remotely accessing a shared presentation, narrated by the in-house trauma team on call. A website, as well as a social media platform, has been created by the Department, to provide patients with reliable information and injury-specific advice. Morning ward rounds have been condensed to two registrars and one intern. There are currently thirteen members of the orthopaedic team, and morning round attendances are rotated between members who have completed full mandatory PPE training. Core orthopaedics is preserved and allows redundancy in the staffing system to allow redeployment (at times redeploying to our medical colleagues who are actively treating COVID-19 positive patients, relieving healthcare workers who have been advised to self-isolate).
Modifications of the consultant and registrar rota allows a senior decision maker to be on the front line at all times. With national social isolation and 'cocooning' there has been a reduction in trauma referrals. The fall off in trauma coupled with the cancellation of elective surgeries has created a level of redundancy in orthopaedic staff commitments. This has allowed one consultant each day to maintain a daily administrative liaison roll. This consultant has no clinical duties and is available to attend, advise and receive regular updates from the hospitals 'COVID-19 Management Team'.
The orthopaedic consultant staff conduct an evening video conference for handover and dispersal of information relating to the day’s events. The meeting is scheduled after normal working hours to facilitate a full complement of consultant staff. The meeting is led by the lead administrative consultant on that day and follows a set “constant agenda”. This meeting updates all senior members of the team and allows consensus and seamless decisions when engaging with management and other clinical stakeholders. A briefing and debriefing are performed with consultants via video conference, discussing the case load and escalation plans. This avoids differing opinions regarding patient management when patient’s present under a different consultant and team for scheduled trauma surgery. A consensus opinion regarding envisaged management for trauma patients is attained by the consultant team courtesy of this daily meeting. This also allows a cohesive approach for the team when dealing with the rapidly changing fluid environment of information and updates relating to COVID-19.
In a situation where a team member is a confirmed close contact to a COVID-19 positive patient, strict precautions have been taken under the advice of occupational health, which may require fourteen days of self isolation with close symptom monitoring. This, though effective in protecting both staff and patients3, can unfortunately have a negative effect on staff morale, often leading to guilt and anxiety regarding sick leave. Studies have shown that under normal circumstances, doctors have a relatively high rate of sickness presenteeism (82%), with the main reason for working through an illness being 'not wanting to burden other colleagues'4. The resultant negative effect on staff morale and mental health must be considered, and thus the Healthcare Worker COVID-19 Helpline5 has been welcomed. Now, more than ever, occupational health guidelines must be strictly adhered to. Exposure risk must be carefully weighed up against feelings of truancy amongst staff during this pandemic state.
Strict measures are required in order to safely deliver high quality care to our vulnerable patients, whilst decreasing the risk of COVID-19 transfer between the hospital and community. Cancelling elective activity, virtualising trauma clinics and teleconferencing are measures that have been taken in our Department over the past fortnight. These testing times require creativity, determination, resilience and support within teams so as to maintain standards, whilst mitigating risk. Never before has there been such a pivot in the way we practice orthopaedics. It has been quick but the in this current crisis 'speed trumps perfection'.
References
1. Chang Liang Z, Wang W, Murphy D, Po Hui J. Novel Coronavirus and Orthopaedic Surgery. The Journal of Bone and Joint Surgery. 2020:1.
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. Arabi Y, Murthy S, Webb S. COVID-19: a novel coronavirus and a novel challenge for critical care. Intensive Care Med. 2020 Mar 3. doi: 10.1007/s00134-020-05955-1. [Epub ahead of print]
4. Tan PC, Robinson G, Jayathissa S, Weatherall M. Coming to work sick: a survey of hospital doctors in New Zealand. N Z Med J. 2014;127(1399):23-35.
5. Health Service Executive. Staff: minding your mental health. Available from: https://healthservice.hse.ie/staff/news/coronavirus/staff-minding-your-mental-health-during-the-coronavirus-outbreak.html. Accessed 26 March 2020.