By Moloney DP, Feeley I, Hughes AJ, Clesham K, Kiernan C, Niall D
Orthopaedics and Trauma Department, Midlands Regional Hospital Tullamore
Corresponding e-mail: [email protected]
Published 13 April 2020
Delivery of care across all medical specialties is challenged by the current SARS-CoV2/COVID-19 pandemic1. Pathogen virulence and global spread has overwhelmed many developed nations medical infrastructure2-4. Advances in technology have facilitated significant improvement in orthopaedic trauma care in our unit in recent years. The current crisis has stimulated further development of safe 'hospital distancing' care for many injuries.
Our Orthopaedic Unit is a regional referral centre with a catchment population of 400,000, over a significantly rural setting. The service provides trauma care to two other Regional Hospitals and several Minor Injuries Units in the catchment area, none of which have Orthopaedic Services on site. The ambulance service provides Trauma 'bypass', bringing the critically injured direct to our unit. The outpatient /non-critical trauma care is streamed through a comprehensive Virtual Fracture Clinic service, involving a daily teleconferencing system which communicates trauma management decision-making both to our own in-house referrals and all the satellite units, where Clinical Nurse Specialists disseminate all management information to the patients and arrange casting/physiotherapy etc. Orthopaedic trauma outpatient management relies on radiological diagnostics almost exclusively for decision making and the National Digital Radiology system has facilitated development of our Virtual Fracture Clinics (now called Trauma Assessment Clinics) over the last seven years5,6. Follow-up clinics are provided by Musculoskeletal Physiotherapists who are involved in the initial management decisions. All conferencing occurs in a central Ortholive 'hub' office in the hospital, with Consultant Surgeon, Clinical Nurse Specialist and Musculoskeletal Physiotherapist daily. This system has been validated and proven to be robust7 and has been templated out to other Orthopaedic units in our health service. The model has been well received by end-users with high satisfaction rates and significant cost savings5.
Since the Coronavirus pandemic, this system has expanded to provide real-time advice from our central hub, to patients and General Practitioners (using a Trauma helpline and emailing interfaces for all patients and GPs, to minimise hospital visitations. All follow-up trauma care visitations are now interfaced in advance by telephone call to the patient. With the use of removable splints rather than casts in recent years, a physical visit is often unnecessary. Follow-up x-ray if necessary is ordered electronically in the outreach hospitals, and the patient re-interfaced with result by phone or email. Our pre-pandemic delivery model of outpatient care with burdened patient numbers confluencing in a waiting area for x-ray and clinical review, with predominantly predictable satisfactory outcomes, is replaced by our interface model, with a small number of patients necessitating attendance.
The Physiotherapy follow-up clinic has also been converted to an Interface Clinic. A National website www.orthotac.ie was established to guide patients in their fracture and recovery expectations. A key part is a comprehensive spectrum of explanatory videos for physiotherapy exercises for all common injuries and a listing of frequently asked questions. All follow-up trauma patients are contacted by the physiotherapist, guided to the website and are given specific instruction in relation to their injury. A video link facility is set up to facilitate any patients who require direct patient conferencing, and an appointments system facilitates this. An email address allows patients to contact the service to request video conferencing.
In relation to staff in the department, social distancing have been facilitated by Teleconferencing apps for departmental trauma conferencing. The consultant staff teleconference daily to hand over clinical and managerial issues. All staff are now facilitated with remote privileged computer access to the National Irish Medical Imaging System (NIMIS), patient information and laboratory systems from home. The secretariat are facilitated with flexibility in shift work, allowing for social distancing. Teleconferenced research meetings have commenced, with team members making use of periods of self-isolation whilst awaiting swab results following close contact with positive patients.
In summary, whilst trauma surgery itself cannot be 'virtualised', there have been many steps taken to reduce the in-hospital physical footprint of the orthopaedic service since the corona pandemic. This article highlights how a trauma unit can use technology to allow for service provision to continue through these testing times. The expansion of virtual clinics, offsite X-ray facilitation and the introduction of teleconferencing services has been proven to be effective in delivering remote care. The Virtual Clinic model is scalable, potentially extrapolating to hospitals outside the catchment area that may lose trauma services because of the pandemic. Physiotherapy colleagues have maintained their outpatient services through the use of a centralised HSE-approved teleconferencing service and a National Website, to continue rehabilitation protocols without physical contact. Remote access privileges to hospital systems have facilitated clinicians and secretariat support to work from home. Whilst the COVID-19 crisis has precipitated these measures, they are welcomed potentially in the longer term to streamline our hospital services in a more cost efficient and patient friendly way.
Funding disclosure: No authors received funding for this publication.
Acknowledgements: The authors would like to acknowledge the diligent work of international scientists and healthcare workers in the fight against coronavirus.
- Campbell M, Hughes AJ, Daly B, Hanahoe A, Moloney DP, Sheehan E, Merghani K. Orthopaedic social distancing and manpower management throughout COVID-19. The Transient Journal of Trauma, Orthopaedics and the Coronavirus. March 2020. Available at: https://www.boa.ac.uk/resources/orthopaedic-social-distancing-and-manpower-management-throughout-covid-19.html.
- Remuzzi A, Remuzzi G. COVID-19 and Italy: what next? Lancet. 2020;395(10231):1225-8.
- Velavan TP, Meyer CG. The COVID-19 epidemic. Trop Med Int Health. 2020;25(3):278-80.
- Saglietto A, D’Ascenzo F, Zoccai GB, De Ferrari GM. COVID-19 in Europe: the Italian lesson. Lancet. 2020;395(10230):1110-1.
- 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.
- 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.