COVID-19 and resuming elective paediatric orthopaedics in a London major trauma centre and a tertiary referral centre

09 Oct 2020

By Gemma Green1, Deborah M Eastwood2,3, Aresh Hashemi-Nejad3, Peter Calder3, Sally Tennent3, Tahir Khan3, Jonathan Wright3, Andrea Yeo1, Neel Mohan1 and Yael Gelfer1,4
1St George’s Hospital, London
2University College London
3Royal National Orthopaedic Hospital
4St George’s University of Londo

Published 09 October 2020

ABSTRACT

Purpose: To define the volume of paediatric orthopaedic surgical work requiring re-prioritisation and resourcing at two major hospitals following the COVID-19 pandemic. 
Methods: All patients on the waiting list as of 23rd March 2020 at two institutions were reviewed. The data recorded included demographics, diagnosis and treatment needed. As advised by the Royal College of Surgeons (RCS), each patient was categorised in terms of priority for surgery. Cases were also analysed in terms of potential harm if further delay took place: factors considered included the avoidance of additional, or more complex surgery or a poorer long-term outcome. The estimated time for every procedure was calculated to define the theatre resources needed for each hospital.
Results:  197 patients requiring 225 procedures were reviewed. Of the 225 procedures 115 were RCS category 3 and 110 category 4. Our assessment suggested the delay to surgery was associated with a mild/moderate risk of adverse effects in 135/225 cases. We estimate that 143 half-day (4hr) lists are required to complete these procedures, with 78 of these needed for the category 3 patients.
Conclusions: 51% of patients awaiting paediatric orthopaedic elective surgery in our institutions are RCS priority 3, requiring surgery within three months. However, some procedures should not be undertaken until community resources have returned. The health service aims to recover by providing extra short term capacity but the resources needed to achieve this have not been quantified and the consequences of delaying treatment should be acknowledged.

Introduction

The COVID-19 pandemic had an unprecedented impact on healthcare systems1,2, requiring significant restructuring of services, including cancellation of all non-urgent surgery, to accommodate the increased critical care requirements. The impact on patients awaiting elective procedures, especially those which may be time-sensitive has not been assessed3-5.

During the initial phase of the pandemic, the RCS defined general priority levels for all surgical specialties to aid allocation of limited theatre resources, (Table 1). Bone and joint infection, tumour and trauma were classified as priority 1 or 2, and were largely unaffected by COVID-19 measures. The British Orthopaedic Association (BOA) and the British Society of Children’s Orthopaedic Surgeons (BSCOS) published advice on prioritisation of care in the pandemic aftermath to minimise harm during the elective restart6-9. Both acknowledged that children’s orthopaedic care may be affected detrimentally by delays to elective treatment and the early conservative treatment of two conditions, DDH and CTEV was recognised as a particular cause for concern.

Table 1: Royal College of Surgeons of England definition of case priority

Priority

Description

Timing

Example*

1a

Emergency

<24 hours

Septic arthritis, open fracture

1b

Urgent

<72 hours

Displaced fractures, SCFE

2

Time Critical

Within 1 month

Suspected bone tumours

3

Time Dependant

Within 3 months

Primary DDH, CTEV, epiphysiodesis

4

Routine

Can be delayed for >3months

Secondary joint reconstructions

*this definition recognises that each case must still be assessed individually with respect to relative risks of surgery vs delay.

Many other paediatric orthopaedic conditions require time-dependant treatment. Patients awaiting epiphysiodeses or guided growth for limb length discrepancy or limb malalignment have a short timeframe during which surgical correction will be effective. After skeletal maturity subsequent surgical intervention risks increased complications and/or lifelong orthotic management with a significant reduction in QoL10,11. For these reasons, BSCOS suggested that a re-prioritisation of these techniques from RCS priority 3 to priority 2.

Medical harm can be defined as any systemic failure in the health care system that results in negative psychological or physical consequences12. In paediatric orthopaedic terms, this includes an escalation in the complexity of surgery required to treat the disease, the need for additional surgery, the development of permanent deformity and poorer outcomes overall. Parental and patient anxieties are often exacerbated by uncertainty and the cancellation/postponement of treatment.

The aim of this study was to quantify the effect of the COVID-19 pandemic on our patient cohort awaiting surgery and to define the theatre resources now required to treat them. We also considered revision of the existing priority definitions for paediatric orthopaedic patients as the second wave of infections approaches.

Methods

The paediatric orthopaedic surgical waiting list (as of March 23rd when elective surgery stopped) at two major centres (St George’s Hospital and Royal National Orthopaedic Hospital) was reviewed. One centre is a major trauma centre (MTC) and the other a tertiary referral centre (TRC) for orthopaedics.

The data collected included demographics, diagnosis and procedure required. Each patient was assigned a RCS priority. Through discussion amongst the lead authors and based on current evidence, an effect on outcome if surgery was delayed was predicted for every patient. Each hospital then cross checked the other hospitals predictions. An unfavourable outcome was defined as one where we felt that a delay in treatment was likely to result in the need for additional or more complex surgery, a more prolonged or difficult recovery time and/or poorer long-term function as shown in Table 2.

Table 2: Effect of delay on management and outcome

 

Management

Outcome

No effect   

No change in treatment

No adverse effect on outcome

Mild effect   

Delay to same operation

e.g. mild deformity with no significant impact on functional activities

Moderate effect

 

Increased surgical complexity e.g. an additional osteotomy

e.g. residual LLD or deformity

Significant effect

Requires an additional operation

e.g. ongoing significant deformity and/or degenerative changes likely

The NHS management systems produce an average time for any given surgical procedure which can be modified by the surgeon to reflect patient co-morbidities or the technical difficulties of the individual procedure and thus for each procedure on the waiting list an estimated theatre time based on pre-COVID performance adjusted for severity/co-morbidities was documented. The estimated time included anaesthetic time and any concurrent cast application and/or orthotic fitting.

Results

A total of 197 patients (SGH=67, mean age 6y, RNOH =130, mean age 11.2y) requiring 225 procedures were identified. The case complexity was higher at the RNOH.

All patients were RCS priority 3 or 4 as all priority 1 or 2 patients had been treated according to the national guidelines for emergency/urgent surgery. In both centres, 51% of waiting list cases were RCS priority 3 patients awaiting time sensitive surgery.

In terms of overall effect on outcome none of the patients waiting for surgery are currently judged to be at risk of severely compromised long-term outcomes due to the COVID-19 delays. Across both hospitals, the current surgical delay is likely to have had no significant effect in 40% of patients but a mild effect in 29% and a moderate effect in 31%. Overall, 60% of patients are therefore likely to require more resources in terms of theatre time and/or rehabilitation and are at risk of a poorer outcome if surgery does not now take place in a timely manner. Both centres are now subject to similar service provision challenges despite different remits within the NHS.

The estimated total number of hours required to complete the surgical procedures on the waiting list now is 429 (165 SGH, 264 RNOH). In this recovery phase, it is estimated that the theatre time per case should be increased by 30% due to the slower turnaround time, increased anaesthetic time and theatre cleaning secondary to current infection control measures5. If this is correct, a total of 570 hours of theatre time is required which equates to 143, four-hour (NHS half day) operating lists. This calculation assumes maximum efficiency in both planning and execution of the list.

In order to address the priority 3 patients who are deemed to be at risk of a moderately adverse effect on outcome with additional delay in treatment a total of 78 lists are required between the two centres (26 lists for SGH, 52 lists for RNOH) within the next few weeks.

Discussion

COVID-19 presented our health care system with significant challenges during the height of the pandemic and now presents different but equally significant challenges during the restart period. This paper looked at just one aspect of this recovery process. Planning for the future care of our existing patients who require surgery in a timely manner must take into account factors such as the ongoing staffing issues  and resource depletion as well as the requirement to treat RCS priority 1 and 2 patients as they present.

It is important to identify those patients and conditions where further delay will adversely affect outcome, in order to prioritise service provision (and safe pathways) based on previous and present capacity. We accept that our assessment of risk of an adverse outcome is subjective and a limitation of this study but the agreement between the consultants involved was high. In both units, a significant number of patients are now at risk of a poorer outcome: this must influence service delivery.

Certain conditions are highly time dependent such as physeal surgery for leg length discrepancy or deformity and closed reduction for dislocated hips.

Other procedures such as tendon transfers, ACL reconstruction and elective arthroscopy are less urgent and may have a lower overall long-term impact as the surgical intervention required does not change with delay although ongoing cartilage damage may be occurring. The parents of these children will need to be counselled that although these cases cannot be prioritised in the immediate restart period, they have not been forgotten and their orthopaedic condition will not be adversely affected by the delay. Nevertheless, any delay experienced by the non-urgent cases does impact on their function and comfort and may be associated with increased anxiety and depression13.

It should be acknowledged that prioritisation is a continuous process and not a one-time assessment. What is considered a low priority today may become an urgent case over time. Many factors may lead to a change of category and despite the current difficulties in holding face-to-face clinic appointments, both the BOA and NHSE recognised that regular communication with the patients and families is essential to identify any changes in symptom level or function and relieve anxiety levels14,15.

The priority 3 and 4 cases on our waiting list at the time of ‘lockdown’ require an estimated 140 half-day lists between the two centres to manage these patients. An individual surgeon within the NHS is allocated 3 half day lists per week. Our analysis suggests that 78 half day lists are required for priority 3 patients alone within the next 2-3 months in order to reduce the risk of an adverse effect on the outcome of these patients. This additional capacity will not be available and despite current recovery plans a recent BODS/BOA survey reported that 75% of responders felt that their current practice remained at 50% or less of pre-COVID levels16. We believe that further strategies to minimise harm must be considered.

The national advice has been to concentrate on priority 3 patients as with time many of these will become priority 2. However, the extent to which the delay to surgery could contribute to each individual patient’s outcome is also affected by their underlying pathology and the complexity of their comorbidities as well as their social environment and the availability of ongoing care from allied health professionals. Normal delivery of such hospital and community services is unlikely to resume for several months. This raises the question as to whether it is correct to operate on a child, even if they are a priority 3, if the outcome of surgery is likely to be compromised by the lack of supporting resources. As in other times of crisis, it may be that in the current situation it would be more appropriate to operate on priority 4 patients who may rely less on ancillary support services and may still gain a good outcome.

Various national and international studies have shown children to be at low risk from coronavirus complications, and transmission between children has not been proven17-20. This should facilitate a prompt and low risk return to paediatric orthopaedic surgery particularly in children with few associated co-morbidities.

Conclusions

The wide reaching effects of COVID-19 have affected more than just the critical care units. The impact on us and our paediatric orthopaedic patients is likely to be long lasting. The key now is to identify the patients and conditions who are most likely to be adversely affected by further delays in surgery. Stratifying waiting lists by priority and effect on outcome allows us to identify such patients and plan safe delivery in order to minimise harm and optimise use of resources and personnel. In both centres  the number of lists required to manage our patients far exceeds the capacity of the workforce and the hospital resources.

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