Information for BOA members on trauma and orthopaedic care in the UK during coronavirus pandemic

24 Mar 2020

Version 3 – published 24 March 2020 (Latest updates are marked with an *)

Please note this guidance is continually being revised to reflect the latest Government position.

The BOA strapline of “Caring for patients, supporting surgeons” has seldom seemed more apposite. In the fast changing circumstances of the past days we have been co-operating with others in producing guidance relevant to Trauma & Orthopaedic surgeons. The guidance and associated documents are naturally in a state of flux but we feel it important to keep colleagues as well informed as possible.

The coronavirus pandemic is unprecedented in recent times, and the UK’s health systems are making changes to respond to this. The BOA has been in active discussions on these issues over the past week and this statement sets out the key developments and issues, and provides links to other available resources.

For all of our members: All of us will be changing aspects of what we do and how we do it. It is difficult at present to be sure what will change. It is likely that some T&O surgeons will spend more time delivering trauma care as the elective work reduces. The GMC has given support for doctors to work in areas outside their usual sphere of practice and expertise, and it is probable that some of us will be involved in the care of coronavirus patients. We realise this can be a particularly challenging aspect of the plans, and we encourage you to read the guidance carefully on this. At this time of national emergency it will be important that we work together, supporting one another and rising to the challenge ahead.

(GMC guidance available here).

Regarding trauma surgery and fracture services: The BOA has worked with NHS England to prepare guidance which is available here. This guidance discusses the handling of trauma patients during the period when there is increased pressure on the NHS from treating coronavirus patients. It includes a ‘T&O Escalation Policy’ (p.5), which our members have been telling us is useful, and it is clear some areas of the UK are already progressing up the escalation stages.  We encourage all members to read this at the earliest opportunity. The BOA intends to work with other relevant bodies to share ideas and good practices about ways of working during this time.

*The BOA has published guidance on 24th March, entitled ‘Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic’, which is designed as a series of ‘COVID BOASTs’ and includes sections on management of inpatient, outpatient, paediatric and hand trauma. This is available here.*

Regarding elective surgery: Since our first statement on 16 March there have been several statements about suspending non-urgent elective surgery (NHS England letter here, Scottish government statement here), while Wales had already announced this. In England, the advice read that that this suspension would last at least three months. *Feedback received by the BOA suggests that for T&O most elective operating has now stopped, although the NHS England deadline for this was mid-April.*

Social distancing, remote consultations and reducing pressure on the NHS

The guidance published in England also highlights that the NHS is to adopt other measures for ‘social distancing’ and reducing pressures on the NHS:

  • For GP, diagnostic and outpatient appointments, providers are being asked to roll out remote consultations ‘as a priority’. ‘Face-to-face appointments should only take place when absolutely necessary.’ We are in the process of developing BOA guidance on this issue, which we hope to have available soon.
  • It discusses (albeit briefly) the issue of NHS staff who are pregnant and those who are at increased risk of severe illness from COVID-19, and more guidance is expected on these issues.
  • The public are to be asked to greatly limit visitors to patients, and to consider other ways of keeping in touch such as phone calls.
  • All routine CQC inspections and GIRFT visits are being cancelled.

Regarding elective patients: Additional delays to their planned surgery, at a time when waiting times have already increased significantly in recent years, will have a huge impact on patients, and the waiting list will undoubtedly grow significantly over the coming weeks and months. We are:

  • Publishing some ‘Frequently asked questions’ for patients today, which we will keep updated as the coronavirus situation unfolds.
  • Liaising with the NHS England National Clinical Director for MSK to discuss the handling of elective patients over the coming weeks and months, particularly in terms of interim arrangements for those with worsening or ‘red flag’ symptoms and ensuring there are pathways for urgent elective patients.
  • Highlighting to NHS England that a ‘recovery plan’ will be needed once elective surgery resumes to handle the extended waiting lists.

Regarding trainees: The Royal Colleges of Surgery have flagged an ‘inevitable’ impact on training and progression of surgical trainees. We are discussing the evolving situation with BOTA and with the SAC for T&O, which is actively engaging with the main stakeholders to help deliver a pragmatic solution to the wide range of training issues that will affect everyone this year. We will provide further updates on this. Please bear with us on this as the situation is changing rapidly and we hope to provide more information very soon.

The president of BOTA, Trica Campbell, has recorded a podcast outlining the changes for trainees that are taking place due to Coronavirus. The podcast can be found here.

  • Regarding rotations of trainees, an HEE letter was published earlier this week (see HEE letter here). In general no trainees are moving to new hospitals, but some rotations within a hospital are still occurring with appropriate permissions and where there would not be a requirement for new hospital induction processes to take place.
  • Regarding national selection, a letter has been published last week about this process (due to be held 1-3 April in Leeds for T&O), advising that these will not happen face-to-face but different recruitment processes are being considered (HEE letter available here). A further statement regarding national selection is expected, and we are working closely with the SAC on this as we appreciate there are important issues to clarify and resolve.

Contingency planning is still in progress in a range of areas and please be assured that we are doing everything we can to provide accurate information relating to these and other related issues as soon as possible.

For training more widely: It is expected that there will be cancellations to study leave and that courses/learning opportunities will be suspended both locally and nationally. The BOA is keeping under review the courses that we run, and currently booked participants on upcoming courses have already been contacted to discuss this. You can read more about the current situation with our courses and how BOA activities are affected by coronavirus here. This also explains how to contact the BOA during this period when many of our staff are working remotely.

Regarding private patients: Surgeons should be applying the same standards to private patients as to those in the NHS. Therefore it is advisable to limit face-to-face consultations and surgery to those patients where this is essential, especially in at-risk groups including the over 70s. 

As of 17 March, the Independent Healthcare Providers Network (IHPN) was reporting that the independent sector was in discussions about making thousands of hospitals beds available to the NHS and engaging staff employed by independent sector providers to support the NHS ‘at every level’ (which is also mentioned in the NHS England letter of 17 March). The IHPN stated that until this occurred, both NHS and private planned care could continue in independent providers. (The IHPN statement can be found here).

What’s happening with community and rehab services related to musculoskeletal conditions?: NHS England guidance has been published regarding community and rehab services, listing which services should continue and those that should stop or change. It covers both children and young people services and adult and older people services and is available here.

*Personal protection equipment (PPE): Personal Protective Equipment (PPE) is a key issue and the most recent PHE guidance on infection prevention and control is available here. The BOA has obtained clarifications regarding plaster cast removal. The use of plaster saws is not considered as an Aerosol Generating Procedure (AGP), therefore the guidance surrounding the use of AGPs would not apply here. We are aiming to seek clarification on other matters particularly relevant to T&O practice.*

*Research and clinical trials: Due to the coronavirus pandemic, a large number of NIHR Trauma and Orthopaedic studies have been paused. Only follow ups involving safety checks (e.g. drug levels) are continuing at the moment. The Urgent Public Health Committee of the NIHR Clinical Research Network is currently having a videoconference three times a week to ensure the implementation of new studies related to Covid-19, of which there are already several open studies. For more information, please see the NIHR website here.*

*Operating theatre ventilation: We are aware this is an important issue. National guidance states that for COVID19 positive or suspected patients, "theatres should not be used by staff or patients for 20 minutes after the patient leaves if conventionally ventilated, or 5 minutes if ultraclean ventilation is used." It is implied from this sentence that the ventilation remains fully on. This guidance is issued jointly by the Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS) and Public Health England  For more information about using theatres for COVID19 positive or suspected patients see here. (Updated 26 March 2020)*

Other resources:

  • BMA coronavirus resources hub here.
  • Public Health England guidance for all NHS staff here.

We will continue to update members on the current position and the impact on trauma and orthopaedics.