The Change in Practice in the Trauma and Orthopaedic Department in the Royal Devon and Exeter Hospital and the Influences for the Post-COVID-19 Era of the National Health Service

By Morgan Bayley, Alex Goubran, Omer Salar, Andrew Toms and Jonathan Howell
Princess Elizabeth Orthopaedic Centre, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK

Corresponding author e-mail: [email protected]

Published 14 August 2020

As students of the British Orthopaedic Association’s 'Future Leadership Programme' we have been exposed to new ideas into how leadership models work in healthcare. The COVID-19 pandemic has been an unprecedented period for the NHS. The BOA has demonstrated strong leadership with regular updates^1,2 in response to the rapidly changing situation.

Elective services in our unit ceased in March. The department was divided into three 'pods', each containing a range of grades, experience and sub-specialties. Extended Scope Practitioners (ESPs), therapists, and Surgical Care Practitioners (SCPs) were divided amongst the pods. The priority was to ensure that one pod was on site working to provide 24-hour trauma care. A 'standby pod' was ready to be deployed as required for self-isolation or redeployment requirements. A third 'pod' was off site resting and recovering.

A senior Consultant was designated 'Divisional Duty Consultant', coordinating communications, meetings and roles. Pod members were working in an unfamiliar environment and re-engaged with elements of trauma that they had not experienced for some time. Pod members were upskilled to use a Mini C-Arm, allowing manipulations of fractures and dislocations. Refresher courses were held for ATLS, immediate life support, and basic plaster application.

Clinical leaders usually have clearly defined targets, with time to work up plans this evidently was not the case during COVID-19. Our goal was to deliver definitive Consultant lead, multidisciplinary treatment for patients with musculoskeletal injuries at presentation. There were many unknowns regarding patient pathways, a change of infrastructure, logistics, staffing, intra-departmental communication and extent of the outbreak. The focus was placed on personnel and patient management.

Patients were referred to the newly formed 'Musculoskeletal Injuries Unit'. This contained a plaster room, X-ray facilities, and therapy services. Governance was employed to facilitate review and evolution of the service.

The key to this was team working, clear leadership and communication. Remote telecommunication soon became pivotal. We discussed daily jobs and roles and were encouraged to be proactive as opposed to reactive including suggesting adaptations, which was vital in the evolution of the service.

Acute trauma care provision moving forward

During the COVID-19 era trauma patients received consultant led definitive treatment at presentation. However, this labour-intensive service is not be sustainable long term. Central to the transition back to normal practice is communication and flexibility. So much has been learnt in last few months that will change our trauma care going forward.

Initial assessment of trauma patients will be returned to ED; however new pathways should be developed to improve patient flow and treatment. The old fracture clinic model requires review and improvement. We propose a 'hot' fracture clinic to run alongside normal fracture clinic during office hours. When ED identify an acute trauma patient they should be transferred to the hot clinic, allowing a definitive plan to be formulated. Out of hours patients should be booked into the next hot clinic and have their initial treatment by ED. Many Emergency Department ESPs have worked in our pods and have thrived in their modified roles. We propose integrating the ESPs into the hot fracture clinics to enhance skills and maintain newly formed working relationships.

Creating trauma teams covering all subspecialties or having rostered surgeons available to review patients would facilitate subspecialty care for patients and reduce unnecessary appointments. The BOA COVID-19 guidelines allowed pragmatic treatments whenever possible¹. However, our COVID-19 experience has given us confidence to be more pragmatic about certain injuries, and not overtreat. Pathways should be established for common injuries including scaphoid fractures and soft tissue knee injuries. Early scans detect important injuries, provide faster appropriate treatment and reduce attendances. Working with radiology to ensure acute slots for imaging and rapid reporting will be crucial. Therapists will potentially see patients earlier in their treatment. We must therefore have a safety net allowing swift review in fracture clinic if required. Likewise fracture clinic should have rapid access to therapy services and the use of telephone or video clinics as an alternative to face-to-face consultations thus creating space in clinic.

A Trauma Admissions Unit allows rapid transfer of non-ambulatory trauma requiring admission from ED to the trauma ward, but only after X-ray review by the orthopaedic team. The unit should be run by Trauma Nurse Practitioners (TNPs), as they are a constant within the department, whereas juniors regularly rotate. Training and up-skilling TNPs allow up-skilling of rotating juniors in turn.

Creating trauma teams covering all subspecialties or having rostered surgeons available to review patients would facilitate subspecialty care for patients and reduce appointments. The BOA COVID-19 guidelines allowed pragmatic treatments whenever possible¹. Hopefully we can continue with similar approaches with more traditional initial treatments for some injuries. However, our COVID-19 experience has given us confidence to be more relaxed about certain injuries, and not overtreat.

Restarting elective orthopaedic services

In May the BOA produced guidelines for restarting non-urgent orthopaedic care².  With these in mind our directorate has started planning for the transition back to elective services. However, a 'second wave' may cause significant disruption. We must be prepared for all eventualities, facilitating a rapid return to the COVID-19 pod system if required.

Elective out-patient services

Telephone clinics have been successfully utilised and should be considered for routine follow up of patients, limiting throughput in the department, alleviating waiting lists and triaging new referrals. ESPs could vet new patient referrals in a centralized MSK assessment service.

During the COVID-19 period almost all decisions have been consultant led, often through an MDT providing definitive treatment at presentation. A similar model could be utilised in the future. Efforts should be made for patients to see various MDT members during a single visit. For example, pre-operative patients should have their consent, anaesthetic assessment, pre-operative work up and radiology all in a one-stop service. Online resources including websites, apps and podcasts should be improved to help with patient information such as joint school and consent.

Elective surgery

Safety of both patients and staff should be central to decision making. Recent literature has demonstrated high mortality in patients undergoing surgery who developed COVID-19³. Therefore, re-starting elective surgery will be challenging with a higher threshold to operate. Each case should be assessed on an individual bases and discussed at MDT meetings. Prioritisation of clinical need as suggested by the BOA² including each patient’s associated medical conditions is vital. Entire hospitals or departments should be designated as 'clean' areas to reduce infection risk. Staff and patients alike should isolate and have negative COVID-19 tests prior to elective procedures. Staff numbers should be kept to a minimum, with anaesthetic and surgical techniques modified to minimise the aerosol generating procedures. Minimising surgical time and avoiding unfamiliar techniques or implants is important. To minimise cross contamination, the department could be divided into elective and trauma teams, working on different sites.

Post-operative care will be challenging and is likely to be modified. Patients can be encouraged to manage their wounds whilst using absorbable sutures and reducing follow-up appointments. Rehabilitation should be in clean sites and modified to reduce contact. Private and smaller community hospitals can be utilised as, clean sites allowing safe post-operative recovery away from the 'dirty' unit and allowing elective services to run. A period of seven-day working would ease elective backlog.

Leadership during the post-COVID-19 transition

Strong leadership will be required throughout the service with communication and teamwork essential. The COVID-19 response demonstrated that major changes could be achieved quickly when staff unite; we should utilise our new working relationships to move onto the next phase. Discussion must be had with all stakeholders, to understand their concerns and aspirations. If people feel valued and involved, they will buy into a shared vision to create positive changes utilising transformational leadership to inspire the team, drive change and maintaining a motivated and enthused workforce. Involving people at various levels in management and devolving leadership roles will certainly help. Staff were enthusiastic about their different roles, gaining new knowledge and skills. Promotion of continued learning and upskilling is important for motivation and skillset.

Negotiations will be required both in and between different departments. Working patterns will change and this may not be universally welcomed. Resistance to change may occur and clear benefits to must be highlighted to encourage buy in. Regular surveys and discussion groups with patients and the families should be established to ensure a compassionate patient centric service.

Governance is central to change in the NHS. We must be honest and open about negatives that occur so that lessons are learned, and mistakes not repeated. As with all changes, continued assessment and improvement should happen simultaneously. We should follow the PDSA model, whereby changes are put in place and reviewed to see if they have been beneficial and if further improvements are needed. Central to all change is patient safety and providing high quality care.

During this pandemic, the leaders in our department have offered support, guidance and tools to improve our own performance. The horizontalisation of leadership and what could be achieved collaboratively was inspirational and is encouraging for the shape of post COVID-19 orthopaedic services.

References

1. British Orthopaedic Association (2020). BOAST - Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. Available at: https://www.boa.ac.uk/resources/covid-19-boasts-combined.html.
2. British Orthopaedic Association (2020). Re-starting non-urgent trauma and orthopaedic care: Summary guidance. Available at: https://www.boa.ac.uk/resources/boa-guidance-for-restart---summary---final-pdf.html.
3. Nepogodiev D, Glasbey JC, Li E, Omar OM, Simoes JFF, Abbott TEF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet 2020;396(10243):27–38.