From Elective Orthopaedic Centre to a COVID-19 Trauma Unit: Rapid transformation

By S Govilkar, C Dover, D Dass, J-H Rhind, E Ramhamadany, D Ford, R Potter, P Cool, C Meyer, R Singh and C Kelly
Postgraduate Graduate Department, Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Oswestry, UK

Corresponding author e-mail: [email protected] (Mr. Siddharth Govilkar)

Published 19 May 2020

Abstract

The medical profession is facing one of its biggest challenges in modern history. Declared as the cause of a global pandemic by the World Health Organisation on 11th March 2020, COVID-19 has now been confirmed in over 3.5 million people worldwide. COVID-19 has undoubtedly had an impact on society as a whole; disrupting day-to-day routine, work, and leisure activities. Within our field of orthopaedics, there has been a complete cessation of elective surgery. Our centre, which normally has an annual turnover of over 12,000 patients, has been remodelled to receive trauma from across the county. In this paper, we discuss the impact COVID-19 has had on our local elective orthopaedic centre, and describe how the service provision of a hospital can be redefined in a matter of days. We can demonstrate how an urgent, yet effective, trauma unit can be established to receive trauma from multiple satellite centres. 

Introduction

The Coronavirus pandemic (COVID-19) swept the world from east to west over a four-month period, with the first cases reported in Wuhan, China on New Year’s Eve¹. With over 125,000 patients diagnosed with COVID-19, the WHO officially declared a pandemic on 11th March 2020¹. COVID-19 has now been confirmed in 3,517,345 people worldwide, with a mortality rate of 6.9%².

The subsequent lock down, enforced by the UK government on the 23rd of March 2020, has had a profound impact on orthopaedic practice³. The increase demand on the National Health Service, for ITU beds and ventilatory support, has led to the cessation of all elective orthopaedic activity. In this article, we discuss the impact COVID-19 has had on our local elective orthopaedic centre, and share the experience and strategies employed to establish an effective trauma unit in the face of a global pandemic. During this period, our trust has set clear primary goals for our service:

• Ensure delivery of essential orthopaedic trauma services.
• Optimise and conserve staffing and resources in neighbouring hospitals.
• Maintain and deliver orthopaedic care as per BOAST (COVID-19) guidance³.
• Provide continuity of care for existing elective patients.
• Protect both patients and healthcare staff from COVID-19 infection.
• Maintain essential services (tumour, spinal emergencies, and rehabilitation).

Normal service

Our centre is a specialist tertiary referral centre for spinal trauma, spinal injury rehabilitation and musculoskeletal oncology, which also provides an elective upper and lower limb orthopaedic service, with an annual turnover of almost 12,000 patients, (see Table 1).

Last year we had an average length of stay of 3.59 days, with over a quarter of surgery performed (27.7%) being that of arthroplasty. We have four general orthopaedic wards, as well as dedicated paediatric and tumour wards. Our catchment area includes Shropshire, Staffordshire, East Cheshire, Mid and North Wales.

Table 1: Data for last two years for our centre

Figure 1: Admissions by sub-specialty

Hospital models

The 'generic model' of a hospital is normally devised to meet the targets, aims, services and general 'principles' of that secondary care centre⁴. An effective model has previously been described as one that is "general, flexible, intuitive and simple"⁴. The current COVID-19 situation required the creation of a specific service-led model, with time constraints preventing flexibility in planning. For trauma systems, the importance of a 'well-organised structure' has previously been emphasised when configuring Major Trauma Centres in Europe⁵, with the need for effective triage and signposting to the relevant surgical specialty highlighted⁵.

Papers have previously described the 'Discrete Event Simulation' as an effective method of managing a surgical-led service, encompassing staffing levels, number of beds, theatre provision and discharge as key features of such a model⁶. Potential challenges to this model have been previously identified as including theatre scheduling conflicts, theatre turnaround times, bed capacity and delays to discharge⁴.

For our model, key considerations included bed capacity, staffing, local population, and average length of stay, with the latter predicted using data provided by the two neighbouring district general hospitals, for their trauma patients under normal circumstances. Our model was then updated to allow intake of ambulatory trauma from a third district general hospital. Further considerations included theatre capacity (with COVID-19 precautions) and ventilatory support being required in neighbouring hospitals for the management of COVID-19 patients.

Figure 2: Change of workload and conversion to essential services (DGH = District General Hospital)

Figure 3: Ventilator Transfer to Acute COVID-19 Trusts

Timeline for planning

With the cessation of all elective surgery, our unit transformed into a local trauma service for Shropshire, initially receiving trauma from two local district general hospitals. Using the following strategies and model, we were able to 'go live' with this service within one week of the nationwide lockdown (Friday 27th March 2020). We were then able to reapply these same management principles to receive trauma from a third centre, with this model being implemented within just two days. This was organised and led by a small team of five senior  clinicians and the clinical director.

Strategy and performance planning

The clinical and non-clinical management teams within the trust set about exploring the avenues to accommodate local trauma by project planning. Tools used included that of a clinical service model, quality impact assessment analysis (QIA), risk assessment, and data protection impact assessment (DPIA), pending the transfer being approved by the Office of Assurance^7-11.

This process began by a planning assumption for 80% of the trauma volume from each hospital, considering the reduction in demand in the context of lockdown. This was based on guidance from Public Health England, the British Orthopaedic Association, and the National Orthopaedic Alliance, generated from national and international trends in trauma admissions during a pandemic state^3,8,12.

The clinical service model analysed the most common twenty admissions or procedures recorded on the trauma database, and analysed the referral, triage and management pathways required to deliver care in accordance with the British Orthopaedic Association Standards for Trauma (BOAST), whilst also assessing length of stay and bed occupancy³.

A pathway for each admission was described, with an in-depth assessment of all the different resources that would be required, such as Personal Protective Equipment (PPE), COVID-19 testing, staffing, additional services, equipment and post-operative care.

Each department was accountable for evaluating its own processes and ensuring that the practicality of delivering its service for trauma patients was possible^10,11.

Regular remote meeting with bronze, silver and gold command, as per the National Health Service and Public Health England model, ensured accurate and live re-evaluation of the hospital service, with adaptation of services where required^7,10,12.

Patient journey

The flow chart (figure four) depicts the patients journey from presentation, through triage, assessment and, ultimately, to definitive management. The patients were defined as being either low risk or high risk for COVID-19, and placed onto either the green or red pathway, respectively. Those patients requiring escalated respiratory care were not transferred to the elective orthopaedic site, due to lack of ventilatory and ITU support. These patients were managed in the medical wards and ITU setting of the local district general hospital, but were subsequently transferred when medically stable for their definitive orthopaedic management^13,14.

Figure 4: The patient journey pathway, used to screen and deliver appropriate care

Logistics

The logistical considerations were multiple, and utmost priority was given to the safety of patients and healthcare staff. To limit risk of COVID-19 transmission, a variety of practice alterations were implemented following multidisciplinary discussion, with involvement of nursing staff, clinicians, microbiology/infectious disease team, and managers, in accordance with Public Health England guidance^8,12,15.

Personal protective equipment

Structured and clear guidelines for personal protective equipment (PPE) from Public Health England (PHE) were implemented¹². All staff were fitted and taught the appropriate techniques of protecting themselves with PPE gear, including donning/doffing techniques and handwashing.

Areas of the hospital were defined as low, moderate and high risk as per PHE guidelines¹², and all patients were initially screened with the use of a COVID-19 questionnaire. The patients were asked if they had fever, respiratory symptoms, or history of recent travel. During the lockdown there were further significant updates provided by PHE on PPE and screening guidance, which resulted in all symptomatic patients being PCR COVID-19 tested prior to transfer and surgery^4,12,13,16.

There was regular interaction and direction from the infectious disease team locally and nationally, with further support provided by a PPE clinical lead, who monitored stock and performed daily and weekly audits.

Medical staffing and rota

To minimise risk of COVID-19 transmission between healthcare workers, staff were stratified by occupational health into high and low risk from COVID-19, using guidelines provided by PHE¹². High risk staff (those with underlying medical conditions or immunocompromise, with existing respiratory condition, or those aged above 60 years) were advised to work from home or in low risk areas such as outpatients⁴.

The relevant rotas and shifts for all staff were altered to accommodate for sickness and, most importantly, safety. Clinical teams were redefined to include a mix of subspecialty experience, with both junior and senior staff involvement.

Rotas ensured that staff were staggered in their work patterns and held in reserve if required due to sickness. All communication was via email, video link, instant messaging platforms, such as WhatsApp and Microsoft Teams, with face to face meeting kept to a minimum.

Information technology

Information technology (IT) was a challenge. Clinical staff required access to imaging, pathology and electronic patient records (EPR) from all three referring hospital sites, with each having slight variations in programme software and set-up. This was achieved with data protection and security at the forefront.

New software was developed and implemented by a local surgeon that logged all admissions via a database, whilst integrating the radiology, pathology and EPR. The theatre database continued with the use of the Bluespier Web Management System and, in particular, utilised the trauma 'whiteboard' add-on function.

There were two multi-disciplinary team (MDT) meetings daily at 8am and 4pm, attended virtually by relevant healthcare staff using the Microsoft Teams software, with only essential staff present to limit face-to-face interactions. These meetings ensured discussion of each new trauma admission and all inpatients, in an MDT setting, to plan theatre lists and to improve theatre efficiency and patient flow^4,13,16.

Figure 5: The MDT meeting format

Wards and inpatients

The traditional layout of our centre includes four surgical wards, two spinal injury wards, two rehabilitation wards and a high dependency unit. All admissions prior to surgery were COVID-19 screened. Having redefined the hospital into three zones based on risk, all patients initially, unless COVID-19 tested negative, were admitted into the amber zone. If tested negative, patients could then be transferred to the green zone for their definitive management. If the patients were symptomatic or confirmed COVID-19-positive they were admitted onto the COVID-19 isolation ward (red zone). This ward was structured with single en-suite rooms, and patients remained here until de-isolated by infectious disease specialists¹⁴.

Patients were continuously assessed and reassessed during their inpatient stay to ensure that they did not exhibit signs of COVID-19. If necessary, they were then transferred for isolation and retesting, in accordance with PHE policy¹².

The new rota structure ensured that separate inpatient teams managed the orthopaedic patients with suspected COVID-19 than the remaining orthopaedic patients, to allow for physical segregation of both patients and healthcare staff to minimise transmission risk⁴.

All new patient arrivals were given fluid-repellent surgical masks, with advice to wear them at all times, even when in bed. Hand hygiene was reinforced daily by nursing staff. Unless in a palliative situation, all inpatient visitations were stopped.

The orthogeriatric team and relevant support staff from the district general hospital, such as discharge and trauma coordinators, were transferred across to our centre on temporary contracts. They provided best practice for the care of elderly patients as per National Hip Fracture Data Base and NICE guidance, whilst facilitating discharge planning to the community¹⁷.

Theatres

The theatre infrastructure changed dramatically in the presence of the pandemic, with two full day trauma lists (one upper and one lower limb), a half day tumour list and an emergency spine list Monday to Saturday, with provisions for an emergency list on Sunday if required. 

The allocation of staff in theatre had to be restructured as per an emergency COVID-19 rota that separated the clinicians into teams, to avoid mixing of the workforce. The surgical team consisted of the scrub staff, ODP, two anaesthetic consultants, and two trauma (T&O) consultants. Further to this, the competency of scrub staff and T&O consultants for specialist trauma procedures was assessed to ensure safe delivery of service. Thus, ideally the arthroplasty team dealt with the hip and lower limb long bone fractures, while the foot and ankle team dealt with lower limb trauma.

As our centre was traditionally an elective hospital, the relevant trauma kit and tables were transferred across from the local district general hospitals. In addition, operative staff received training to familiarise themselves with the kit prior to use.

The patients admitted semi-electively or as an in-patient admission for urgent procedures (e.g. fracture fixation), were assessed as stated previously for COVID-19. Patients COVID-19 positive and with significant medical compromise stayed under the medical teams for respiratory system treatment and were only transferred if stable and suitable for surgery. The assessment was led by the anaesthetic team and the consultant-led medical team in the district general hospitals. For all patients suspected as COVID-19 positive, specific pathways were created in collaboration with other allied healthcare specialists from anaesthesiology and infectious diseases^14,18.

All healthcare staff were required to don full PPE when handling suspected or confirmed COVID-19 cases in the theatre and recovery areas, as these were established as high risk zones due to the generation of aerosol.

Outpatient clinics

All elective clinic lists for new and follow up patients were triaged to identify the non-essential and essential appointments. Some of these essential reviews required clinical and radiological assessment, and thus needed to be a face-to-face interaction. The non-essential reviews were done as telephone consultations, with collection of Patient Recorded Outcome Measures (PROMs) data¹⁸.

Fracture clinic facilities were also re-configured at our site, with referrals screened by the on-call trauma consultant, prior to allocation to one of the twice daily clinics. The site was equipped with plaster room facilities, orthotics, and physiotherapy.

On arrival at our outpatient department, all patients were screened for COVID-19. If they were symptomatic, or suspicious of being positive, PPE was worn in accordance with PHE guidelines¹². All visitors were required to wear fluid repellent masks before being allowed into the hospital. Hand sanitiser was made available freely throughout clinics and hand hygiene was strongly encouraged.

In the outpatient setting, most patients were treated non-operatively, and non-urgent conditions were given longer duration of follow-up appointments, as per BOAST COVID-19 guidelines³.

Additional services

The COVID-19 pandemic has had an impact on all services within the hospital model. With the initiation of fracture clinic, and to meet increased demand on the plaster room, plaster technicians from our neighbouring hospitals have been employed to join our local workforce. In accordance with recently published BOA guidelines³, there is a move towards the increased use of removable casts, to minimise exposure and in-hospital traffic. Plaster room technicians are using water-repellent surgical masks, as instructed by Public Health England, during these close patient encounters. We pre-emptively increased stock of orthotics on site, to meet anticipated demand. The orthotic service has been reconfigured to cover the wards throughout the week, as well as to provide support in fracture clinic¹⁹.

Physiotherapy is still being provided on the ward during the post-operative period, with Personal Protective Equipment being worn in accordance with Public Health England guidance¹². This is particularly important for aerosol-generating chest physiotherapy procedures. For those patients confirmed positive and in isolation, physiotherapy has had to be limited to individual rooms.

Administration staff have also received a change in rota and, at times, location. Non-clinical staff have been encouraged to work remotely from home where possible, and to attend work on a staggered rota, thereby ensuring only one member of staff in the office at a given time. The provision of remote working facilities is also promoted by the BOA³. The vast bulk of our admissions have been neck-of-femur fractures, with no routine follow-up arranged to, again, minimise exposure to this high-risk group of patients. 

Conclusion

The orthopaedic community is seldom directly involved in the management of pandemics, but we hope the challenges we have faced and overcome nationally can benefit our colleagues internationally in managing their respective orthopaedic services during this crisis.

Key points

• COVID-19 is an international pandemic, which has resulted in the cessation of elective orthopaedic surgery.
• Trauma care has been altered to meet a change in demand and to minimise in-hospital patient encounters.
• We have drawn on our own experiences to describe the challenges faced with a change in hospital service.
• Our hospital model can be used to facilitate the implementation of a trauma service within two weeks.

Conflict of interest

None to declare

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