Trauma transformed: A positive review of change during the COVID-19 pandemic.

Charles Moore in The Telegraph recently described the NHS as 'lumbering'.1 Far from this description, it has been our experience that the NHS has rapidly transformed across specialties in order to respond to the unprecedented global crisis of COVID-19. We describe here the multiple ways in which the plastic surgery trauma service at Salisbury District Hospital swiftly adapted over a two-week period in March 2020. Our aim is to deliver a tailored trauma service whilst adhering to the same high standards of patient care established prior to the COVID-19 pandemic. It is our view that many of these changes will be positive enduring practices for the future.

Dear Sir,

Salisbury District Hospital (SDH) is based in Southwest England and provides a plastic surgery trauma service across the south coast, serving six local hospitals and the designated major trauma centre (MTC). Prior to the COVID-19 pandemic all patients referred to the trauma service, apart from open lower limb trauma, were reviewed in person within the trauma clinic. If surgery was required, it was usual for patients to return on a separate day for their operation and in most instances this was carried out under general anaesthetic in the main operating theatres. After discharge, patients were referred to the hand therapy and plastics dressing services and returned in person for all follow-up visits including dressing changes and therapy. Patients with lower limb injuries from the MTC were transferred from Southampton General Hospital as inpatients to SDH for all complex reconstruction including free tissue transfer.

At the start of the COVID-19 crisis, it became quickly apparent that reducing patient footfall within our department was necessary to protect both patients and staff from the disease. This included reducing inpatient stays in hospital. We responded to this challenge in the following ways and hope that our experience will be of assistance to other trauma services over the course of the global pandemic.

Firstly, all patient protocols underwent significant redesign following which changes to the layout of our plastic surgery outpatient facility were made and patient flow through the department was altered and reduced. Now, when patients are referred to our hand trauma service from peripheral hospitals, the initial patient consultations are carried out remotely using the ‘attend anywhere’ video platform. We are following the BSSH Covid-19 Hand trauma guidelines for patient management. All patient decisions are discussed with the trauma consultant of the day. We are managing a greater number of patients conservatively and to aid this we have designed comprehensive patient information leaflets that enable our patients to increase understanding of their own management.

Patients who need to be seen in person at our department are screened for symptoms of Covid-19 and their temperature taken at the department entrance. Level 2 PPE is worn by staff at all times.

For hand trauma patients requiring surgery, this is provided on the same day to maximize efficiency and reduce the need for multiple visits. We have transformed our minor operating theatres, located adjacent to our clinic, into fully functional theatres equipped with a mini C-arm and all instruments for trauma operating. This reduces the need for our patients to be taken into the main hospital theatre suite. Operations are carried out either under local anaesthetic, WALANT or regional block depending on complexity. All theatre staff wear level 3 PPE and staffing is kept to a minimum. All wounds are closed with dissolvable sutures. Immediately post operation, our on-site hand therapists review patients. Splints are made on the same day and patients are educated about their post-operative management at this time. All follow-up is subsequently carried out virtually by the hand therapy team using ‘attend anywhere’.

With our hub and spoke service set up for lower limb trauma patients, we have ensured that there is an on-site consultant at the MTC every day. Wound coverage is being undertaken for all patients at the MTC. Two plastic surgery consultants in conjunction with the orthopaedic team carry out operating for these patients. All inter-hospital transfers for this group of patients have been stopped. Choice of wound coverage for these patients is being designed to minimise inpatient stay and reduce operative time.

The changes that we have made to our service in a short period of time have already been beneficial for patients, streamlining their care and reducing time spent in hospital. Figure 1 shows the drop in numbers of trauma patients that we have seen during the first four weeks of the UK lockdown (n = 213 in January 2020 to n = 75 over the first 4 weeks into lockdown). This is in line with reports from other UK units. This has given us time to refine our protocols for an expected upsurge of patients as the lockdown is lifted. Furthermore, during this period where we have had extra capacity, our registrars have been trained to carry out new techniques. They now undertake insertion of both mid-lines and PICC lines for medical inpatients under ultrasound guidance to support and reduce the burden placed on our anaesthetic and critical care colleagues who previously would have placed these.

Figure 1

Graph showing the reduction in trauma patients presenting during the COVID lockdown period compared to the month of January 2020 prior to the COVID- 19 Pandemic.

It is our expectation that many of the changes we have implemented to our service will be continued in the long-term. We will continue to learn and adapt our protocols as this phase of work continues. Whilst many of the outcomes of the Covid-19 pandemic will be negative, it has also been the catalyst for significant positive change within the UK NHS.