Managing Hand Trauma during the COVID-19 pandemic using a One-Stop Clinic.

Dear Sir,

The COVID-19 Pandemic has shifted clinical priorities and resources from elective and trauma hand surgery with general anaesthesia (GA) to treat the growing number of COVID patients. At the time of this correspondence, the pandemic has affected over 2 million people resulting in 129045 deaths worldwide, with 12868 UK deaths, with numbers still climbing.

This has particularly affected our Hand Trauma services which serves North London, a population of more than 2 million. We receive referrals from a network of 8 hospitals in addition to 3 Emergency Departments of the Royal Free Group of Hospitals and numerous GP practices and urgent care centres.

In the first week following The British Government lockdown, which commenced March 23rd, we experienced a 75% drop in referrals, from 25 to 6 a day. Subsequently, numbers have been steadily rising to 12-14 a day by 6th of April. The British Association of Plastic, Reconstructive and Aesthetic Surgeons, the British Society for Surgery of the Hand and the Royal College of Surgeons of England, have all issued guidance: both encouraging patients to avoid risky pursuits, which could result in accidental injuries and to members how to prioritise and optimise services for trauma and urgent cancer work.

We have adapted our Hand Trauma Service to a ‘One Stop Hand Trauma and Therapy’ clinic, where patients are assessed, definitive surgery performed and offered immediate post-operative hand therapy where therapists make splint and give specialist advice on wound care and rehabilitation including an illustrated hand therapy guide.

Patients are categorised based on the BSSH Hand Injury Triage App. We already have a specific ‘closed fracture’ Hand Therapy led clinic, to manage the majority of our closed injuries. We combined this clinic with the plastic surgeons’ led hand trauma clinic, and improved its efficiency further by utilising the Mini C-arm fluoroscope within the clinic setting. This enabled us to immediately assess fractures and perform fracture manipulation under simple local anaesthesia.

We have successfully been able to perform 95% of our operations for Hand trauma under Wide Awake Local Anaesthesia No Tourniquet (WALANT). Prior to the pandemic, we used WALANT for selected elective and trauma hand surgical cases. In infected cases, where local anaesthesia is known to be less effective, we have used peripheral nerve blocks.

Previous data showed 50% of our trauma cases were conducted under GA, 33% under LA, and 17% under brachial or peripheral nerve blocks.

We have specifically modified our wound care information leaflets to minimise patient hospital attendance. Afterwards patients receive further therapy phone consultations and encouragement to use the Hand Therapy exercise App developed by the Chelsea and Westminster Hand Therapists.

The patient is given details of a designated Plastic Surgery NHS Trust email address, for direct contact with the plastic surgery team: for concerns, questions and transfers of images.

We have to date received 39 emails, of which 21 have been from patients directly, and the remainder from referring healthcare providers. The majority of inquiries are followed up via a telephone consultation and only complex cases or complications, attend face-to-face follow-up.

This model has successfully combined assessment, treatment and post-op therapy into a one-stop session, which has greatly limited patient exposure to other parts of the hospital, such as the radiology and therapy departments. The other benefit of such clinic is an improved outcome through combined decision making.

There is also a cost saving benefit compared to our traditional model of patient care. We have treated 31 patients based on this model so far, who have been suitable for remote monitoring. On average we have saved 2 Plastics Dressing Clinic (PDC) visits for wound checks per patient, as a very minimum. We have previously calculated the cost of PDC at our centre at £155 per visit and for our 31 patients this translates to an approximately saving of £9000 per month just on PDC costs. If 30 patients each month could be identified for remote monitoring, this could potentially lead to an annual saving of more than £110,000. In addition, the estimated cost-saving by converting the mode of anaesthesia from GA to WALANT has been shown to cause a 70% reduction.

The concept of a one-stop clinic has already been successfully implemented in the treatment of Head & Neck tumours, following introduction of NICE guidelines in 2004 and the COVID-19 Pandemic has made us redesign a busy metropolitan service for Hand Injuries along the same lines.

We believe this model is a good strategy and combining this with more widespread use of the WALANT technique, technology such as apps and telemedicine, as well as encouraging greater patient responsibility in their post-operative care and rehabilitation; is the way forward.

We hope sharing this experience will result in improved patient care at this time of crisis.