Looking ahead to a trauma service with COVID-19.

Dear Sir,

We read with interest about the implementation of a one-stop hand trauma clinic at the Royal Free Hospital and the correspondence from Leeds Teaching Hospitals regarding patterns of hand trauma during the COVID-19 lockdown. Over recent years North Bristol Trust (NBT) Plastic Surgery department has moved away from the one-stop clinic model as we have evolved our hand trauma service. However, during the COVID-19 pandemic we note that single contact care is the gold standard in order to avoid repeated trips to hospital and to minimise the risk to both patients and staff members of contracting COVID-19.

Furthermore, the joint memorandum from the Royal College of Surgeons and the Royal College of Emergency Medicine (RCEM) to the House of Commons select committee, makes it clear that we cannot expect to return to our old systems and infrastructure. As suggested by the RCEM President, Dr K Henderson, we must rapidly expand our same day emergency care models to relieve pressure on our Emergency Departments, who are working with a reduction in capacity due to infection control measures and social distancing.

Similar to that described by the Royal Free we set up a one-stop Plastics Trauma Clinic in anticipation of high volumes of hand trauma and a concurrent increase in demand related to directly seeing all minor trauma from the Emergency Department (ED). Within our one-stop Plastics Trauma Clinic setting we built in the ability to assess patients on the day of referral, image injuries using a Mini C-arm fluoroscope, and ensured open access to a day case theatre. A summary of all the changes made to our service is seen in Table 1 .  However, our experience has been similar to that reported by Garude et al. in that we actually saw a significant reduction in hand trauma during the lockdown period.

Table 1

Changes to the plastic surgery department during COVID-19 pandemic.

Referral changes	Practice changes	Follow-up changes
New traffic light referral system for hand and burn injuries for local & regional referrals	Mini C-arm use in one-stop clinic	Preference for telephone review to replace face-to-face
Direct route into Trauma Clinic from ED triage	“Amber” and “Green” zones	Video conferencing for Hand Therapy with Physiotherapy & Occupational Therapy
One-stop Trauma Clinic	Absorbable suture material as standard	Implementation of traffic light system for follow up
Extension of Trauma Clinic open hours (8am-8pm)	Regional or local anaesthetic preference	Patient Information Leaflets for common injuries and post-operative care
Telemedicine referrals for regional burns injuries	Open access to trauma day case theatre (8am-5pm)	Patient managed dressings wherever possible with telephone or teleconferencing support

Following the easing of restrictions and the return to a ‘new normal’ we are continually having to adapt our trauma service. This is influenced by the needs of the regional population as well as those of the hospital, whilst respecting new Infection Control guidelines including social distancing. Particular challenges include theatre availability as the elective surgery programme restarts, bed capacity within amber ‘COVID-unknown’ pathways, physical space for seeing increasing numbers of patients, and personnel issues where doctors and specialist nurses may be required to self-isolate for prolonged periods at short notice. As lockdown lifts, and particularly with the return to work of manual labourers, we are once again seeing an increase in injuries presenting to the unit despite no longer taking all minor injuries from ED. We anticipate a further spike in injuries with the opening of pubs, bars and restaurants in the near future.

As a Plastic Surgery department we can expect to see an increase in referral volume if the proposed diversion of minor injuries from ED is adopted. This potential increased service provision will require upskilling of existing nursing staff and the employment of Emergency Nurse Practitioners in order to safely and effectively provide point of contact, same day emergency plastic surgery care.

Going forward we believe the one-stop model is essential in achieving the desired same day emergency care model, but it is the ability of the service to expand and contract to demand which is essential. We have discussed some of the measures implemented by our Plastic Surgery department and these will continue forwards as we find new ways of working alongside the presence of COVID-19 and the threat of a second wave. We advocate for increased flexibility within departments with a preference for single-stop service for trauma patients.

Ethical approval

N/A.

Declaration of Competing Interest

None.