Comments about: COVID-19: Initial experience of an international group of hand surgeons.

Dear Sir,

Ducournau et al. elegantly demonstrated the impact of the COVID-19 pandemic on hand surgeons worldwide [1], largely resulting from measures taken to reduce the risk of in-hospital transmission and consequent reduction in operating capacity. Our department has undertaken similar modifications to our protocols, supported by national guidance [2].

While on the surface these may appear to be purely an expedient response to current limitations, there are advantages to reconsidering treatment pathways. In particular we can reassess routine assumptions; for example, that vasoconstrictor is harmful in digits [3], adequate sterility for short procedures [4], the balance of non-surgical management in hand fractures [5], and that general anesthesia is benign or that a negative wound exploration under it should be routine [6]. Other specialties are making similar re-evaluations, such as increasing the non-surgical treatment of appendicitis [7].

However, there remain many conditions whose treatment remains surgical. At our institution we have a treatment room, previously used for minor local anesthetic procedures. This included nailbed repair and diagnostic wound exploration, particularly of small, predominantly dorsal hand wounds.

Since March 2020 we have increased the scope of practice provided in this setting. Treatment is led by a consultant or registrar, and has been enabled by enhanced equipment including theatre plastic sets and tourniquet machine. These procedures increase patient convenience, may improve patient engagement, allow early involvement of hand therapy and reduce attendances. For the surgeon, early access to the wound reduces the hostility resulting from bacterial replication, edema and tissue retraction. Finally, performing procedures in the treatment room allows the junior team to observe and learn.

Between 18th March 2020 and 1st June 2020 we performed 176 procedures, whose details are summarized in Table 1 . 49% were treated on the same day as Emergency Department presentation, 33% the following day (18% over two days or referral time uncertain), with an average time from presentation to procedure of 12.1 h; 6.7% were admitted for further medical or surgical treatment.

Table 1

Plastic trauma clinic procedures.

Procedure	Number
Digital nerve repair	4
Tendon repair	18 (17 extensor)
Terminalization/Completion amputation	6
Open finger fracture/dislocation reduction and closure with external splintage	7
Infected wound washout	23
Wound exploration/suture	79
Nailbed repair	22
Other procedure	18

The outcomes of such procedures should be audited, and the current exigency should not be used to justify poor outcomes. Of the 65% of patients seen for follow-up (rather than being discharged to primary care or not attending), we identified two patients with a new wound infection, and three who required repeat washouts. No other complications were identified.

We are collecting formal patient feedback, but informally many patients were impressed with their expedient definitive treatment, and relieved at minimizing hospital time during a pandemic.

It is important that care provided in this or similar settings is appropriately coded for reimbursement and recording department activity. Following discussion with the coding team we found that only inpatient procedures had been regularly processed, and so worked to improve capture of these outpatient events. Proper coding is known to be challenging in plastic surgery, due to a mix of factors including the wide variety of procedures performed [8]. Without comprehensive coding data, commissioners may incorrectly assume that this care stopped during the pandemic, and could continue to be limited as activity normalizes.

Disclosure of interest

The authors have no conflicts of interest to declare.

No funding was sought or obtained for this work.