Strategic planning of plastic surgery emergencies during the COVID-19 pandemic: Lessons learnt from a tertiary plastic surgery centre.

Dear Sir,

In March 2020, the NHS began navigating the strategic planning minefield caused by the COVID-19 pandemic. A national lockdown to help control virus transmission, involving closure of non-essential businesses and schools and a requirement for social distancing was enacted on 26th March 2020. St. George's University Hospitals NHS Foundation Trust (St. George's) is a tertiary plastic surgery unit serving a population of 3.5 million people in South West London. Locally, a number of changes were required, including more senior receiving teams due to staff redeployment, reduced theatre services to onsite local anaesthesia/WALANT lists three days per week and twice weekly offsite GA capacity.

The aim of this study was to determine how the COVID-19 pandemic and lockdown affected the disease/injury profile and management of patients presenting to the plastic surgery emergency service at St. George's and identify how this may influence strategic planning in future surges.

We prospectively analysed the health records for patients presenting with plastic surgery emergencies from 1 March to 1 June 2020 and compared this to the same period in 2019. Data points included diagnosis, referral and treatment times, treatment delivered and follow up arrangements. Patients with multisystem or multispecialty conditions were excluded. Statistical significance for time intervals was calculated using a Mann-Whitney U test. Statistical significance for diagnosis, type of anaesthesia and type of follow-up were evaluated using a Chi-square test.

Emergency referrals to St. George's decreased from 1070 in 2019 to 692 in 2020. This significant decrease of 35.3% (p<0.01) corresponds to data in other studies. , There was a similar gender distribution in both years. The age distribution in the adult population was also similar in the two study periods (Figure 1 ). Patients under the age of 18 accounted for a large proportion in both years, with 493 patients (46.4%) in 2019 and 255 patients (36.8%) in 2020. We postulate that this relative reduction of 9.6% may be caused by decreased team-based activities as a result of school closure and the requirement of social distancing.

Figure 1

Age distribution of plastic surgery emergencies referred to St. George's University Hospital.

Children accounted for a large number of plastic surgery emergencies in both study periods. Age distribution was similar for all age groups, except for school aged children.

Although we anticipated a possible delay in presentation, the mean time was 1.6 days in 2020 compared to 1.0 days in 2019, suggesting that fear of attending the hospital was not an issue for patients. The time interval from assessment to treatment, either non-operative or operative, was similar, suggesting that the resources available were adequate to meet the reduced demand without significant delay.

With lockdown, we expected a change in injury patterns with a fall in work related injuries and an increase in ‘do-it-yourself’/gardening activities. Our study supports this demonstrating a significant relative reduction in closed hand fractures (200 (18.7%) in 2019 vs 56 (8.1%) in 2020 (p<0.01)). There was a relative increase in open hand fractures (98 (9.2%) in 2019 vs 81 (11.7%) in 2020 (p = 0.04)) and tendon injuries (40 (3.7%) in 2019 vs 59 (8.5%) in 2020 (p<0.01)). Table 1 shows the overall distribution of injury patterns.

Table 1

Diagnoses of plastic surgery emergency referrals to St. George's University Hospital.

Table 1 shows the distribution of the referrals in the study periods in 2019 and 2020, which demonstrates a relative reduction in closed hand fractures and a relative increase in open hand injuries in 2020.

Diagnosis	2019		2020		p value
	N	%	N	%
Hand
Closed fracture	200	18.7%	56	8.1%	p<0.01
Open fracture	98	9.2%	81	11.7%	p = 0.04
Tendon injury	40	3.7%	59	8.5%	p<0.01
Other soft tissue trauma	418	39.1%	253	36.6%	p = 0.52
Infection	101	9.4%	74	10.7%	p = 0.78
Face
Facial trauma	109	10.2%	76	11.0%	p = 0.86
Facial infection	4	0.4%	3	0.4%	p = 1.00
Lower limb †
Soft tissue injury	51	4.8%	49	7.1%	p = 0.08
Other
Burn	4	0.4%	4	0.6%	p = 1.00
Postoperative complication	18	1.7%	8	1.2%	p = 0.93
Other: trauma	17	1.6%	18	2.6%	p = 0.84
Other: infection	10	0.9%	11	1.6%	p = 0.88
Total
Total	1070	100%	692	100%

Excludes major trauma.

Crisis support services reported an increase in contacts during lockdown. However, this did not translate into increased patients presenting following domestic violence, (1.2% and 0.9% of emergencies in 2019 and 2020, respectively), or deliberate self-harm (1.3% and 1.4% of attendances in 2019 and 2020, respectively). Prolonged or repeated lockdown combined with ongoing economic and psychological burden may influence this in the future.

For patients that required surgery at St George's, general anaesthesia was the most common type of anaesthesia in 2019 (286 patients, 54.2%). During the COVID-19 pandemic, we tried to avoid general anaesthesia wherever possible to minimise the risk of exposure by aerosol generating procedures (including endotracheal intubation). Whilst local anaesthesia/WALANT is most useful in patients with upper limb and hand injuries, it could only be used in 197 (51.8%) of all of our patients undergoing surgery, as non-hand trauma and complex hand injuries commonly require regional or general anaesthesia. In future surges, anaesthetic support must therefore be maintained.

Face-to-face follow-up decreased from 75.8% in 2019 to 67.1% in 2020, as a result of virtual/telephone clinics that were introduced during the pandemic. The benefits of telemedicine are recognised, facilitating post-operative review of remotely located patients, thereby minimising inter-human contact and reducing the risk of transmission. This was effective with a conversion of 50 (9.3%) emergency patients to virtual/telephone review (p<0.01). These facilities are now standard in our unit.

Overall, this analysis sets out lessons learnt in response to an evolving situation and how these may be used in future planning for similar scenarios. In acknowledging the unpredictability of the pandemic, we can ensure we remain flexible yet responsive to further pressures which may present different challenges. Forward planning for unknown incidents is a new reality to which we must adapt to ensure services remain safe and effective.

Ethical approval

Not required.

Funding

None.

Declaration of Competing Interest

None.