Post-COVID-19 trauma care: The end of the new patient trauma clinic?

Ian Crowther, Nick Kalson and Simon Chambers

(On behalf of the Orthopaedic and Emergency Departments,Great North Trauma Centre, Royal Victoria Infirmary, Newcastle upon Tyne)

Ian Crowther is a ST5 Orthopaedic trainee in the Northern Deanery. He completed his undergraduate studies at Newcastle University and has completed both his foundation and early surgical years in the North East of England.

Nick Kalson is an NIHR Clinical Lecturer in Orthopaedics and ST7 trainee, Newcastle.

Simon Chambers is a Consultant Orthopaedic surgeon and is the Clinical Lead for Trauma at the Newcastle MTC. His subspecialty interests are in limb reconstruction and foot and ankle.

The COVID-19 pandemic that struck in March 2020 has forced hospitals to adopt new ways of working. To protect the public and reduce pressure on a stretched workforce systems were implemented to reduce hospital attendance.

Government and BOA guidance recommended [1,2] that patients with traumatic injuries receive consultant delivered care with an emphasis on providing a definitive management plan at first presentation to the emergency department minor injury unit (ED-MIU). In our unit, a major trauma centre in England, we removed the new patient trauma clinic and instead provided the ED-MIU with 12-hour consultant cover. This successfully reduced the patient re-attendance rate by over 50%. Oneyear later and with a successful vaccination programme, decreasing COVID-19 incidence and a return to more familiar working patterns, rather than return to the tried and tested pre-COVID system we have developed a sustainable model to deliver definitive management on day of presentation without the need for a next-day newpatient trauma clinic.

Traditional next-day trauma clinic pathway

The pre-COVID-19 trauma pathway at our unit was similar to many other hospitals nationwide. A normal day would see 120-150 patients attend the ED-MIU; of these a significant proportion would have a musculoskeletal problem. Initial consultation was by the ED doctors/MIU nurse practitioners, who either discharged the patient or referred to the orthopaedic team. Typically, this would be via a next-day face-to-face acute trauma clinic. On average our consultant led clinic was seeing ~20 new patients per day (~7,000 appointments annually).

Figure 1: Pre-COVID-19 trauma pathway

COVID-19 pathway

During the early stages of the pandemic ED-MIU attendance dropped ~50% to an average of 64 presentations per day. A move to a virtual fracture clinic was considered but not implemented in particular because of the potential need for reattendance, which would fail to reduce hospital visits. To optimise patient flow and minimise further attendance our unit redeployed a consultant to the ED-MIU from 08:00 to 20:00. This resulted in patients receiving specialist review at first presentation, often without the need for re-attendance. An emphasis on definitive care and the increased use of removable casts, splints and boots resulted in a >50% reduction in follow-up appointments generated. This reduction rendered the traditional next-day trauma clinic unnecessary and it was suspended. If patients did require subsequent review, they were streamlined into an existing clinic for follow-up. No new slots were required because these were patients who would have been reviewed again routinely. Outside these hours the on-call StR provided the same service, with plans marked as provisional prior to consultant discussion at the following day’s trauma meeting.

Figure 2: Current pathway

Orthopaedic same day review pathway

After the initial wave of COVID-19, presentations to ED-MIU increased, and by September 2020 were at >80% of pre-pandemic levels. With the increased trauma workload and the resumption of elective work it was no longer feasible to provide ED-MIU with 12-hour consultant attendance. To continue to sustainably deliver this care model we reduced consultant presence to 09:00 to 12:00. This is the period that the consultant was previously in the trauma clinic pre-COVID-19 and therefore did not require additional manpower. From 12:00 to 20:00 the consultant is available for advice or face-to-face review as required.

From 20:00 to 08:00 the on-call StR performs face-to-face reviews in ED-MIU, implementing provisional plans with telephone support from a consultant. These plans are then either confirmed or altered in the morning trauma meeting. A letter to the patient and their GP is dictated by the consultant as it would have been had they been seen in clinic.

What does the new system achieve?

Immediate same-day review of walking wounded presenting to our ED-MIU saves >4,000 acute trauma clinic appointments per year whilst maintaining a consultant led service. Providing a definitive management plan on day of presentation has reduced the follow-up clinic appointment burden by >75%. There are several reasons for this:

• Same day specialist review

• Consultant led plan for all patients

• Streamlining of patients requiring follow-up into subspecialty clinics

• Increased use of removable casts, splints and boots

• Provision of injury specific patient information leaflets

The current system is more efficient and has released resources and personnel which is important as we tackle the post-COVID-19 backlog. There are also financial considerations; our department is saving an estimated £150,000 [3] on acute trauma clinics alone, this figure rising to over £500,000 if the savings on review clinics are included.

Whenever practice changes there will be challenges. There is increased workload for the on-call team, with over twice as many referrals. Additional time is required in thetrauma meeting to finalise management plans from the previous day. As a department we feel this is an acceptable trade off.

From a patient’s perspective there were teething problems. Initially we found that >50% of the patients discharged at first presentation would have preferred follow-up, with over one third of them re-presenting to ED-MIU or their GP with queries or concerns. In an attempt to address this, we developed injury specific patient information leaflets for common injuries with a focus on rehabilitation and recovery. These have reduced the re-attendance to under 7% and improved satisfaction.

The effects of COVID-19 will long be felt throughout the healthcare service. As focus shifts from urgent and emergency care to re-establishing elective services it is vital to improve efficiency. Significant changes have been rapidly implemented; it isimportant to identify those that should be maintained. In our unit COVID-19 stimulated the development of a system that allowed us to remove the fracture clinic and definitively manage walking wounded on day of presentation. This has widespread benefits for patients and is proving to be safe and sustainable and should encourage other units to consider definitive management on day of presentation for common orthopaedic injuries as part of their post-COVID recovery plan.

Acknowledgements

Liam Alcock and Chris Thornhill, orthopaedic trainees, contributed to data presented and helped write this report. The support of Peter Worlock, Helen Whittaker (Orthopaedics) and Matt Cadamy (ED) was vital to this project’s success. •

References

1. NHS England and NHS Improvement [2020]. Clinical guide for the management of trauma and orthopaedic patients during the coronavirus pandemic. Available from: https://sogacot.org/wp-content/ uploads/2020/03/specialty-guide- orthopaedic-trauma-and-coronavirus-v1-16- march-2020.pdf. Accessed 28th August 2020.

2. British Orthopaedic Association [2020]. Management of patients with urgent orthopaedic conditions and trauma during the coronavirus pandemic. Available from: www.boa.ac.uk/uploads/assets/ee39d8a8- 9457-4533-9774e973c835246d/4e3170c2- d85f-4162-a32500f54b1e3b1f/COVID-19- BOASTs-Combined-FINAL.pdf. Accessed 28th August 2020.

3. Andersen GH, Jenkins PJ, McDonald DA, et al. Cost comparison of orthopaedic fracture pathways using discrete event simulation in a Glasgow hospital. BMJ Open. 2017;7(9):e014509.