Features
A letter in response to: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? A plea for caution Peter M Lewis, Miriam Day, Lisa A Williams, Laura Lougher, Glenn J Clewer and Stephen Sarasin Letter originally published 22 April 2020 in response to the article: COVID-19 causes a SHiFT in the sands for proximal femoral fracture management? https://www.boa.ac.uk/policyengagement/journal-of-trauma-orthopaedics/journal-of-trauma-orthopaedics-and-coronavirus/ covid-19-causes-a-shift-in-the-sands-for-proximal.html. Published in TJTOC&C 17 April 2020.
We read with interest the article written by the Swansea orthopaedic surgeons with regard to the treatment of patients with a fractured neck of femur (FNOF) during the present COVID-19 virus crisis1. Although this endeavour is to be congratulated on a ‘be prepared for the worst’ basis, we have considerable reservations with their conclusions and therefore its use.
T
he Swansea team offer a scoring system for Trauma and Orthopaedic departments in UK hospitals to use in patients with a FNOF and provides treatment protocols to be undertaken either within the hospital or with patients remaining based at home. Their scoring system, abbreviated SHiFT (Swansea Hip interrogation Fracture Tool), offers a scoring tool to determine if patients warrant surgery or conservative management. We therefore ask the question firstly, is this scoring system indicated at present because of the serious and severe shortage of beds/ surgeons/operating lists etc. and secondly, is this SHiFT scoring system supported by the established orthopaedic literature. Firstly, of significance, on the 16th April 2020 Chief executive of NHS Wales Dr Andrew Goodall warned against waiting too long to seek emergency treatment or choosing not to access regular services at the present time2. He stated,
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although understanding services are disrupted “I am concerned people may not be seeking medical help for illnesses and symptoms not related to COVID-19”. He reinforced the message that “urgent and emergency services for both physical and mental illness are still open and accessible”. Therefore, thankfully at present, although elective operating lists have been cancelled, emergency lists for life threatening conditions can continue. Of relevance to patients with FNOF, A&E emergency attendances are currently 60% down compared to this time last year and ambulance arrivals reduced by 20%2. ‘Patient activity’ for GPs has also fallen by 25% lower than usual. Furthermore, all Health boards in Wales are reporting a ‘green’ status, and with around 49% of their critical care beds remaining vacant with only one in three occupied with a Coronavirus patient2. Although staff sickness is increased during this pandemic to 9.2%, the average for this period is 5%. In conclusion, at least in Wales, there is at present
no requirement for such a triage system and patients with FNOF should continue to attend hospital on an urgent basis. With regard to the second question, namely does the SHiFT scoring system help in prioritising those patients who can be operated upon and leave others better treated by a conservative approach? Patients with FNOF are a surgical emergency with universal acceptance, nationally and internationally, that the standard of care should be an operation undertaken within 24-48 hours of admission3, and with recommendations in the UK remaining the same during this current COVID-19 crisis4. In an extensive recent review article published by one of the senior authors of this response, it states, “unless a patient is likely to die rapidly, any patient with a fracture of the hip should undergo surgery. The patient is out of severe pain and can be nursed comfortably in a dignified fashion”3. Does this remain true during a pandemic crisis? The SHiFT system itself is an extension to the Nottingham Hip Fracture Score (NHFS)5 which is a validated predictor of 30-day mortality for patients undergoing hip fracture surgery along with the addition of a Clinical Frailty Scale. The resultant Swansea scoring system was then validated by a study by the authors over the three winter months of 2019. Not unsurprisingly, the greater the patient frailty, in addition to their NHF score, the greater the 30day mortality identified (up to 58% in certain patients). With minimum score of 4 and maximum of 19, the SHiFT system stratified patients into three groups, being Surgery, Potential Surgery and Non-operative, with the fittest patient always undergoing operation first. Those falling into the intermediary group, if failing to receive surgery within the first seven days, it is envisaged following a further review, they will then be transferred to the
