04.12.2020

Playing our part in the COVID-crisis by transitioning from elective surgery to trauma to support acute hospitals

The National Orthopaedic Hospital Cappagh is an elective orthopaedic hospital, offering orthopaedic, sports and exercise, and rehabilitation medicine. As a tertiary referral centre, we plan patient appointments and surgical lists to precision. Each week, 100 day-case and 65 overnight surgical procedures are performed at the Hospital. Currently, five of the Hospitals seven surgical theatres are in active use. Limited physical space, bed capacity and resourcing restrict patient numbers, obviating the need to activate additional theatre suites. On March 13th 2020, as the country braced itself for the impact of COVID-19, an emergency meeting of the Medical Board convened at the Hospital. Those in attendance unanimously assented to suspend all non-essential procedures and outpatient clinics, and transition to trauma services for the first time since the Hospital opened its doors in 1908. The Hospital’s primary objective was to alleviate pressures on the COVID-designated acute hospitals and ensure that patients continued to receive the vital care they needed, in a safe environment.

From the outset, the Senior Management Executive and Medical Board identified several challenges that included disparate admission, screening and referral protocols at referring hospitals, the absence of an intensive care unit for critical patients. A radical transformation was necessitated to overcome these challenges and prepare for the changes ahead. The transition to trauma services began with the appointment of trauma leads Prof. John O’Byrne, Head of the Professorial Unit, Mr Paul Curtin, Chair of the Medical Board, and Mr Peter Keogh, Clinical Director at the Hospital. Drawing from their extensive experience in trauma, they undertook a forensic analysis of the patient journey and touchpoints. Staff from every discipline were invited to participate in the transition process (5).

A  new trauma pathway algorithm was formulated through the inter-disciplinary collaboration of orthopaedic surgeons, anaesthetists, medical physicians, nursing and support staff. Taking inspiration from national and international guidance, this iterative pathway governed all stages of the patient journey from referral to post-discharge patient care (3), regularly adapting to reflect stakeholder feedback, emerging evidence and best practice.

Clear communication was central to the safe, effective and efficient treatment of patients. To this end, referring hospitals were given (a) New protocols for patient screening (1); (b) A referral form eliciting optimal information to facilitate appropriate planning (2) and (c) Electronic patient information packs for dissemination to patient referrals communicating precautions to be taken in advance of admission and the admissions process, and providing details of pertinent imaging, documentation and medications to bring on the day of Admission (4). Referring Consultants used Siilo, the secure medical messaging App, to collaborate and exchange real-time patient data with NOHC Consultant Orthopaedic Surgeons and the visiting Ortho-Plastic Consultants granted temporary operating privileges at the Hospital.

The Hospital is not suited to the treatment of COVID-infected patients as it does not have an ICU and the HDU has limited capacity. Maintaining a COVID-free environment was, therefore, paramount to patient and staff safety and service continuity. For this reason, we immediately imposed visitor restrictions, introducing stringent admission protocols and staff directives to prevent viral infiltration of the Hospital. Patients for admission undertook risk assessment and COVID-testing at referral sites where possible. In the absence of risk assessments and COVID test results, patients presumed to be infected until proven otherwise, and appropriate safety measures were taken in the delivery of care. Patients were triaged by telephone the day before admission and screened and tested on the day of access by nursing staff in PPE gear, at a designated parking bay. Patients suspected of infection were discussed by the surgical team, to determine whether the urgency of their treatment and whether an acute hospital might better manage their needs. Spinal and regional anaesthetics were administered where possible to reduce the risk of anaesthetists, improve postoperative patient mobilisation and expedite discharge.

Surgical teams were divided into pods and assigned colour-coded scrubs identifying pods. Separate changing rooms and toilet facilities were allocated to each pod to limit the prospect of cross-contamination in the event of infection, and lessen the impact of the virus, should a team member fall ill or be in close contact with a COVID-positive case. Trauma huddles convened each morning to discuss patients for surgery and in the evening to review challenges, share successes, and prepare practicably and mentally for the following day.

High-risk members of staff were redeployed from frontline positions, and agile rostering and agency staff were employed by HR to ensure sufficient resourcing for the provision of quality patient care. Contact tracing was implemented, and occupational health services made available to staff on sick-leave, in recovery and returning to work post-infection. Staff at the Hospital worked tirelessly with the HSE and independently to source adequate supplies of PPE gear for the safe provision of services. Staff in referring hospitals were most helpful, providing essential equipment, theatre sets and trauma-specific training. To reduce the risk of infection, we placed greater emphasis on day case procedures and expediting discharge. Postoperative patients were evaluated on a case-by-case basis to determine if an in-person or virtual outpatient appointment was necessary post-discharge and comprehensive Care Plans were given to all patients on discharge from the Hospital.

In the period from March 18th to July 18th, whilst operating as a trauma centre, 341 trauma, 1,289 essential elective orthopaedic, and 191 ortho-plastic procedures were performed at the Hospital and 805 patients received treatment in the plasterbay. During this time, Trauma Services were provided for open, hip, periprosthetic, long-bone, complex foot and ankle fractures. Contrary to standard work practices at the Hospital, staff were placed on call 24/7. Surgical theatres operated seven days a week for extended periods; however, the number of active theatres reduced as staff succumbed or were exposed to infection, and surgical pods were forced to isolate. The Outpatient Department held in-person consultations for 3,934 patients (1,075 new patients/2,859 patients for review appointments). Also, 825 patients attended Virtual Outpatient Clinics (453 new patients/372 patients for review appointments). The Specialist Rehabilitation Unit at the Hospital welcomed 65 new patients (17<65 years; 48 >65 years) and discharged 112 patients from the unit in this period. During the admissions process, 16 patients were suspected of COVID-19. Six of these patients were redirected to the referring hospital for surgery, and two subsequently tested positive for COVID-19. Resourcing was perhaps the most significant challenge presented by the pandemic, as staff were precluded from service because of ill health or close contact exposure. In all, 57 staff contracted the virus. Teams, departments and wards were closed, and several patients were transferred to COVID-designated Hospitals for care.

 

Indicators Of Success

The successful implementation of new protocols and practices delivered improved efficiencies and outcomes that include:

  • Co-ordination of the patient journey with appropriate screening, referral, anaesthesia, sub-specialtity surgical expertise, postoperative therapeutics and care plans.
  • We have improved communications and collaboration with referring hospitals.
  • Agile mobilisation of teams in response to the need for rapid change and enhanced cross-departmental, interdepartmental and interdisciplinary collaboration.
  • Safe practice checks ensured the transition to trauma was seamless for staff and patients.
  • The preservation of a COVID-free environment – no COVID-positive patient referrals were admitted to the Hospital (although several staff acquired the virus through close contacts and community transmission, and false-negative test results contributed to the spread of infection)
  • No reported surgical site infections in follow-up visits.
  • Most patients did not require an outpatient appointment post-discharge and few postoperative complications arose, bearing testament to the success of the postoperative Patient Care Plans.
  • Two patients transferred to an acute hospital following surgery for treatment of cardiac arrhythmia and pulmonary embolus and were subsequently discharged following treatment.
  • Staff sourced highly sought after PPE gear directly from suppliers at competitive rates.

On resumption of elective services, management at the Hospital requested feedback from personnel across the organisation, to learn what worked well, and what did not. A Major Outbreak Committee has been established to instruct NOHC personnel on Major and Minor Outbreak Management to ensure efficient recognition management, containment and communication during an outbreak. Going forward, departments are charting essential tasks for the delivery of services and care, and plans are in place to cross-skill personnel to ensure the continuity of critical services despite absenteeism. The Hospital remains committed to playing a crucial role in patient care in times of crisis, and we will apply learnings from this outbreak to inform future operations to enhance patient care and enable an agile response to future pandemics.