Utilising the impact of COVID-19 on trauma throughput to adapt elective care models for more efficient trauma care.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has necessitated adaptations in local trauma services, with implementation of novel methods of practice, strategic adaptations, and shifting of resource management. Many of these may serve the driver for landmark changes to future healthcare provision. AIM: To analyse the impact of COVID-19 on service provision by comparing throughput and productivity metrics with preceding years to identify differences in practice that were successful, cost-effective, and sustainable. METHODS: We quantified orthopaedic trauma care provision at a single University Teaching Hospital over a three consecutive year period, from 1st January 2018 to 31st December 2020. Each year was split into four phases based on the 2020 national COVID-19 pandemic periods. We quantitatively analysed change in rates of inpatient trauma operative case load, sub-specialty variation, theatre throughput, and changes in management strategy. Qualitative analysis was based on multidisciplinary team interviews to highlight changes to care pathways. RESULTS: Of 1704 cases were admitted in 2020, 11.9% and 12.4% fewer than 2019 and 2018, respectively. During phase 1, hip fractures encompassed the majority (48.8%) of trauma throughput, with all other subspecialties seeing a reduction. Mean length of stay was shorter during phase 1 (5.7 d); however, the time in theatre was longer (144.3 min). Both, Charlson (0.90) and Elixhauser (1.55) Comorbidity Indices indicated the most co-morbid admissions during 2020 phase 1. CONCLUSION: COVID-19 has resulted in a paradigm shift in how care is accessed and delivered, with many evolving changes and adaptations likely to leave an impression upon healthcare provision in the future.

The impact of deprivation on patients awaiting planned care.

AIMS: Deprivation underpins many societal and health inequalities. COVID-19 has exacerbated these disparities, with access to planned care falling greatest in the most deprived areas of the UK during 2020. This study aimed to identify the impact of deprivation on patients on growing waiting lists for planned care. METHODS: Questionnaires were sent to orthopaedic waiting list patients at the start of the UK's first COVID-19 lockdown to capture key quantitative and qualitative aspects of patients' health. A total of 888 respondents were divided into quintiles, with sampling stratified based on the Index of Multiple Deprivation (IMD); level 1 represented the 'most deprived' cohort and level 5 the 'least deprived'. RESULTS: The least deprived cohort were older (mean 65.95 years (SD 13.33)) than the most deprived (mean 59.48 years (SD 13.85)). Mean symptom duration was lower in the least deprived areas (68.59 months (SD 112.26)) compared to the most deprived (85.85 months (SD 122.50)). Mean pain visual analogue scores (VAS) were poorer in the most compared to the least deprived cohort (7.11 (SD 2.01) vs 5.99 (SD 2.57)), with mean mood scores also poorer (6.06 (SD 2.65) vs 4.71 (SD 2.78)). The most deprived areas exhibited lower mean quality of life (QoL) scores than the least (0.37 (SD 0.30) vs 0.53 (SD 0.31)). QoL findings correlated with health VAS and Generalized Anxiety Disorder 2-item (GAD2) scores, with the most deprived areas experiencing poorer health (health VAS 50.82 (SD 26.42) vs 57.29 (SD 24.19); GAD2: 2.94 (SD 2.35) vs 1.88 (SD 2.07)). Least-deprived patients had the highest self-reported activity levels and lowest sedentary cohort, with the converse true for patients from the most deprived areas. CONCLUSION: The most deprived patients experience poorer physical and mental health, with this most adversely impacted by lengthy waiting list delays. Interventions to address inequalities should focus on prioritizing the most deprived.Cite this article: Bone Jt Open 2022;3(10):777-785.

What can we learn from the experiences and expectations of patients on growing waiting lists for planned care in the COVID-19 pandemic?

AIMS: COVID-19 has compounded a growing waiting list problem, with over 4.5 million patients now waiting for planned elective care in the UK. Views of patients on waiting lists are rarely considered in prioritization. Our primary aim was to understand how to support patients on waiting lists by hearing their experiences, concerns, and expectations. The secondary aim was to capture objective change in disability and coping mechanisms. METHODS: A minimum representative sample of 824 patients was required for quantitative analysis to provide a 3% margin of error. Sampling was stratified by body region (upper/lower limb, spine) and duration on the waiting list. Questionnaires were sent to a random sample of elective orthopaedic waiting list patients with their planned intervention paused due to COVID-19. Analyzed parameters included baseline health, change in physical/mental health status, challenges and coping strategies, preferences/concerns regarding treatment, and objective quality of life (EuroQol five-dimension questionnaire (EQ-5D), Generalized Anxiety Disorder 2-item scale (GAD-2)). Qualitative analysis was performed via the Normalization Process Theory. RESULTS: A total of 888 patients responded. Better health, pain, and mood scores were reported by upper limb patients. The longest waiters reported better health but poorer mood and anxiety scores. Overall, 82% had tried self-help measures to ease symptoms; 94% wished to proceed with their intervention; and 21% were prepared to tolerate deferral. Qualitative analysis highlighted the overall patient mood to be represented by the terms 'understandable', 'frustrated', 'pain', 'disappointed', and 'not happy/depressed'. COVID-19-mandated health and safety measures and technology solutions were felt to be implemented well. However, patients struggled with access to doctors and pain management, quality of life (physical and psychosocial) deterioration, and delay updates. CONCLUSION: This is the largest study to hear the views of this 'hidden' cohort. Our findings are widely relevant to ensure provision of better ongoing support and communication, mostly within the constraints of current resources. In response, we developed a reproducible local action plan to address highlighted issues. Cite this article: Bone Jt Open 2021;2(8):573-583.

Foot and ankle trauma management during the COVID-19 pandemic: Experiences from a major trauma unit.

The COVID-19 pandemic has resulted in a paradigm shift in clinical practice, particularly in ways in which healthcare is accessed by patients and delivered by healthcare practitioners. Many of these changes have been serially modified in adaptation to growing service demands and department provision capacity. We evaluated the impact of the pandemic on the foot and ankle service at our trauma unit, assessing whether these adaptations to practice were justifiable, successful and sustainable for the future. This was a single-centre, retrospective cohort study analysing the patient care pathway from admission to discharge, for two pre-defined timeframes: Phase 0 (pre-lockdown phase) and Phase 1 (lockdown phase). Patients were split into stable and unstable injuries depending on their fracture pattern. The follow-up modality and duration were evaluated. Trauma throughput for the equivalent timeframe in 2019 was also analysed for comparison. There were 106 unstable fractures and 100 stable fractures in 2020.78 interventional procedures were performed on 72 patients with unstable fractures in Phase-1. Close contact casting was performed on 13 patients at presentation in the ED. Selective patients underwent partial fixation in theatre, which still provided adequate stability. 35% of patients with a stable fracture were discharged directly from the ED with written advice from a review letter. The treatment modality in selective patients, particularly the vulnerable should be carefully assessed. Interventions performed at presentation often negate the need for admission. Partial fixation reduces intraoperative time and surgical insult. Integrating telemedicine into the care pathway, particularly for stable ankle fractures reduces the need for physician-patient contact and eases follow-up burden. Many of our recommended changes are easily replicated in other clinical settings. Should these adaptations demonstrate long-term sustainability, it is likely they will remain incorporated into future clinical practice.