The Impact of Harm Review Service on Patients Awaiting Elective Orthopaedic Foot and Ankle Surgery for More Than 52 Weeks.

Background and objective There has been a significant increase in waiting times for elective surgical procedures in orthopaedic surgery as a result of the coronavirus disease 2019 (COVID-19) pandemic. As per the hospital policy, patients awaiting elective surgery for more than 52 weeks were offered a consultant-led harm review. The aim of this study was to objectively assess the impact of this service on the field of foot and ankle surgery. Materials and methods The data from harm review clinics at a District General Hospital related to patients waiting to undergo elective foot and ankle procedures in the year 2021 (wait time of more than 52 weeks) were assessed. Clinical data points like change in diagnosis, need for further investigations, and patients being taken off the waiting list were reviewed. The effect of the waiting time on patients' mental health and their perception of the service was assessed as well. Results A total of 72 patients awaiting foot and ankle procedures for more than 52 weeks were assessed as a part of the harm review service. It was noted that 25% of patients found that their symptoms had worsened while 66.1% perceived them to be unchanged. Twelve patients (16.9%) were sent for updated investigations. Twenty-one patients (29.5%) were taken off the waiting lists for various reasons with the most common one being other pressing health concerns; 9% of patients affirmed that the wait for surgery had a significant negative impact on their mental health. Conclusion This study concludes that the harm review service is a useful programme as it helps guide changes in the diagnosis and clinical picture. The service is found to be valuable by most patients, and its impact on the service specialities and multiple centres could be further assessed to draw broad conclusions.

How Effective Are Telephone and Video Consultations in Shoulder and Elbow Clinics? Analysis Using an Objective Scoring Tool.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic resulted in disruptions of clinical services, which saw more clinics being conducted as telephone and videos. The study aimed to assess and compare the effectiveness of consultations, that is, telephone, video, and face-to-face (F2F) in a shoulder and elbow clinic. METHODS: A total of 84 clinic letters from a shoulder and elbow clinic at a district general hospital were analysed using the Ashford Clinic Letter Scoring System. Of these, 30 were F2F, 30 were telephone, and 24 were video consultations. The letters were analysed and scored based on four parameters, that is, whether a working diagnosis was formulated, relevant investigations were requested or available, a clear management plan was formulated, and whether the consultation was deemed valuable by both the clinician and patient. RESULTS: The mean score (out of a total possible of eight) for F2F was 7.967, 7.667 for video, and 7.333 for telephone consultations. Amongst new referrals, F2F performed the best, followed by video with telephone consultations scoring the lowest. With follow-up referrals, the performance of telephone and video consultations was similar but more inferior compared to F2F. Videos performed nearly as well as F2F when it came to formulating treatment plans for patients.  Conclusion: F2F consultations remain the gold standard in a shoulder and elbow clinic; however, careful stratification of patients into video, telephone, and F2F clinics can help in optimal delivery of care. These findings can be applied to other surgical specialties and medicine in general. Virtual clinics are viable and potentially cost-effective options to the traditional F2F.

Efficiency changes in orthopaedic trauma surgery and implications for resource allocation.

BACKGROUND/AIMS: The trauma and orthopaedic surgery department needed to modify practices as a result of the COVID-19 pandemic. This study quantitatively assessed the effects of changes in resource allocation on the efficiency of trauma, specifically the number of operations performed per defined trauma session. METHODS: Trauma lists were reviewed pre-COVID, at the peak and at the tail of the first wave of COVID-19 infections at a hospital in the UK. Efficiency was calculated before and after the reallocation of resources and this was defined as the number of cases per trauma session as well as turnaround times for each part of the surgical patient journey. RESULTS: The mean trauma list efficiency was 1.73 cases per session in February 2020 compared to 1.89 in February 2019. It reduced to 1.21 during the COVID peak in April 2020 compared to 1.90 in April 2019 and improved to 1.48 per session in June 2020 vs 1.82 in June 2019. CONCLUSIONS: Measures introduced at the start of the pandemic are likely to continue for the foreseeable future. Increased allocation of resources would be needed to allow urgent trauma surgery to provide a timely and efficient service.

Hospital transmission rates of the SARS-CoV 2 disease amongst orthopaedic in-patients in a secondary care centre: A quantitative review.

INTRODUCTION: Orthopaedic practice changed during COVID-19 with elective work ceasing, trauma reducing and work forces redistributed to medical areas. During the United Kingdom lockdown, hospitals were stretched thinly with admissions of SARS-CoV-2 positive patients. AIM: Evaluate orthopaedic admissions to a district general hospital during lockdown and the volume of those who subsequently were found to be COVID-19 positive. METHOD: Retrospective study of patients admitted under trauma and orthopaedics between March 23, 2020-June 18, 2020. Data includes; diagnosis, COVID-19 swab dates, results and mortality using orthopaedic admission sheets, patient and pathology electronic recording system. RESULTS: 3/4 of admitted patients tested negative for SARS-CoV-2 initially. Of these 240 patients, 12.5% subsequently tested positive during their stay, often within one week of their admission. 17.8% of patients were never tested. 7.8% mortality rate of which 48% were neck of femur fracture (NOF#) patients. 28 NOF# were confirmed COVID-19 positive; mortality rate of 21.4%. 87 NOF# were COVID-19 negative; mortality rate 6.9%. Mortality relative risk (RR) for NOF# and COVID-19 positive was 2.6. COVID-19 positive mortality 27% as compared to 4% in COVID-19 negative patients. Patients who acquired COVID-19 whilst in hospital had a mortality relative risk 6.4. CONCLUSION: 12.5% orthopaedic in-hospital viral transmission rate amongst orthopaedic patients despite the segregation measures taken, possibly due to asymptomatic health care workers or inpatients awaiting swab results. We emphasize the importance of testing all inpatients and regular testing of healthcare workers.

COVID-19 - Changes in the presentation and management of shoulder and elbow trauma in a UK district general hospital orthopaedic department.

INTRODUCTION: COVID-19 has had a significant impact on healthcare systems. We aim to quantify the impact of this outbreak on shoulder and elbow trauma in our institution. METHODS: We prospectively collected data on patients presenting to our hospital with shoulder and elbow injuries during COVID-19. This included the number of attendances to the emergency department, fracture clinic, inpatient admissions and operative treatments. This was compared to a pre-COVID-19 period. We also assessed the efficacy of telephone clinics. RESULTS: There has been a noticeable decrease in the number of emergency department and fracture clinic attendances with upper limb complaints. The number of in-person fracture clinic reviews also decreased, with a reciprocal exponential increase in telephone consultations. We recorded a decrease in the number of shoulder and elbow trauma procedures performed. There was a small increase in the proportion of injuries treated conservatively during COVID-19. Our telephone clinics yielded a diagnosis and management plan in many cases and patient perspective appeared favourable. CONCLUSION: We have noted significant change in the upper limb caseload. Certain injuries have reduced, likely due to COVID-19 lockdown. Moreover, we consider several changes to current practices could be taken forward after the pandemic.

Objective assessment of the efficacy of telephone medicine consultations in dispensing elective orthopaedic care using a novel scoring tool.

BACKGROUND: Telemedicine consultations have increased significantly as a result of the COVID-19 pandemic. As remote consultations have been employed across specialities, there has been limited analysis of their efficacy. The goal of this study is to objectively assess if telephone medicine is valuable for clinical consultations in elective orthopaedics using a novel scoring tool. METHODS: A literature review and survey were performed to determine the objectives of a specialist consultation. Based on the results, a four-component scoring system was developed with a set of guidelines. Eighty telephone consultation letters from a hip and knee clinic were scored by two independent observers. The results were compared and the guidelines were clarified. Clinic letters from previous face to face consultations from the same clinic were scored and compared to telephone medicine letters. The inter-observer reliability was calculated using Cronbach's Alpha. RESULTS: The mean score of the telephone consultations was 7.3 as compared to 7.9 (Maximum possible score-8) with face to face consultations. Second opinion referrals scored the least when consulted over the telephone, while follow-up patients both pre-operative and post-operative scored similar to face to face consultations. The inter observer reliability co-efficient was more than 0.8 for every component of the score suggestive of good reliability. CONCLUSIONS: This study identifies the areas where telephone medicine can make a valuable contribution to making diagnosis and treating orthopedic patients. We plan to use this to stratify future clinic appointments. The score is a simple, concise and reliable tool whose role may not be limited to orthopaedics but can be extended to other medical fields.

Redeployment of the trainee orthopaedic surgeon during COVID-19: a fish out of water?

Background and purpose - COVID-19 has had a significant impact on health services and the entire healthcare sector, including trauma and orthopaedics, has been compelled to adapt. At the heart of this was the redeployment of the orthopaedic trainees to support "frontline specialties". This paper sheds light on the experience of orthopaedic trainees in redeployment. Methods - In this retrospective study, we asked orthopaedic trainees in the KSS (Kent, Surrey, Sussex) and London Deaneries to complete a survey regarding their experience in redeployment during the COVID-19 outbreak. The study took place in the Kent, Surrey, Sussex, and London regions of the United Kingdom over a period of 8 weeks from 15th of March 2020 until 15th of May 2020. The study was based at East Kent Hospitals University NHS Foundation Trust and participants were recruited from a number of secondary and tertiary care centres across the region. 120 orthopaedic trainees were contacted, working in 21 teaching hospitals. Of these, 40 trainees (30%) from 13 hospitals responded and completed the survey. Results - 50% of the surveyed trainees were redeployed to other specialties. Trainees spent varying amounts of time in the redeployed speciality and gave differing views on how comfortable they felt and how useful they felt the experience was. One-third of trainees experienced symptoms and/or tested positive for COVID-19 and the majority of these were redeployed to other specialties. Interpretation - Orthopaedic training appears to have taken a temporary back seat at this time but trainees have made a significant contribution to reinforcing key front-line specialties in the fight against COVID-19.