Transformation of an independent sector treatment centre to a regional trauma centre during COVID pandemic

ABSTRACT

ContextOn the 11th March 2020, the WHO declared SARS-CoV-2 (COVID) outbreak a global pandemic. Healthcare facilities in the UK faced an unprecedented challenge of managing the outbreak, whilst maintaining basic healthcare services such as cancer and trauma. The NHS and independent sector partnership allowed a safe work stream, a relationship that continues now to support the elective recovery coming out of the pandemic.Issue/ChallengeReorganisation of healthcare provision led to the transformation of Practice Plus Group (PPG) hospital, Ilford to a green site for Barking Havering and Redbridge NHS University Trust (BHRUT) trauma service from 30/03/2020 to 10/06/2020. PPG Hospital had to rise to the challenge mobilising quickly from an elective service to a trauma unit serving a local population of over 1 million. The hospital transformed over one weekend, mobilising staff and equipment to deliver a trauma service. Their service went on to exemplify gold standard treatment of the very sick. The unit responded, adapted and developed outpatient clinics, plaster room, trauma ward and theatres to manage COVID-negative trauma cases that BHRUT received.Assessment of issue and analysis of its causesClinical staff had to upskill to take on the very sick (ASA 4) who may require end organ support, to carry out trauma surgery and procedures that were never performed before at the unit. Surgeons and surgical trainees from the trust became part of the multidisciplinary collaboration whilst the senior leaders developed a strong relationship to ensure good governance throughout the period. All of PPG staff had to get involved in ward care. Staff were trained with regards to personal protective equipment (PPE), Aerosol generating procedures (AGPs), pressure area care and applying traction to realign bones as some of the examples. The staff involved came from the following groups theatre staff, outpatient staff, the anaesthetic consultants, ward staff, endoscopy, pharmacy, physio, housekeeping, infection control and portering.ImpactConsultant anaesthetists had a steep learning curve to both update their trauma knowledge and sharpen their skills. The guidelines of fracture hips were reviewed. The weekly teaching meetings’ topics were all about anaesthesia for emergency surgery, trauma and COVID. Anaesthetic work rota modified to provide a suitable recovery time following long days in theatres. The necessity of rest periods improves immunity.InterventionThere were some logistic hurdles, including the lack of availability of a suitable meeting facility that can accommodate a large number of attendees. There was a need to have a combined meeting with the BHRUT team in the red zone. On the first day, the meeting was carried out on the ‘ZOOM’ platform on smart phones. Within a couple of days. The trauma meeting was held in the capacious theatre reception, using a wall-mounted big screen for audio-visual display. This allowed better communication with all clinical teams including orthopaedic surgery, anaesthesia, nursing and coordinators.Involvement of stakeholders, such as patients, carers or family membersThe PPG team implemented the pillars of clinical governance to improve the quality of care. The virtual monthly morbidity meeting included clinicians from all disciplines. A brief update of previous monthly data was reviewed. An initial internal audit showed that the average anaesthetic start time was 0939. 19 lists (out of 23, 83%) started even after 0915. The identified causes for this delay included late sending time, and the patient not being ready at the ward due to longer pre-operative checks and staff shortage. A ‘Golden Patient' was not always identified. A collaborative multi-disciplinary approach aimed to streamline the admission processes to ensure availability of both the surgical team and the patient to ensure a prompt theatre start. A repeat audit confirmed that the average anaesthetic start time has become 0903. Only four out of 24 lists had an anaesthetic start time of 0915 or later (17%). Th t is an Improvement of 69%.Key MessagesAs COVID created so much pressure on BHRUT, we quickly formed a positive can do working relationship both clinically and managerially to set up the Trauma service in just a few days. The 30 day mortality rate of patients with fracture neck of femur was less than the national average. This positive approach has enabled us to continue working together to help ease pressure off the lengthy patient waiting lists in Orthopaedics and General Surgery.Lessons learntPPG was proud to receive many compliments from patients and BHR staff. A patient wrote ‘I am so humbled and impressed by the amazing team-work and skill of the staff here that I want to congratulate you on what is an outstanding success amongst all the many stories coming out of the corona pandemic. Watching the way in which staff from so many different departments and skills bases are coming to this ward and learning nursing techniques with humility and patience as well as bonding in an upbeat, joyful team is something I will always remember. A surgical trainee mentioned The Independent Sector Treatment Centre (ISTC) team has been absolutely excellent so far. They have made us feel welcome and have worked hard to optimize the service'. This COVID cooperation paved the way for the ongoing cooperation between BHR and PPG, Ilford.Measurement of improvementThe outcome data shows that the service was able to successfully manage fractured neck of femur with better outcomes against national KPI. During the period from 30/03/20 to 10/06/2020, 85 patients had surgery for an emergency fracture neck of femur (Table 1). At PPG, the 30 days mortality rate was 3.5%. The national mortality rate for patients with fracture neck of Femur was 6.1%.75 patients with fracture neck of femur had surgical fixation within 36 hours.Strategy for improvementCollaborative cooperation between NHS and PPG led to set up of new pathways, governance and processes that enable patients to be transferred directly to us as well as creating capacity for BHRUT surgeons to operate in our hospital, supported by our theatre and ward teams.