key: cord-0785325-nwt1whvv
authors: Markeson, D.; Romilly, N. Freeman; Potter, M.; Tucker, S.; Kalu, P.
title: Restarting plastic surgery; drawing on the experience of the initial COVID-19 pandemic to inform the safe resumption of services
date: 2020-08-22
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2020.08.046
sha: 69566b240a5eb026067ae231a08ca6a405a9f199
doc_id: 785325
cord_uid: nwt1whvv

COVID-19 has caused an unprecedented demand on healthcare resources globally. In light of the arrival of a novel contagious and life-threatening virus, the NHS has responded by making difficult decisions to maintain care for patients and protect staff. The response has been frequently amended following updates in UK Government policy as scientific understanding of the virus has improved. Our Plastic Surgery practice has adapted to mitigate risk to patients by reducing face-to-face contact, downgrading emergency procedures and deferring elective surgery where possible. This has inevitably resulted in a backlog in elective surgery and outpatient appointments. An assessment of the long-term health, social and economic impact of NHS wide service reconfiguration upon patient outcomes is yet to be seen. In this paper, we review the demonstrable early effects of service changes upon our unit and compare those to national and internationally published data. We also outline some of the considerations being made as we consider strategies to resume services in the light of the ongoing COVID-19 pandemic.

The 2019 novel coronavirus (2019-nCOV) outbreak is thought to have begun in Wuhan, China in late December 2019 and was named COVID-19 by the World Health Organisation (WHO) on 11

February 2020. 1 Following the initial outbreak in China, the disease spread rapidly across the world with Italy, Spain and the United Kingdom (UK) the most severely affected countries in Europe.

The UK Government published the 'Coronavirus action plan' outlining the stepwise approach in managing the outbreak in the UK, with the 'Mitigation Phase' requiring NHS service providers to support early discharge from hospital, defer non-urgent care and triage service delivery. 2 The Plastic Surgery service in Oxford responded to this unprecedented national medical emergency by reconfiguring services and patient pathways. This paper sought to compare the initial observations seen after the commencement of the UK 'lockdown' to that seen 1 year earlier. We also outline the framework upon which we will begin reinstituting services for the coming 'new normal' period.

We conducted a retrospective review of plastic surgery trauma patient interactions, skin cancer surgery and breast reconstructive surgery for April 2019 and compared this data with April 2020the first full month following lockdown. An EMBASE (Ovid), Pubmed, Google and Cochrane Library search was subsequently conducted in June 2020 for publications related to 'COVID-19' and 'Plastic 

Since the beginning of the Coronavirus pandemic, available Intensive Care Unit (ICU) capacity has almost entirely been diverted to the management of COVID-19 with the knock-on effect of almost completely halting elective, general anaesthetic procedures in favour of emergency, cancer and daycase procedures. Plastic surgeons were encouraged to adopt new surgical pathways, use virtual follow up where possible and to only see urgent cases in clinics. 3,4 Meanwhile, BAPRAS also conducted a public information campaign, warning self-isolating patients of the risks of DIY and other avoidable injuries at home. 5

The Royal College of Surgeons of England (RCSE) identified plastic surgery procedures that could be deferred for up to 4 weeks (Priority level 2), up to 3 months (Priority level 3) or more than 3 months (Priority level 4). The latter category included all cleft lip and palate surgery, scar contracture releases and breast reconstruction. The British Burn Association (BBA) also advised that elective non-urgent cases should be postponed and burns managed non-operatively where possible. They also advised increasing the provision for day case procedures and minimising outpatient attendance with senior decision making at the first point of contact, alongside utilising electronic photo referrals. 6

The British Orthopaedic Association and the British Society for Surgery of the Hand made COVID-19 related changes to recommendations for trauma inpatient and outpatient management. These included access to senior advice for A&E and GP's at an early stage, non-operative management where possible and a shift towards predominantly day case/WALANT surgery. 7

In our unit we saw over 700 new face-to-face trauma referrals per month prior to COVID-19. We therefore made the following changes to minimise hospital footfall and reduce risk to patients and clinicians: 8  All new referrals from 09:00 to 17:00 were made directly to a triaging consultant working from home and from 17:00 to 08:00 to the on-call registrar.

 We used telemedicine to avoid unnecessary patient contact but still facilitate decision making and, when appropriate, community-based care.

 Patients thought to require surgical intervention following telemedicine consults, were assigned directly to a theatre list and managed on a 'see and treat' basis.

 A daily virtual paediatric clinic reviewed all referrals from the past 24 hours. We then telephoned parents to provide phone advice if their child had a minor injury and only required expectant management.

A large North London teaching hospital made similar changes to mitigate risk to patients and staff from COVID-19. 9 They adapted their Hand Trauma Service to a 'One Stop Hand Trauma and Therapy' clinic categorising patients based on the BSSH Hand Injury Triage App and were able to perform 95% of operations for Hand trauma under WALANT 10 . Previously, less than 50% of their trauma cases had been conducted under local anaesthetic or peripheral nerve block. 11

In April 2020, the Association of Breast Surgeons published their restarting strategy in the 'new normal' to follow up from their earlier COVID-19 guidance. 12, 13 They advised that surgeons should think very carefully before embarking on immediate breast reconstruction, in particular implant reconstruction with its relatively higher levels of post-operative infection and readmission rates, adding that those requiring non-breast cancer related surgery, risk reducing surgery and delayed breast reconstruction may need to wait for their operation.

.

The British Association of Dermatologists advised considering deferring surgery for many BCC's and some low risk SCC's as well as wide excision for completely excised T0 and T1a melanomas. U.K.

plastic surgeons and dermatologists met at the end of May 2020 as part of a BAPRAS COVID-19 series of webinars and asserted the case for a paradigm shift in the management of skin cancer. 14 They suggested that in order to limit surgery, non-invasive confocal microscopy could be used as a diagnostic tool for equivocal BCCs or for lentigo maligna. They also asserted that lentigo maligna may be better treated medically rather than surgically and that given the exceedingly low risk of local recurrence in AJCC stage 1B melanoma, we should not be performing wide local excisions in patients in the current situation, especially those with comorbidities. They also suggested rationalising how frequently we follow up low risk patients and whether we should limit sentinel node procedures for 1B melanomas who rarely meet the criteria for adjuvant therapy.

An estimated 28,404,603 surgical operations from all specialties globally were predicted to be cancelled or postponed during the peak 12 weeks of disruption due to COVID-19. 15 It was projected that even by increasing normal surgical volume by 20%, it would take a median of 45 weeks to clear this backlog notwithstanding the extra delays associated with current operating practices such as 'donning and doffing' in addition to deep cleaning of theatres between cases.

Trauma: Table 1 shows the re-distribution of plastic surgery trauma referrals as a result of the changes made to patient pathways with an aim to reduce hospital footfall and face-to-face contact.

The total number of referrals fell 61.5% from 720 to 277 with the number of face-to-face trauma clinic reviews falling to 82 (88.6% reduction). 31 of 195 telemedicine consultations were reviewed on a 'see and treat' basis so in total only 113 trauma patients were seen face-to-face in April 2020 compared to 720 in April 2019, an 83% reduction. 

The COVIDSurg Collaborative assessed outcomes for surgical patients that were COVID-19 positive.

They found that less than one third of patients were diagnosed prior to their surgery and nearly one quarter died within 30 days of being in theatre. Risk factors for mortality were age of 70 years or older, male sex, poor preoperative physical health status, emergency versus elective surgery, malignant versus benign or obstetric diagnosis, and more extensive (major vs minor) surgery. 22 As this study was pan-specialty and included those with comorbidities it is important not to incorrectly conclude that all surgery is now high risk (for comparison the NELA (UK emergency laparotomy audit) study had a similar 30-day mortality of 23.4% in frail patients over 70 years). We looked at 364 patients having surgery in our unit from March to the end of April 2020 and found that less than 1% developed COVID-19 symptoms post-operatively and only 4 patients were diagnosed with confirmed COVID-19 post-op, of which the 2 that died were both aged over 80 with significant comorbidities. whereas a patient aged 40 had a hazard ratio of approximately 0.5. Public Health England published a paper on 'Disparities in the risk and outcomes of COVID-19' 24 reaffirming these findings showing that people aged 80 or older when diagnosed with COVID-19 were seventy times more likely to die than those under 40. Risk of dying was also higher in males, in those living in more deprived areas and in BAME groups.

Ensuring the safe and efficient restarting of plastic surgery will require significant ongoing adaptations to current practice as new information and treatments become available. Initially, we can use data from ICNARC and NHS England to risk stratify the population, but strategies released by surgical, anaesthetic and intensive care colleges will need constant monitoring and amending as our evidence base grows.

The changes that have been implemented to accommodate for the COVID-19 pandemic have allowed rapid innovation including new patient pathways, the increased use of telemedicine and virtual clinics and a wide range of webinars by world-leading experts in plastic surgery to improve training. Our new pathway for plastic surgery trauma ensured that 59.2% of referred patients were managed without needing to be seen in person, not only protecting both patients and staff from unnecessary contact that could risk transmission of COVID-19 but conserving departmental resources. The new hand trauma service at the Royal Free Hospital estimated that their conversion to predominantly WALANT surgery could reduce costs by up to 70% 25 and that reduced face-to-face appointments could lead to an annual saving of more than £110000 in their department. 9 Although virtual clinics remove the cost and inconvenience of travel and may be more cost-effective to the healthcare system they could also be clinically less robust. An increase in conservative management may lead to an increase in the number of revision surgeries required and a potentially corresponding rise in patient dis-satisfaction, operating hours and over all costs. 6 Further, although consultations could be helpful to some older people who may find it difficult to travel because of comorbidity, telemedicine raises the possibility of increased inequality of access for example to the elderly or lower socioeconomic classes. 26 In addition, the need for patients to be assessed and operated on by the most senior personnel to limit repeated reviews and reduce staff exposure has markedly decreased training opportunities while reducing of departmental capacity has significantly increased waiting lists for elective procedures including cancer cases. The COVID-19 crisis has been used to shoe-horn several changes to clinical practice that in other times would have been far more thoroughly evaluated. If practices such as the increased use of telemedicine continue they should be subject to the same levels of discussion and scrutiny as would have been the case pre-COVID-19.

Considering breast surgery, there is an undoubted benefit of immediate reconstruction for a sizable cohort of women which must be mitigated with risks of operating in the current environment. As anaesthetic and theatre staffing capacity returns to normal the main issue relating to breast reconstruction will be COVID-19 related risks which in a well governanced setting can be minimised. 27 patients. NHS England information should be analysed to plan delivery of surgical services.

Less than 6 months ago 'R' values, 'lockdown', 'social distancing' and 'PPE' were words and phrases rarely used within our society. However, COVID-19 has likely changed the global landscape for years to come and as healthcare providers we must continue to learn and adapt in order to best care for our patients and each other. We now know that increasing age, male sex, low socioeconomic class, black and minority ethnic (BAME) background, certain comorbidities and obesity are all independent risk factors for death from COVID-19. This information, together with local and national data provided by NHS England and the NHS 'track and trace' service will make it possible to ensure patients are adequately informed regarding the extra risks posed by COVID-19. We now have surgical management strategies to use if there is a 'second wave', and also know that we can adapt if these strategies are insufficient. Until then, we must be ready to "get back to normal" -whatever "normal" now is. o Update patients on procedure prioritisation criteria and up-to-date safety risks.

A plastic surgery service response to COVID-19 in one of the largest teaching hospitals in Europe

Managing Hand Trauma during the COVID-19 pandemic using a One-Stop Clinic

How the Wide Awake Tourniquet-Free Approach Is Changing Hand Surgery in Most Countries of the World. Hand Clin

Hand Trauma Service: efficiency and quality improvement at the Royal Free NHS Foundation Trust

Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans

Covid-19: A&E visits in England fall by 25% in week after lockdown

Fewer cancer diagnoses during the COVID-19 epidemic in the Netherlands

Mitigating the risks of surgery during the COVID-19 pandemic

Cost Savings and Patient Experiences of a Clinic-Based, Wide-Awake Hand Surgery Program at a Military Medical Center: A Critical Analysis of the First 100 Procedures

Virtual online consultations: Advantages and limitations (VOCAL) study

Unshackling Plastic Surgery from COVID-19

Funding: No