key: cord-0838491-zbz1cioi
authors: Li, Zoe; Leong, Samantha; Malik, Mohammad; Ibrahim, Nader; Sin-Hidge, Claire; Clancy, Rachel; Dobbs, Thomas D; Jessop, Zita M; Duncan, Robert T; Hemington-Gorse, Sarah; Tickunas, Tomas; Yarrow, Jeremy; Drew, Peter J; Boyce, Dean E; Whitaker, Iain S
title: Rapid redesign & effect on clinical workload of a supra-regional burns & plastic surgery service during the COVID-19 pandemic
date: 2021-10-07
journal: J Plast Reconstr Aesthet Surg
DOI: 10.1016/j.bjps.2021.09.016
sha: 7cc222aab8753d38fe267f0e81af798502a7b3d3
doc_id: 838491
cord_uid: zbz1cioi

INTRODUCTION: In March 2020, South Wales experienced the most significant COVID-19 outbreak in the UK outside of London. We share our experience of the rapid redesign and subsequent change in activity in one of the busiest supra-regional burns and plastic surgery services in the UK. METHODS: A time matched retrospective service evaluation was completed for a seven week “COVID-19” study period and the equivalent weeks in 2018 and 2019. The primary aim was to evaluate plastic surgery theatre use, and evaluate the impact of service redesign. Comparison between study periods was tested for statistical significance using two-tailed t-tests. RESULTS: Operation numbers reduced by 64% and total operating time by 70%. General anaesthetic cases reduced from 41% to 7% (p<0.0001) & surgery was mainly carried out in ringfenced daycase theatres. Emergency surgery decreased by 84% & elective surgery by 46%. Cancer surgery as a proportion of total elective operating increased from 51% to 96% (p<0.0001). The absolute number of cancer-related surgeries undertaken were maintained despite the pandemic. CONCLUSION: Rapid development of COVID-19 SOPs minimised inpatient admissions. There was a significant decrease in operating, whilst maintaining emergency & cancer surgery. Our ringfenced local anaesthetic Plastic Surgery Treatment Centre was essential in delivering a service. COVID-19 acted as a catalyst for service innovations and the uptake of activities such as telemedicine, virtual MDTs and online webinars. Our experiences support the need for a core burns and plastic service during a pandemic, and show that the service can be effectively redesigned at speed.

In March 2020, South Wales experienced the most significant COVID-19 outbreak in the UK outside of London. We share our experience of the rapid redesign and subsequent change in activity in one of the busiest supra-regional burns and plastic surgery services in the UK.

A time matched retrospective service evaluation was completed for a seven week "COVID-19" study period and the equivalent weeks in 2018 and 2019. The primary aim was to evaluate plastic surgery theatre use, and evaluate the impact of service redesign. Comparison between study periods was tested for statistical significance using two-tailed t-tests.

Operation numbers reduced by 64% and total operating time by 70%. General anaesthetic cases reduced from 41% to 7% (p<0.0001) & surgery was mainly carried out in ringfenced daycase theatres. Emergency surgery decreased by 84% & elective surgery by 46%. Cancer surgery as a proportion of total elective operating increased from 51% to 96% (p<0.0001). The absolute number of cancer-related surgeries undertaken were maintained despite the pandemic.

The outbreak of a novel coronavirus, now termed SARS-CoV-2, was first reported in impact. In this manuscript, we share our experience of the rapid redesign and subsequent change in activity of our supra-regional burns and plastic surgery service, in the hope it will add to the growing body of evidence which will inform future healthcare resource planning.

The vast majority of plastic surgery operations relate to wound management and neoplasia, with a significant health economic impact 4 

The incidence of COVID-19 in the UK began to rapidly increase in March, following trends experienced in Italy. Live government collected health data at COVID-live.co.uk

showed that during March -April 2020, South Wales experienced the most significant coronavirus outbreak in the UK outside of London 8 . Emergency national and local 6 responses to the escalating threat are illustrated alongside the cumulative number of cases per 100 000 population in Figure 1 .

Service redesign was aimed at minimising transmission of COVID-19 and maximising surge capacity alongside a core service for life-saving cancer treatment, emergency burns and trauma care. Core principles were efficiency and safety, whilst balancing the specialty specific aerosol generating procedural risks with the global and regional shortages of personal protective equipment (PPE). 9

We aimed to limit the number of patient attendances and inter-hospital transfers to minimise patient-staff transmission of COVID-19. In line with specialty guidance 10, 11 and in collaboration with local stakeholders, we developed local standard operating procedures (SOPs) for common trauma presentations. SOPs were disseminated to local referring units at all levels by the clinical director, supplemented with discussions to manage trauma in-house where possible. Our tertiary service catering to facial and limb soft tissue injuries was decentralised to local orthopaedics, maxillofacial surgery and ear, nose and throat services. Senior-led triage provided specialist advice at the point of referral and expedited decision-making.

We used the transfer of clinical photographs and videos to augment patient histories and enable virtual patient management. New guidance from NHS Wales and NHSX approving the use of mobile messaging, videoconferencing and the use of clinical photographs between clinicians further augmented our emerging telemedicine service 12, 13 . A Trust email for trauma referrals and an encrypted tablet and mobile device were used for the secure transfer of confidential electronic referrals and clinical photographs.

All referrals, including telephone advice to referring clinicians, and assessments were recorded in a database to ensure patient safety, safe transfer of information and longterm follow-up. All trauma referrals were discussed with the on-call consultant, and any ambiguous or complex cases were put to a collaborative consultant group forum.

A trauma clinic was introduced, with one-hour time slots, allowing staggered patient assessments and appropriate social distancing. A "see and treat" approach was adopted, with most minor operations performed under local anaesthesia in our specialised trauma clinic, the Emergency Department or minor operations suite. The creation of a "mobile procedures backpack" 14 with single-use surgical instruments, local anaesthetic agents, sutures, head-torch, sterile drapes and dressings significantly expedited treatment time in less well-equipped clinical areas.

Minor procedures performed included wound debridement, nailbed repair, extensor tendon repair, digit terminalisation as well as flexor sheath washout, all of which were done under WALANT 15 . More complex cases were performed in our on-site Plastic Surgery Treatment Centre (PSTC) or a peripheral day surgery unit, developed at Singleton Hospital. The latter was established as stand-alone "clean" site for additional operating capacity within our regional network for the pandemic (Table 1) . Cases 

All non-cancer elective outpatient clinics and theatre lists were cancelled as per government guidance 3 . Consultants reviewed their waiting lists and screened urgent cancers, in concordance with guidance from the NHS and specialty peer-reviewed policy recommendations [16] [17] [18] [19] We introduced telemedicine in the outpatient setting, using telephone consultations for new and follow-up patients. Patients were triaged remotely based on the history and clinical photographs of the lesion and booked straight onto a theatre list to minimise the number of hospital attendances. Regional lymph node status for skin cancers and sarcomas were documented on the day of surgery and any further investigations organised thereafter. Multi-disciplinary team meetings for sarcoma, head and neck cancer, and skin oncology continued via virtual teleconferencing using the Microsoft Teams platform.

During the initial phases of the crisis, our centre was one of two in the UK alongside Chelmsford with an independent burns ITU. As such, we were not subjected to the same pressures as centres where ITUs were filled with COVID-19 patients, limiting their ability to admit ITU level burns. The National Burns Operational Delivery Network Group published a contingency plan in which our centre was one of the "centres of last resort" for referral of ITU burn patients from areas where ITUs were full. Thankfully the pandemic coincided with low numbers of burns admissions nationally, and admissions to our centre from the South West Burns Network (SWBN) have not been necessary.

There was an increased focus on telemedicine. All external referrals required an email, which included clinical photographs and senior triage. Patients with small burns were discharged with patient-led wound care advice to minimise hospital attendances. Those requiring clinician-led burn follow-up were discharged to practices, district nurses, and wound management hubs. We continued to operate a virtual burns outreach service for those requiring outpatient specialist-led burn care. Intensive care burns inpatients underwent COVID-19 screening due to the anticipated need for multiple procedures and interventions, many of which are aerosol generating i.e. bronchoalveolar lavage, intubation, tracheostomy, dermatome for STSG. Full PPE was employed in theatre for staff protection given most cases necessitated the generation of aerosols.

The cancellation of most elective work reduced departmental staffing needs enabling us to support surge capacity through workforce redeployment. Staff safety and well-being was designated as a priority in our reconfiguration. We ensured staff attended PPE training and upskilling, and our clinical leaders were at the forefront of lobbying for and securing high levels of PPE for all staff. Departmental teleconferences were held weekly with all doctors, senior nurses and management to provide updates, raise emerging issues and facilitate appropriate service responses. Junior doctors and the wider multidisciplinary team were included in directorate meetings to ensure their voices were heard and concerns identified.

Rota contingency planning addressed uncertainties around redeployment dates and staff COVID-19-related absence. A new rota with standby allocations at all tiers was created to ensure adequate rest and restriction of on-site attendance. Alternative rotas were planned should an entire tier be required for redeployment. This was actioned following redeployment of foundation and core trainees to the general medical COVID rota. There has been an impact on plastic surgery training nationally 20 , and many of the registrars changed their research focus and increased their managerial duties to contribute support to efforts relating to the COVID pandemic.

We performed a time matched retrospective service evaluation for a seven week "COVID-19" study period, between 23 March to 10 May 2020, and the equivalent weeks and "COVID-19" data was tested for statistical significance using two-tailed t-tests.

Operating within plastic surgery reduced by 64% overall (853.5 mean number of cases pre-COVID-19 vs 309 cases COVID-19) ( Figure 2 ).

Cancer-related surgery as a proportion of total elective operating significantly increased from 51% to 96% (p<0.0001). The absolute number of cancer-related surgeries undertaken were maintained despite the pandemic (231 vs 225) (Table 3, Figure 3 ).

The proportion of cases undertaken with general anaesthesia reduced from 41% to 7% (p<0.0001), local anaesthesia increased from 57% to 83% (p<0.0001) & the use of nerve blocks from 2% to 8% (p=0.0001). Spinal anaesthesia remained the same at 1%.

Main theatre usage reduced from 99% of all operative work to 9% during COVID-19

(p<0.0001). The use of day case theatres increased from 1% to 91% (p<0.0001).

There was no statistically significant difference in the proportion of operations carried out with a consultant as primary surgeon (37% vs 34%, p=0.252). There was an increase in senior house officer operating (5% vs 23%, p<0.0001) and a reduction in registrar-led operating (58% vs 43%, p<0.0001). Average duration of procedure reduced from 71.4 minutes to 59.2 minutes (p=0.280).

A window of opportunity, following the lessons learned in Italy and London enabled our department and hospital to evolve in order to provide the necessary surge capacity in a pandemic whilst maintaining a core burns and plastic surgery service. Adoption of COVID-19 SOPs minimised inpatient admissions and streamlined patient flow through our see-and-treat approach. Senior led telemedicine enhanced the quality of our remote support to peripheral units in trauma and burn care and proved invaluable in maintaining outpatient services and MDTs during the pandemic. There was a significant reduction in operative caseload, particularly pronounced in emergency surgery (84%) (Figure 2 ).

This was a cumulative effect of more cases being treated peripherally by local surgeons, see and treat operating by registrars in trauma clinic and the Emergency Department (not logged on TOMS) and reduced access to GA emergency theatres on the main site due to staffing and theatre redesignation as extended ITU facilities. All microsurgical equipment was available if required, however during the study period no microsurgical cases were performed.

In line with NHS guidance emphasising the "equitable treatment of patients with lifethreatening cancer who need access to surgical and critical care capacity, in relation to COVID-19 patients" 21 , life-saving or prolonging cancer surgery as a proportion of total elective work significantly increased from 51% to 96% with the unit maintaining its absolute numbers of cancer-related surgeries (Figure 3 ). Unit activity was largely supported by our ringfenced local anaesthetic Plastic Surgery Treatment Centre (PTSC), a separate dedicated operating hub with two theatres, patient waiting area and recovery. We were able to maintain this hub as a "clean site" with patient screening questionnaires and observations. The drive to encourage conservative management and reduce general anaesthetic usage due to emerging evidence of high postoperative mortality rates in patients with SARS-CoV-2 infection 22 saw a significant reduction in GA use to 7% of all surgeries in the COVID-19 period, with enhanced uptake of local and regional block anaesthesia. The increased proportion of SHO-led operating can be explained by a shift in the complexity in the trauma. With a senior led approach running the service & approving referrals, core surgical trainees with a plastic theme were permitted to perform routine procedures. More complex cases were performed by either a consultant or a registrar with consultant support.

The long-term impact on our patients remains a key concern. It is unknown how long this pandemic will last, and the duration of public health strategies may result in a longlasting impact on surgical capacity. Development of "clean sites" to reduce the risk of COVID-19 is likely to increase operating capacity, and guidance is evolving as research outcomes are published [23] [24] [25] [26] .

The reduction in outpatient clinics and elective surgeries is generating a backlog of patients [27] [28] [29] . This "second and third wave" of patients will have worse outcomes as a result of delay in treatment 28, 30 . Oncology patients will experience disease progression, trauma patients with delayed definitive treatment will develop more complex morbidity requiring multistage reconstruction. Collateral effects of the pandemic extend to patients who are apprehensive in seeking medical help due to the risks of contracting COVID-19

in health centres. Delayed presentations will likely lead to greater morbidity and mortality.

Although this represents a "snapshot" of activity, our findings support the need for a core burns and plastic service during a pandemic, and show that the service can be redesigned at speed to ensure effective and safe delivery. Team spirit and compassion have been essential during the pandemic, allowing the service to adapt to changing circumstances. Junior leadership was nurtured by the service leads, with many innovations instigated by our registrar group and swiftly integrated by the consultant body. Consultants expanded remote teaching sessions for all juniors to ensure "standby"

periods were spent upskilling. The involvement of junior doctors in remote directorate meetings was essential in boosting morale amidst junior redeployment and staff sickness. pandemic has shown the resilience and plasticity of the department who have risen to the challenge, and the pandemic has acted as a catalyst for service innovations and activities such as telemedicine, virtual MDTs and online teaching provision. Many of these innovations have continued in practice, such as telemedicine for referrals and outpatient appointments, and ongoing use of green pathway operating sites. The primary focus is to prepare for further waves, optimise patient care in the "return to a new normal", and integrate lessons learnt from shared experiences to act as a springboard for further service development. 

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The authors declare that they have no conflict of interest.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. This study did not have study sponsors.

This article does not contain any studies with human participants or animals performed by any of the authors.

No writing assistance was used for this study.