U.K. Response to the COVID-19 Pandemic: Managing Plastic Surgery Patients Safely

Abstract

The novel coronavirus threatens to destabilize health systems worldwide. As the pandemic spreads, it has become critical to evaluate our strategies as a busy plastic surgery unit in London, United Kingdom, to adapt and continue to provide a safe and high-quality service for our patients. Our dynamic approach to ensuring patient safety involves a continuous cycle of reflecting on services, analyzing resources, optimizing efficiency of emergency services, reducing risk to patients and staff, and adapting periodically. First, we reviewed our scope of practice and assessed the balance of trauma and elective cases in our unit. The decision was made early to suspend elective operations, in line with guidance from the British Association of Plastic and Reconstructive Surgeons1 for medium level prevalence of coronavirus disease 2019 (COVID-19) at this time. Second, to optimize efficiency, we revised our plastic surgery trauma triage protocol. This encompasses the following: category 1, operate immediately; category 2, operate urgently; category 3, operate in order of presentation (with a plan to shift to category 4 if the situation worsens); and category 4, no surgery in most circumstances (Table 1). Table 1. - Royal Free Hospital COVID-19 Trauma Triage Protocol Category 1: operate immediately Necrotizing fasciitis débridement Compartment syndrome decompression Category 2: operate urgently Abscess drainage Flexor sheath infections Palm space infections Septic arthritis washout Removal of infected implants Washout of animal/human bite injuries Digit replantation Open hand fractures Subtotal amputation of finger Category 3: operate in order of presentation* Flexor tendon repair Extensor tendon repair Unstable closed hand fractures Ligament injury repair (e.g., ULC) Category 4: no surgery in most circumstances Minor nail-bed injuries Simple lacerations (e.g., forehead, lip) Composite fingertip grafts Vacuum-assisted closure therapy (to avoid multiple changes) ULC, upper lateral cartilage.*Plan to shift category 3 to category 4 if the situation worsens. To implement this effectively and reduce patient risk, we have followed the recommendations of the British Society for Surgery of the Hand (Table 2) available in the Hand Injury Triage App from the British Society for Surgery of the Hand.2 Specifically, we have mobilized a previously underused minor operating room in our trauma clinic setting, to provide a “one-stop shop” for same-day operations. Here, we perform appropriate procedures using local anaesthetic/wide-awake no anesthesia no tourniquet technique, which may have previously been carried out under regional or general anesthesia (e.g., infection washouts, tendon repairs, and closed fracture fixations with Kirschner wires). We are suturing our wounds with absorbable sutures and providing patients with increased education and nursing advice at this first, and potentially only, clinic visit. Table 2. - Summary of British Society for Surgery of the Hand COVID-19 Hand Injury Triage Guidelines Ensure staff are up to date with standard hand trauma management guidelines, to ensure best practice Reconfigure to “one-stop shop” trauma service; mitigate need for follow-up visits or return on different date for operating room Embrace WALANT/local anesthetic procedures Set up well-equipped and sterile procedure rooms; eliminate reliance on operating room availability Relocate miniature C-arm to designated procedure room Use absorbable sutures for direct closure of wounds Do not bury Kirschner wires Provide patients with dressing packs and educate on wound care Provide physiotherapy advice on first encounter Set up video consultation facilities for all essential follow-up and physiotherapy WALANT, wide-awake no anesthesia no tourniquet. Furthermore, skin cancer cases have been similarly triaged, taking into account 5-year survival, recommended time to treat, and metastatic potential. Malignant melanoma cases are the priority, followed by squamous cell carcinoma, and then basal cell carcinoma. Wide local excisions are being carried out under local anesthetic with sentinel lymph node biopsies being halted, to free up our anesthesia colleagues. In addition, we are working collaboratively to reduce the burden on our emergency department. We are accepting referrals for hand injuries and infection directly from the emergency department, following only simple assessment for COVID-19 status and nature of injury. This has helped to reduce waiting times and improve our patient turnaround times noticeably from day 1. As a department, we have also embraced technology, to improve communication and safely enhance our immediate clinical provision for patients being referred from outside units. We have quickly implemented telemedicine referrals and telephone/video consultations, which were not previously used. These have been adopted rapidly and further reduced the need for unnecessary personal contact and time spent in the hospital. We still have a lot to learn to ensure the continued safety of our patients and staff, which must be sustained throughout the duration of the COVID-19 pandemic. We acknowledge that there will be regional variation in the United Kingdom, the United States, and internationally. Still, we hope that other units may be able to share their experiences of managing their plastic surgery emergency workload, to encourage open collaboration and develop an international consensus on the most appropriate way forward during these challenging times for our specialty and the medical profession as a whole. DISCLOSURE The authors have no conflicts of interest or financial interests to report in relation to the content of this article.