key: cord-0948648-opcn7las
authors: O'Hagan, Patrick; Drummond, Isabella; Lin, David; Khor, Keng Suan; Vris, Alexandros; Jeyaseelan, Luckhsmana
title: Impact of the COVID-19 pandemic on the management of open fractures in a major trauma centre
date: 2021-08-11
journal: J Clin Orthop Trauma
DOI: 10.1016/j.jcot.2021.101509
sha: d295cd555ec5dd9bb5739c4eed9380420b97c174
doc_id: 948648
cord_uid: opcn7las

INTRODUCTION: The Coronavrius-19 (COVID-19) pandemic has presented the biggest challenge that the National Health Service (NHS) has ever seen. As one of the worst affected regions, Orthopaedic service provision and delivery in London, changed dramatically. Our hypothesis is that these restrictions adversely impacted the care of open fractures in our major trauma unit in London. METHODS: This is a prospective case control study comparing the management of patients presenting pre-COVID, to those presenting during the height of the COVID pandemic in London. The pre-COVID, control cohort presented between the 1st October and the November 30, 2019. The COVID cohort presented between the April 1, 2020 and the May 31, 2020. Data was collected that related to the 11 clinical domains of the British Orthopaedic Association Standards of Trauma (BOAST) 4 guidance, as well as early complications. RESULTS: Of the 11 domains, 100 % compliance was achieved in 6 components, across both groups where applicable. During pre-COVID times, the timing to initial debridement was within 12 h for High energy trauma in 16/28 (57.1 %), dropping to 7/22 (31.8 %) during COVID, (p = 0.004). Definitive soft tissue closure within 72 h If not achievable at initial debridement dropped from 9/10 (90.0%) to 4/6 (66.7 %), (p = 0.006). There was no significant difference in early complication rates. CONCLUSION: Coronavirus has changed the landscape of healthcare worldwide and impacted open fracture care by increasing time to theatre. This had no effect on early complication rate but longer term effects remain to be seen.

The Coronavrius-19 (COVID-19) pandemic has presented the biggest challenge that the National 4

Health Service (NHS) has ever seen. As one of the worst affected regions, Orthopaedic service 5 provision and delivery in London, changed dramatically. Our hypothesis is that these restrictions 6 adversely impacted the care of open fractures in our major trauma unit in London. 7

This is a prospective case control study comparing the management of patients presenting pre-9 COVID, to those presenting during the height of the COVID pandemic in London. The pre-COVID, 10 control cohort presented between the 1st October and the 30th November 2019. The COVID cohort 11

presented between the 1st April 2020 and the 31st May 2020. Data was collected that related to the 12 11 clinical domains of the British Orthopaedic Association Standards of Trauma (BOAST) 4 guidance, 13

as well as early complications. 14 Results : 15

Of the 11 domains, 100% compliance was achieved in 6 components, across both groups where 16 applicable. During pre-COVID times, the timing to initial debridement was within 12 hrs for High 17 energy trauma in 16/28 (57.1%), dropping to 7/22 (31.8%) during COVID, (p = 0.004). Definitive soft 18 tissue closure within 72 hours If not achievable at initial debridement dropped from 9/10 (90.0 %) to 19 4/6 (66.7%), (p = 0.006). There was no significant difference in early complication rates. 20

Coronavirus has changed the landscape of healthcare worldwide and impacted open fracture care by 22 increasing time to theatre. This had no effect on early complication rate but longer term effects 23 remain to be seen. Our aim is to assess whether we were able to maintain the highest standards of care in open 65 fracture management during the largest challenge that the NHS has faced since its inception in 1948. 66 Our prediction is that the limitations to our service provision adversely affected the multidisciplinary 67 management of these patients. The null hypothesis is therefore that there would be no difference in 68 care of open injuries between the pre-VOID and COVID study periods. This is a prospective case control study comparing the management of patients presenting pre-74 COVID, to those presenting during the height of the COVID pandemic in London. For ease of 75 terminology, we have used the terms pre-COVID cohort and COVID cohort, to reflect the time at 76 which patient's presented. The pre-COVID cohort presented in a 2 month window between the 1 st 77

October and the 30 th November 2019. The COVID cohort presented during an equivalent 2 month 78 window between the 1 st April 2020 and the 31 st May 2020, corresponding to the strictest Lockdown 79 period in the UK. The pre-COVID group was considered as a control group, as these patients were 80 managed at a time when our trauma service was functioning at normal, full capacity. was also collect for patients presenting on the COVID group. Adherence to the remaining 11 102

Standards of Practice in BOAST 4 were noted and these are summarised in table one below. 103 within 24 hrs vs the pre-COVID group of 9/37 being low energy and 3/9 (33%) had debridement with 142 24hrs (p= 0.073). 143 Within the high energy fracture subsets, medical issues precluded access to theatre within 12 hours 166 in 4/28 (14.3%) in the pre-COVID group and in 2/15 (13.3%) in the COVID group (p=0.67). Similarly, in 167 the lower energy fracture subsets, medical issues causing delay to theatre of more than 24 hours 168 were 1/9 (11.1%) in the pre-COVID group and 1/8 (12.5%) in the COVID group (p=0.09). 169

One patient required an amputation in the COVID group. This patient was appropriately discussed in 170 the MDT setting with Orthopaedic, Plastics, Vascular Surgeons and Therapies support and the 171 amputation was appropriately undertaken within a 72 hrs time window. 172

There were a larger number of early complications (defined in this context as occurring within 1 173 month of injury) in the pre-COVID group -8/37 (21.6%) versus 5/31 (16.1%), a non-statistically 174 significant difference (p=0.17). The complications are summarised in Table 4 . 175 Adherence to BOAST 4 guidance, the focus of which aims to reduce time to definitive fixation and 201 soft tissue coverage, is associated with improved outcomes and reduced infection rates. 6-11 The 202

BOAST 4 guidance is the gold standard of open fracture management in the UK. 203

Of the 11 Standards of Practice assessed in this study, 100% compliance was achieved in 6 204 components, across both groups where applicable. Of the remaining 5 components, documentation 205 of neurovascular status and realigning and splinting of the limb was generally performed in most 206

cases. Photography was poorly performed across both groups. 207

There were statistically significant reductions in initial debridement for high energy trauma within 12 208 hours and definitive soft tissue cover within 72 hours if not achieved at initial debridement. 209

Time to initial debridement revealed that, although seemingly a challenge pre COVID, getting those 210 high energy open fractures to theatre within 12 hours was significantly more difficult during COVID 211 times. With the described impacts on service provision and theatre availability, this was perhaps to 212 be expected. This difference was present at various time points. In total, regardless of energy, 26/37 213 (70.3%) pre-COVID and 18/31 (58.1%) in the COVID group were taken to theatre within the first 24 214

hrs of admission. It should be appreciated that comorbidities precluding fitness for surgery, such as 215 concurrent hemodynamic instability or raised intracranial pressure, might have stopped a 216

proportion of these patients being eligible for primary debridement even when theatre space was 217

available. The percentages of medical delays to theatre was equivalent in both arms. In our major 218 trauma unit, major reconfiguration of both workforce and service structure was necessary to deal 219 with the high volumes of patients see at the COVID peaks. Although operating rooms were available, 220 near all of the anaesthetic teams were redeployed to intensive care. All theatre staff were also 221 redeployed to COVID wards. Our usual guaranteed access to multiple daily theatres was lost. This 222 may account for the resultant delays. 223

Despite the deterioration in time to first debridement, it is interesting to note that this does not 224 seem to have impacted complication rate. This supports the concept that early antibiotic 225

administrations remains a key intervention in the management of open fractures. 14 226

Another key finding is the decrease in availability in plastic surgery availability at initial debridement. 227

Attendance dropped from 70.3% to 45.3% during the COVID group. This is no doubt caused by the 228 large scale redistribution of surgical specialities to assist in the overwhelming Emergency 229

Department and Intensive Care workloads. Consultant grade input into planning was ensured 230 through the use of virtual MDTs, enabling members all of all teams to provide valuable input 231 remotely even while isolating/shielding. This also reduced the need for high volume staff presence in 232 the hospital. We recognise that extent and grading of soft tissue injury is only apparent at actual 233 debridement and that photographs are not substitutes for physically presence in theatre. The merits 234 of remote team meetings which allows connectivity from virtually any part of the world, however, 235 cannot be understated and is something that out department will be continuing as a key part of 236 future collaborative working. We found virtual attendance at meetings was extremely high, ensuring 237 the most senior input at all planning stages. 238

The reduction in number of wound photographs taken may reflect a reluctance to take out ones 239 phone or camera to prevent transmission of the virus. Also, the increased PPE adds a challenge to 240 unlocking modern mobile devices with facial recognition, fingerprint identification and typing on a 241 touch screens. 242

Our data unequivocally shows delays in getting open fractures to theatre in our unit. The subsequent 243 question is where this has impacted patient outcome. In terms of early complication rate, this was 244 actually lower in the group presenting during COVID. This may reflect avoidance of complicated 245 reconstruction techniques and adhering to simple and safe treatments, with a view to reducing in 246 patient stay and recurrent surgical procedures. In fact, our mean length of stay for patients 247 presenting during COVID was 5.5 days less than the pre-COVID group, a statistically significant result. 248

This significant drop in length of stay may also indicate that length of stay in open fracture patients 249 during non-pandemic times can be optimised, without compromising the rate of complications. 250

There was one amputation performed in a patient presenting in the COVID group. This gentleman 251 was involved in an industrial accident, suffering significant multi-level crush injuries to the lower 252 limb. Extensive Consultant led discussions assessed both bony and reconstructive options, with likely 253 multiple theatre visits for debridement and washout. Presenting at the peak COVID presentation in 254

London, the decision was taken for early amputation to establish a definitive treatment pathway. 255

This decision was supported by the BOA COVID guidance, which expressly raises that we should 256 'Consider early amputation in patients for whom limb salvage has an uncertain outcome and is likely 257 to require multiple operations and a prolonged inpatient stay.' This gentleman's treatment was 258 directly influenced by the peak of the COVID-19 pandemic. 259 260

The study does have its limitations. The small cohorts are reflective of the time frame included, 261

which were selected to highlight the impact on treatment during the worst parts of the initial 262 COVID-19 phase. However, no power study was performed to find the ideal sample size. Impact of 263 longer term outcomes is currently unknown but will be identified in due course. 264

It should be noted that the COVID cohort had no diabetic patients and far fewer open tibia/fibula 265 fractures. These patients are may be more prone to complications both from a comorbidity and soft 266 tissue standpoint, especially in combination, and this may skew the data and artificially understate 267 wound-healing issues and infections complications. 268

The results of this study support the findings of other recent publication on the same subject. 13 The 269

clear impact on open fracture management will no doubt be reflected in all aspects of trauma 270 management and further studies looking into this will contribute to service planning for future 271 COVID-19 waves or new disease pandemics. 

The World Health Organisation. WHO Coronavirus Disease (COVID-19) Dashboard

Standard for Trauma and Orthopaedic (BOASTs): Management of patients with 289 urgent orthopaedic conditions and trauma during the coronavirus pandemic

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Impact of the first COVID-19 shutdown on patient volumes and 314 surgical procedures of a Level I trauma center

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Early antibiotics and debridement 325 independently reduce infection in an open fracture model