key: cord-1016143-wi4bjq2q
authors: TAN, Si Heng Sharon; HONG, Choon Chiet; SAHA, Soura; DE, Shamal DAS; Jon, Christopher
title: Standing on your Foot and Ankle during COVID-19: Perspectives from a Singaporean Orthopaedic Foot and Ankle surgery unit
date: 2020-06-06
journal: J Foot Ankle Surg
DOI: 10.1053/j.jfas.2020.05.013
sha: 6187a13ea6e0b8ab24136d1561656e1b2dab93cc
doc_id: 1016143
cord_uid: wi4bjq2q

nan

within the institution and strategies to deal with the pandemic have always made sure that all patients 29 are well taken care of regardless of their COVID-19 status. 30 31 One of the departmental strategies included setting up a "contaminated team" whose main 32 responsibility is to look after patients who are suspected or confirmed to have COVID-19. Each team 33 is led by an attending consultant and comprises of individuals from different levels of practice within 34

Orthopaedic surgery, including the house officer, junior resident, senior resident and attending 35

consultant. The mix of team members ensures that the team can function independently and all 36 matters with regards to these patients can be dealt with by the team expediently. All members of the 37 department take turns to be part of the "contaminated team", including members of the foot and ankle 38 unit. However, as the team functions with only one attending consultant, it is understandably not 39 uncommon for these attending consultants to be faced with cases that were not within their 40 subspecialty. Therefore, when required, the team will obtain assistance from the other subspecialty 41 attending consultants. For instance, in the case of complex foot and ankle trauma or limb salvage 42 surgeries, the "contaminated team" consultant could seek advice from the foot and ankle specialist 43 consultants. Likewise, if we as foot and ankle surgeons face complex cases that are beyond our 44 subspecialties (such as spine trauma), we similarly seek assistance from our spine colleagues. Once 45 directly involved in the care of these patients, the subspecialty consultant involved would then join the 46 "contaminated team" for the rest of the period when they are on duty and return to normal clinical 47 duties together with the "contaminated team" subsequently. The "contaminated team" rotates on a 48 weekly basis with handovers from one team to the next to ensure that the team members had adequate 49 rest and were at their best condition to uphold the standards of care for these patients. Handovers are 50 done via secured messaging platform or via video conferencing to minimize physical contact. 51

The rest of the department are segregated into two teams. Each team is comprised of at least one 53 subspecialty attending consultant from every subspecialty. This is to ensure that the department 54 remains functional should any of the team members contract COVID-19. One team is responsible for 55 delivering care to the inpatients while the other team is responsible for delivering care to the 56 outpatients. Boundaries are drawn clearly, and strict regulations are implemented to ensure that the 57 teams do not meet each other to prevent cross-infection. The inpatient team attends to all inpatients, 58 performs operations and provides on-call services. This means that all foot and ankle patients, 59

including those who were previously taken care of by other consultants, come under the inpatient foot 60 and ankle team"s purview. Handovers are therefore essential from one team to another to ensure 61 continuity of care. All team members ensure that they are contactable at all points in time regardless 62 of the team they are in should the need for clarifications arise. Patients are managed in a universal 63 evidence-based manner, and when the opinions of the consultants differ when a patient is handed over 64 from one to the next, an online discussion is had amongst the consultants in the unit for consensus. 65

The same applies for the outpatients. The outpatient team oversees the running the outpatient 66 specialist clinics. As much as possible, the clinic attempts to arrange the appointments of the patients 67 under their original consultants, however, in the event where a patient"s appointment cannot be 68 postponed, for example due to post-operative wound inspection, infected foot wounds or ulcers, these 69 patients are managed by the outpatient team with telephone consultation from the original consultant 70 if required. 71

Beyond the department, team segregation is also performed at a national level where healthcare 73 professionals are not allowed to travel from one institution to another. All cross-institution 74 deployment and teaching sessions were suspended with immediate effect when local transmission was 75 detected in Singapore. Without cross-institution deployment, the institution also had to ensure that 76 there were adequate specialists from each subspecialty and adequate allied health professionals from 77 each division. Foot and ankle surgeons had to be divided amongst the different sister-institutions to 78 ensure that all foot and ankle patients were attended to regardless of the institution they were in. 79

Patients who were originally under the care of these deployed consultants were then managed by the 80 remaining foot and ankle surgeons in the institute, and some surgeries were subsequently performed 81 by the other foot and ankle surgeons that remained in that institute. 82

In order to further minimise the possibility of cross infection, acute hospital and community hospital 84 pairings were formalised, and all patients were only allowed to travel within the paired hospitals 85 should they require rehabilitation after being admitted in an acute hospital or should they require 86 acute care while undergoing rehabilitation in a community hospital. No transfer of patients is allowed 87 from one institution to another outside of the paired institutions, although prior approval can be 88 obtained from the Chief Executive Officer of the hospital should there be a clinical need to do so in 89 cases where the specific expertise to treat that patient was not available in the paired institution. All healthcare professionals are mandated to perform temperature screening twice daily and input 187 their temperature into the online hospital surveillance system. In order to facilitate this, all healthcare 188 workers within the institution were issued personal thermometers at the beginning of the outbreak. A 189 message is sent to all hospital staff twice daily to remind them to take and record their temperature. 190

Healthcare workers who develop symptoms are advised to seek immediate medical consultation and 191 not report to work. In order to minimise the risk of transmission amongst healthcare workers and to 192 uninfected patients, mandatory travel declaration was similarly imposed on all healthcare workers in 8 history were placed on a mandatory two-week paid leave of absence and are allowed to work only if 195 they remained asymptomatic following the leave of absence. In the battle against what is expected to be a prolonged pandemic, conservation of healthcare 206 resources is of paramount importance. These include the conservation of personal protective 207 equipment (as mentioned earlier), as well as the triaging of cases and early discharge of patients to 208 ensure the efficient use of resources. 209 210 A stepwise reduction in elective orthopaedic surgeries has therefore been instituted. This involved 211 firstly postponing elective surgeries that will require hospital admission in order to free-up hospital 212 beds and resources for COVID-19 patients. Day surgeries and surgeries requiring less than 23 hours 213 of admission were originally allowed to continue during the early stages of the pandemic. This meant 214 that most foot and ankle surgeries could continue in the initial phase of the COVID-19 era in

Singapore; multi-ministry 251 taskforce ramps up precautionary measures. Ministry of Health Singapore

COVID-19, Pandemic, and Social Distancing