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

Published:April 21, 2020DOI:https://doi.org/10.1016/j.bjps.2020.03.027

      Summary

      COVID-19 is presenting a colossal challenge to frontline NHS staff. This paper highlights how plastic surgery teams can use their diverse skills and resources in times of crisis. Through effective strategy and leadership we present how we are adapting as a department to serve our plastic surgery patients, other hospital teams and the Trust.

      Keywords

      Dear Sir,
      We are living through unprecedented times; unexpected by the world and bearing huge impact for the National Health Service (NHS), which has to adapt and redefine itself in response to the continually evolving Coronavirus disease 2019 (COVID-19) pandemic. As a large department we are expected to support the acute specialties, urgently rationalise care, reduce patient footfall and design a new working pattern that protects both staff and the public. We have the crucial responsibility to adjust our practice to both reduce the spread of disease and free up capacity within the system. In this paper we describe our local strategy in terms of leadership, reconfiguring our service and utilising all options in our armamentarium to provide as safe a service as possible.
      COVID-19 was first reported in Wuhan, China in December 2019 and has since spread globally reaching 334,981 confirmed cases and 14,652 deaths globally on 23rd March 2020.

      World Health Organisation (WHO)Novel Coronavirus (COVID-19) Situation Dashboard. https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd[Accessibility verified April 15, 2020].

      The virus initially spread within the Hubei province, where extensive containment measures including lockdowns have led to a decline in new cases.

      Nature. What China's coronavirus response can teach the rest of the world. https://www.nature.com/articles/d41586-020-00741-x[Accessibility verified April 15, 2020].

      ,

      World Health Organisation (WHO). Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf[Accessibility verified April 15, 2020].

      It has now spread globally and by the 15th April 2020, Spain has the highest number of confirmed cases in Europe, of 169,496, and Italy the highest number of deaths in Europe, of 20,465.

      World Health Organisation (WHO)Novel Coronavirus (COVID-19) Situation Dashboard. https://experience.arcgis.com/experience/685d0ace521648f8a5beeeee1b9125cd[Accessibility verified April 15, 2020].

      Around 4.4% of cases require hospitalisation and 30% of those require critical care,

      Ferguson NM et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID- 19 mortality and healthcare demand. https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf[Accessibility verified April 15, 2020].

      predominantly for mechanical ventilation.
      • Yang X
      • Yu Y
      • Xu J
      Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study.
      The first two cases reported in Oxfordshire were reported on 5th March 2020. This catalysed an early Trust and departmental response. There was a progressive increase in the number of cases and reports of seven University of Oxford students being affected by 20th March 2020.

      University of Oxford. Coronavirus (COVID-19) advice and updates. http://www.ox.ac.uk/news-and-events/coronavirus-advice[Accessibility verified April 15, 2020].

      On 14th March 2020, Oxfordshire had the largest reported number of cases for any UK region totaling 14 (London was divided into boroughs) out of a population of 687,524. By 23rd March 2020, it was ranked 34th, with 63 identified cases. By 14th April 2020, it was ranked 16th, with 890 identified cases

      Coronavirus in UK: How many cases are there in your area?https://www.bbc.co.uk/news/uk-51768274[Accessibility verified April 15, 2020].

      Leadership strategy

      Prior preparation and planning prevents poor performance. We seek to better understand the threat in order to plan for all eventualities. We are in the fortunate position in the UK of having colleagues worldwide who have already and are currently facing the same threat. We should capitalise on the global nature of our specialty in aiding the planning of our response to the pandemic.
      Our initial plan or series of plans will be helpful in guiding our initial response, however given that ultimately “no plan survives first contact with the enemy”,
      • Von Moltke HG
      • Hughes DJ
      • Bell H
      Moltke on the Art of War: Selected Writing.
      flexibility, teamwork and dynamic leadership are crucial.
      This is not a time for the heroic NHS pace-setting leadership of old,
      • Rowling E
      Leadership and Engagement for Improvement in the NHS.
      but rather a model of more shared and distributive leadership, setting clear purpose and direction, but leaning towards collaboration and consensus rather than command and control.
      • Rowling E
      Leadership and Engagement for Improvement in the NHS.
      This crisis highlights more than ever our common goal and now is the time to strive for the long overdue improved collaboration between managers and clinicians.
      The traditional leader-follower model of subservience should be ignored and all employees should be treated as potential leaders within their own spheres of responsibility. This includes empowering our junior doctors, encouraging and fostering a future generation of medical leaders.
      • Rowling E
      Leadership and Engagement for Improvement in the NHS.
      ,
      • Mountford J
      • Webb C
      When clinicians lead.
      We should adopt a cohesive approach to the problems faced, seeking enhanced dialogue between levels of responsibility. Individuals should be given autonomy to make decisions at ground level, remaining guided by the overall direction of the organisation, but ultimately releasing those on the frontline from ever-prevalent bureaucracy and top-down micro-management.
      The importance of looking after the workforce, both physically and emotionally, cannot be underestimated. Keeping staff involved, engaged and empowered will not only lead to them feeling more valued, respected and supported, but ultimately lead to greater clinical effectiveness.
      • Rowling E
      Leadership and Engagement for Improvement in the NHS.

      Reducing hospital footfall

      We have implemented numerous strategies to minimise hospital footfall, reducing risk to both patients and clinicians. These are under continual review.
      Department surgeons with national leadership roles have rapidly adapted guidelines to assist in the management of hand trauma

      British Society of Hand Surgery. https://handinjurytriageapp.bssh.ac.uk/page/9[Accessibility verified April 15, 2020].

      (for example promoting conservative management of fractures wherever possible). As a department we collectively accept that an increase in conservative management might come at the delayed cost of revision surgery required at a later date. To reduce admissions for soft tissue infections the ambulatory intravenous antibiotic services have been bolstered.
      All referrals are made directly to a triaging consultant working from home during working hours. Using telemedicine, decisions are made to avoid unnecessary patient contact and facilitate community based care. Heeding the COVID-19 information governance advice from NHSX,

      NHSX Covid-19 information Governance Advice. https://www.nhsx.nhs.uk/key-information-and-tools/information-governance-guidance[Accessibility verified April 15, 2020].

      we feel able to safely share information if it limits the spread of disease. We are able to provide safe video-calling advice and talk through simple procedures for referring professionals (such as removing nail plates and the treatment of paronychia).
      Where patients require face-to-face assessment, they are seen by one doctor in appropriate personal protective equipment (PPE), with notes taken by a colleague two metres away. For in house referrals; to prevent multiple reviews, the most senior person assesses (and treats where possible) during one patient encounter.
      For patients requiring more complex reconstructive procedures, patients are assigned directly to a theatre list and managed on a ‘see and treat’ basis. Decisions and predicted operative times are based on information gathered on referral, telemedicine and clinical imaging. Surgical day case arrivals are staggered to minimise the time in hospital.
      If admitted, patient movement around the hospital is restricted. Once discharged, follow-up is carried out by telemedicine wherever possible; this includes using absorbable sutures, patient/carer-led wound care, removable splints and training in the removal of k-wires to avoid attending a hospital or GP practice.
      A virtual paediatric clinic each morning reviews all referrals from the past 24 hours, with phone advice given to (parents of) patients with minor injuries that could be managed expectantly.
      The department facilitates homeworking wherever possible. This includes undertaking on-calls from home with access to the electronic patient record. This has promoted safe remote practice.
      To help free-up plastic surgeons, public information and advice was disseminated via the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) Voice social media pages, warning self-isolating patients of the risks of DIY and other avoidable injuries at home.

      BAPRAS Voice. To help free up plastic surgeons. https://twitter.com/BAPRASvoice/status/1240666092604973056[Accessibility verified April 15, 2020].

      Team restructuring

      The department has been reconfigured into two ‘mega-firms’, with one covering trauma and the other covering urgent cancer services. At present, both firms run a rolling four-week rota, involving two weeks at home (working or resting) and two weeks on site. If a team member is required to go off for sickness or isolation, they are swapped into the homeworking group and start the cycle again. Building this slack in to the rota enables recovery and self-isolation to be taken in to account, while heeding WHO guidance to minimise face-to-face patient interaction.

      Rational use of personal protective equipment (PPE) for coronavirus disease (COVID19), WHO, 19 March 2020, WHO/2019-nCoV/IPC PPE_use/2020.2.

      The rota will be reviewed and adjusted as the situation evolves.
      Where possible, more junior trainees (foundation and core level) have been assigned to a ward or hospital zone, to minimise the movement of personnel, while also cross-covering other subspecialties. The ability to cross-cover one another has introduced much needed flexibility in to the system; covering staff self-isolation, sickness and the ability to redeploy to other COVID-19 treating specialities as the situation escalates.

      The role of medical students

      Medical training has been almost universally suspended, with examinations being postponed or cancelled. Though the ramifications on long-term training are unclear, this has resulted in the availability of a considerable pool of motivated individuals.
      In order to increase the capacity of clinical staff, medical students who have passed their final exams and prescribing safety assessment, are being asked to work as ‘F0s’ within the Trust. In this role, under close senior supervision, F0s will be undertaking basic clinical tasks, such as ED triage, ordering tests and prescribing medications.

      COVID-19: Oxford medical students join fight against the pandemic. https://www.healtheuropa.eu/covid-19-oxford-medical-students-join-fight-against-the-pandemic/98818/[Accessibility verified April 15, 2020].

      ,

      Oxford medical students step-up to support fight against Covid-19. http://www.ox.ac.uk/news/2020-03-23-oxford-medical-students-step-support-fight-against-covid-19[Accessibility verified April 15, 2020].

      Non-clinical roles are being filled by more junior clinical students, such as assisting with quantitative Polymerase Chain Reaction (qPCR) testing for COVID-19 and helping with administrative or logistical tasks. Additionally, a series of national student-led initiatives are being set up to support NHS professionals with tasks such as childcare.

      COVID-19: Oxford medical students join fight against the pandemic. https://www.healtheuropa.eu/covid-19-oxford-medical-students-join-fight-against-the-pandemic/98818/[Accessibility verified April 15, 2020].

      ,

      Oxford medical students step-up to support fight against Covid-19. http://www.ox.ac.uk/news/2020-03-23-oxford-medical-students-step-support-fight-against-covid-19[Accessibility verified April 15, 2020].

      Reflections of a junior doctor

      “In the last few weeks alone, my role as a junior doctor has become unrecognisable to what it once was and I have had to learn fast how to adapt to the changing demands of my work environment. My role is likely to change further, with the proposed implementation of a rota system that will see a smaller number of doctors covering multiple specialities at once, in order to cover inevitable staff shortages and absence.
      Being on the front line brings with it a great deal of pressure and responsibility. There is a great deal of anxiety amongst juniors and the psychological impact of this situation on staff should not be underestimated. Not truly knowing what lies ahead, having to adapt to constantly evolving patterns of work, knowing that we can be redeployed at any given moment, is very unsettling. Daily, new policy and guidance is released, which can be overwhelming whilst also conflicting. Beyond the coming weeks and months there remains the niggling uncertainty relating to the implications for our future careers, having recently been told that training rotations, examinations and speciality interviews have been cancelled.
      All this, on top of the fear of contracting the virus ourselves or passing it on to our loved ones, has left me feeling at times like the situation is bleak. Though the uncertainty can be scary, it can and is also uniting and reminding us as a profession why we chose this path in the first place, which is first and foremost to serve.”

      Conclusion

      This pandemic is far from over and plastic surgery teams will be required to adapt quickly to new roles, which will be alien and anxiety provoking. There will be a shift in focus and an expectation to directly support the frontline staff tackling COVID-19.
      Modern and effective leadership strategies are required to empower and support staff. Being an adaptable interspecialty, plastic surgeons are needed more than ever to use their skills to serve the acute specialities.
      We must talk openly and honestly to one another to allow us to anticipate and deal with the inevitable clinical and psychological challenges ahead. This is a challenging time for our nation, which will no doubt change us, the NHS and society forever. With those around us struggling with social isolation, we should count ourselves blessed to be able to face this as a united profession, together with the support and camaraderie of our colleagues. Numerous key advances in the delivery of healthcare have been borne through times of war. This crisis is no different and we stand to be inspired by our experiences of great resilience, courage and resourcefulness in the face of adversity.

      Declaration of Competing Interest

      None.

      Acknowledgements

      We would like to acknowledge and thank all Oxford University Hospitals staff, our referring stakeholders and the public for working together to keep our patients and community safe. Please stay at home if you can.

      Funding

      Nil

      Ethical approval

      Not applicable

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      3. World Health Organisation (WHO). Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf[Accessibility verified April 15, 2020].

      4. Ferguson NM et al. Impact of non-pharmaceutical interventions (NPIs) to reduce COVID- 19 mortality and healthcare demand. https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf[Accessibility verified April 15, 2020].

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      Linked Article

      • The impact of COVID-19 on medical electives in plastic surgery – A medical students’ perspective
        Journal of Plastic, Reconstructive & Aesthetic SurgeryVol. 74Issue 2
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          The June 2020 correspondence by Armstrong et al. titled “A plastic surgery service response to COVID-19 in one of the largest teaching hospitals in Europe”  provided thought provoking insight into how the COVID-19 pandemic has affected medical training at every level.1 The reconfiguration of the plastic surgery service in Oxfordshire is a key example of what is happening at the national and global scale. As the UK recovers from the first wave of the COVID-19, the impact of reconfiguration of services on medical education, particularly on senior medical students, is starting to become apparent.
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      • Plastic surgery training during COVID-19: Challenges and novel learning opportunities
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          The COVID-19 pandemic has fundamentally changed the way we work and care for patients. We read with interest the correspondence by Armstrong et al. outlining the response of their plastic surgery department in one of the largest teaching hospitals in Europe including leadership strategies, team restructuring and altered patient pathways.1 However, one vitally important area not discussed is the impact on training. Furthermore, social distancing has necessitated a shift in teaching paradigms and there has been an almost-viral uptake in webinar-based learning opportunities.
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