Reorganisation to a local anaesthetic trauma service improves time to treatment during the COVID-19 pandemic – experience from a UK tertiary plastic surgery centre

Dear Sir

Wythenshawe Hospital, part of Manchester University NHS Foundation Trust, provides tertiary-referral plastic surgery services to Greater Manchester's 2.8 million population. Our trauma service consists predominantly of hand trauma and complex wound reconstruction undertaking around 2900 emergency procedures annually, with an average 66 h theatre capacity every week. Despite this, theatre capacity is frequently insufficient resulting in patients with ambulatory upper limb trauma suffering waiting times longer than advised by national and regional guidelines [1]. It is in this context that we sought to change the delivery of our trauma service, a transformation accelerated by the widespread changes in surgical services as a result of the COVID-19 pandemic of 2020.

In the UK, lockdown measures were imposed on 23 March 2020 [2]. Our trauma service was rapidly reorganised with a view to long-term change in order to address the risk of poorer outcome of COVID-19 for patients undergoing general anaesthetic procedures [3], and due to reduction in availability of redeployed anaesthetists and theatre staff. We established a consultant-led one-stop wide-awake local anaesthetic with no tourniquet (WALANT) service at a peripheral community hospital. Emergency cases requiring anaesthetic support continued to be treated at the regional centre with prioritisation in competition with other surgical specialties.

We sought to compare the demand on the service and compliance with guidelines on time to treatment during the COVID-19 pandemic with the same 10-week period in 2019.

Approval to collect data was granted from the hospital audit department. Data was collected retrospectively for the period of 1 April to 14 June 2019 from electronic patient records for all trauma patients undergoing surgery. Time from injury to treatment was calculated and benchmarked against the regional guidelines based on national guidelines for specific injuries [1]. These were flexor tendon injuries (4 days), extensor tendon injuries (7 days), nerve injuries (4 days), fractures requiring fixation (24 h if open; 7 days if closed). For the period 1 April to 14 June 2020 data in the same fields was collected prospectively. Time from injury to treatment was considered only in primary cases, whilst lower limb orthoplastic trauma and burns injuries were not included as provisions for their treatment are through a separate pathway.

Prism 8.4.2 (GraphPad Software, San Diego, CA) was used to conduct statistical analyses. Mann-Whitney U test was employed to compare 2019 data versus 2020. Department for Transport traffic data during the pandemic was used as a surrogate measure of human activity and Pearson's correlation coefficient used to correlate with the number of new presentations to our service [4].

There was a reduction in trauma patients requiring surgery (2020 N = 284; 2019 N = 398) with significantly fewer new presentations week-to-week in (2020 weekly median = 23; 2019 weekly median = 33; p < 0.0136) (Fig. 1 ). The number of trauma cases in 2020 reached a similar level as experienced in 2019 by May 11th (or week 7) and remained at a similar level for 3 weeks.

Figure 1.

New presentations of Plastic Surgery trauma in 2019 vs. 2020 correlated with Department of Transport official statistics for vehicle use. Week 1 represents week beginning April 1^st 2019 vs. 30^th March 2020.

The anaesthetic requirement changed in keeping with delivery of a WALANT service (2020 90%, N = 255; 2019 40%, N = 158). The time from injury to treatment was significantly less (2020 median = 2 days; 2019 median = 5 days; p < 0.0001). A greater proportion of patients were treated within 4 days from date of injury (2020 83%, N = 212; 2019 47%, N = 179). Analysis of specific categories of injury against pre-defined standards for time from injury to treatment demonstrated greater compliance in 2020 (85%) compared to 2019 (53%) (Table 1 and Fig. 2 ).

Table 1.

Time to treatment for specific injuries against guideline recommendations.

Target met	Flexor (within 4 days)	Extensor (within 7 days)	Nerve (within 4 days)
2019	31 (60%)	19 (70%)	29 (39%)
2020	36 (78%)	28 (100%)	57 (84%)

Figure 2.

Time from injury to treatment (%).

The COVID-19 global pandemic in 2020 required innovative solutions to meet the trauma demands of plastic surgery in Greater Manchester. We report an early reduction in the incidence of trauma requiring surgery attributable to lockdown and social distancing measures which permitted reorganisation of services and a greater number of patients meeting target wait times for treatment. Critically, this has persisted despite returning to 2019 levels of demand in trauma. We attribute this effect to efficiencies afforded by WALANT [5] and more complex cases have been performed under LA when previously GA had been used; revascularisations (n = 4), replantation (n = 1), arterial repairs (n = 5) and hand fractures (n = 32).

Towards the end of lockdown, there was a gradual rise of trauma to normal levels. Week 7 (11 May 2020) coincided with easing of measures to allow people back into work if they could not work from home and ‘unlimited’ exercise In Week 10 (1 June 2020), the schools started to reopen and the public were allowed to meet different households. The rise in trauma demands correlated with the relaxation of lockdown measures and public activity (r = 0.90, Figure 1). The efficiencies of a one-stop assessment and treatment clinic continue to see cases being treated within a desirable time window despite a return to normalcy. We foresee that our service will continue and encourage other units considering or already having reorganised their service to WALANT to develop efficiencies within this new normal.

Declaration of Competing Interest

None