Abstract
Acute upper limb infections represent a large proportion of on-call referrals and emergency theatre time in plastic surgery. To enable us to maintain effective service provision despite reallocation of hospital resources as a result of COVID-19, and to minimise patient exposure in a hospital setting during the pandemic, we introduced a walk-in clinic and dedicated local anaesthetic (LA) operating theatre for these infections. In this work, we sought to analyse our service changes and resulting patient outcomes. Using electronic records, data from patients presenting with upper extremity infections was collected before the pandemic from 1st January to 30th March 2020, then for a period of three months from 30th March until 30th June 2020, after our changes were implemented. Seventy-two patients were included before 30th March 2020, and 49 patients after. Prior to our changes, most patients underwent surgery (n = 58, 80.6%), requiring overnight admission (n = 64, 88.9%), following mainly general anaesthetic procedures (n = 56, 96.6%). After our service changes, a similar percentage of patients were treated operatively (n = 41, 83.7%), but these procedures mostly utilised LA (n = 37, 90.2%) in the outpatient setting (n = 25, 51.0%). Despite this shift in management approach, no statistically significant difference in readmission rates was calculated between the two groups (p = 0.556) and post-operative complications were fewer in absolute terms. Our results suggest that in many instances, these infections can be managed in an outpatient setting without the need for inpatient care. Selective admission with strict follow-up of patients may be feasible, improving patient experience and reducing resource burden.
Keywords: Hands, Upper limb, Infections, Management, Outcomes
Dear Sir,
Introduction
The COVID-19 pandemic has inflicted innumerable pressures on healthcare systems worldwide, including substantial impacts on resource availability. Certainly, for the United Kingdom's National Health Service, this has necessitated reprioritisation of services and redeployment of staff to acute medical departments. As such, surgical services have been particularly affected, where large portions of elective surgery have been cancelled.1
At our unit, hospital-wide pressures resulting in reduced theatre capacity and amalgamation of surgical specialties into a single ward influenced changes in the delivery of our plastic surgery services. Similar to other centres,2 we introduced a triage clinic (OPD4) and dedicated local anaesthetic (LA) theatre for acute trauma, including acute upper extremity infections which represent a significant proportion of on-call work in plastic surgery.3 Delay in the treatment of these infections could have devastating impacts on functional outcomes4 and may even be limb-threatening. We hoped this shift in management would allow us to assess patients as safely and efficiently as possible, without the potential risks of hospital admission or the need to burden limited emergency theatre (CEPOD) resources. In this work, we sought to analyse this change in care delivery and consider how it may alter patient care even after the pandemic.
Methods
Using electronic hospital records, data from patients presenting with acute upper limb infections was collected retrospectively from 1st January to 30th March 2020 (pre-OPD4), then prospectively from 30th March until 30th June 2020, after our service changes were implemented (post-OPD4).
CHI squared and unpaired t-tests were utilised in statistical calculations. Significance level was taken as <0.05.
Results
Seventy-two patients were identified prior to our changes and 49 patients after (Table 1 ). There was no statistical difference between the presenting age of patients between the two groups or in the time from injury/symptom onset to presentation to healthcare services. In both groups, most infections affected the hand (n = 54, 75.0% and n = 42, 85.7%, respectively) and resulted from animal bites.
Table 1.
Patient demographics and referral information.
| Pre-OPD4 | Post-OPD4 | |
|---|---|---|
| Average Age (Range) p = 0.708 |
46.5 (18-91 years) |
47.8 (18-92 years) |
| Patient Sex | ||
| Male | 43 | 24 |
| Female | 29 | 25 |
| Referring Source | ||
| On-site emergency department | 41 | 19 |
| Emergency department in different hospital within the same trust | 19 | 9 |
| Minor injuries unit in different hospital within the same trust | 3 | 5 |
| General practice | 5 | 15 |
| Other | 4 | 1 |
| Time Between Injury (or Symptom Onset) and Presentation (Range) p = 0.233 |
4.83 days (0-44 days) | 6.88 days (0-61 days) |
| Classification of Infection | ||
| Abscess | 6 | 3 |
| Animal bite | 21 | 19 |
| Cellulitis* | 17 | 9 |
| Felon* | 1 | 2 |
| Flexor sheath | 10 | 5 |
| Gout | 2 | 1 |
| Necrotising fasciitis | 1 | 0 |
| Osteomyelitis | 2 | 0 |
| Paronychia*p = 0.018 | 2 | 7 |
| Post-operative | 2 | 2 |
| Septic arthritis | 8 | 1 |
Represent clinically complicated cases of these types of infections where operative management was absolutely indicated. For example, infections requiring debridement or exploration for suspected osteomyelitis, or involving infected foreign bodies.
Prior to the changes in our care delivery, most patients underwent surgery (n = 58, 80.6%), almost always under general anaesthetic (GA) (n = 56, 96.6%), and performed in CEPOD theatre. The majority of pre-OPD4 patients were admitted to hospital (n = 64, 88.9%). After our service changes, however, despite a similar percentage receiving operative treatment (n = 41, 83.7%), these were largely under LA (n = 37, 90.2%). Of those requiring LA, 81.1% (n = 30) underwent surgery in our new dedicated LA theatre, thus significantly reducing the use of CEPOD resources. Patients in this cohort were more commonly managed in the outpatient setting (n = 25, 51.0%).
For both groups, mainly Staphylococcus and Streptococcus spp. organisms were grown. Eight cases of Group A Streptococcus were noted in the pre-OPD4 patient cohort, but none post-OPD4. For patients requiring antibiotics pre-OPD4, the majority received intravenous therapy as inpatients and were then discharged with oral antibiotics (n = 44, 61.1%). However, after our changes, there was a shift in management and instead most patients received oral antibiotics only (n = 26, 56.5%). The duration of antibiotic therapy was not statistically significant (p = 0.505) between the two groups. Co-amoxiclav antibiotic was most commonly prescribed.
Readmission rates were not affected by our services changes (Table 2 ). Beyond readmission, several significant post-management complications were assessed, which were fewer in the post-OPD4 cohort.
Table 2.
Admission type and duration, readmission rates, and complications.
| Pre-OPD4 | Post-OPD4 | |
|---|---|---|
| Admission Type | ||
| In patient | 64 (88.9%) | 21 (42.9%) |
| Day case | 4 (5.56%) | 3 (6.12%) |
| Outpatient | 4 (5.56%) | 25 (51.0%) |
| Average number of days for inpatient stay (Range) p = 0.0002 | 3.74 days (1-21 days) |
1 day (0-7 days) |
| Readmission within 90 days | ||
| Number of cases | 8 | 4 |
| Readmission rate p = 0.5564 | 11% | 8% |
| Complications | ||
| Functional deficit | 4 | 1 |
| Hypertrophic scarring | 2 | 1 |
| CRPS | 1 | 0 |
| Wound dehiscence | 1 | 0 |
Discussion
The results of this study suggest that in many instances, acute upper limb infections can be adequately managed in the outpatient setting with LA procedures, without the need to admit and provide treatment under GA for all patients. Our data has proposed that post-operative outcomes were no different comparing the two groups.
We note the lack of homogeneity between our pre- and post-intervention groups, explained in part by our small patient cohorts, but also the unpredictable nature of trauma. Our study captures a snapshot of a limited number of patients over a short period of time and we acknowledge this as a significant limitation of our study. However, it remains surprising to find that post-OPD4 patients had reduced readmission and complication rates in absolute terms, and we posit that different microbiology patterns could explain these observed disparities. Pre-OPD4 patients grew greater numbers of Staphylococcus aureus and Pasteurella, with eight cases of Group A Streptoccocus compared to none in the post-OPD4 group. Indeed, Streptococcus spp. are associated with more aggressive infections of the hand.5
Despite the obstacles faced in delivering high quality surgical care during a global pandemic, it has remained imperative to maintain emergency surgical services. For patients with acute upper extremity infections, perhaps selective admission (Group A Streptococcus cases, for instance) with strict follow-up of patients with milder symptoms can be feasible. It may prove cost-effective to continue with our dedicated clinic and operating theatre in the longer term, even after the pandemic. Of course, beyond cost efficacy, a shift to outpatient management would most certainly improve patient experience as well.
Ethical Approval
Not required.
Declaration of Competing Interest
None to declare.
Funding
None to declare.
References
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