St Andrew's COVID-19 surgery safety (StACS) study: hand trauma

Abstract

Introduction

Adaptation is vital to ensure successful healthcare recovery during the COVID-19 pandemic. Hand trauma represents the most common acute emergency department presentation internationally. This study prospectively evaluates the COVID-19 related patient risk, when undergoing management within one of the largest specialist tertiary referral centres in Europe, which rapidly implemented national COVID-19 safety guidelines.

Materials and methods

A prospective cohort study was undertaken in all patients referred to the integrated hand trauma service, during the UK COVID-19 pandemic peak (April–May 2020); all were evaluated for 30-day COVID-19 related death. Random selection was undertaken for patients with hand trauma who either underwent non-operative (control group) or operative (surgery group) management; these groups were prospectively followed-up within a controlled cohort study design and telephoned at 30 days following first intervention (control group) or postoperatively (surgery group).

Results

Of 731 referred patients (566 operations), there were no COVID-19 related deaths. Both groups were matched for sex, age, ethnicity, body mass index, comorbidities, smoking, preoperative/first assessment COVID-19 symptoms, pre- and postoperative/first assessment isolation and positive COVID-19 contact (p > 0.050). There were no differences in high service satisfaction (10/10 compared with 10/10; p = 0.067) and treatment outcome (10/10 compared with 10/10; p = 0.961) scores, postoperative/first assessment symptoms (1%, 1/100 compared with 0.8%, 2/250; p = 1.000) or proportion of positive tests (7.1%, 1/14 compared with 2.2%, 2/92; p = 0.349), between the control (n = 100) and surgery (n = 250) groups.

Conclusion

These data support continued and safe service provision and no increased risk to patients who require surgical management. Such findings are vital for healthcare providers when considering service adaptations to reinstate patient treatment.

Introduction

Hand trauma represents the most common presentation to accident and emergency departments internationally, accounting for 10–30% of overall attendances, with up to 42% of overall attendances involving the upper limb.^1–3 Injury may result in long-term disability, loss of work and/or livelihood, psychological issues and withdrawal from society in extreme cases, with subsequent substantial personal and societal economic burden; there has therefore been significant focus on developing hand trauma services to achieve the best outcomes for patients.^{4, 5}

Great challenges have been faced by hospital services worldwide during the COVID-19 pandemic.⁶ On 31 December 2019, The World Health Organization (WHO) received the first report of a cluster of pneumonia cases of unknown aetiology, in Wuhan City, Hubei Province of China.⁷ They subsequently reported the first novel coronavirus case in Thailand on 13 January 2020, in a traveller from Wuhan who had been hospitalised on 8 January 2020.⁷ By 30 January 2020, 7,818 cases had been confirmed worldwide, with 82 of these reported in 18 countries outside China.⁸ With further global spread of the disease, a COVID-19 pandemic was officially declared by the WHO on 11 March 2020; as at 3 October 2020, there have been over 1 million deaths and over 34.4 million confirmed COVID-19 cases reported.⁹

While long-term data are required to improve the interpretable accuracy of reported statistics, the COVID-19 clinical spectrum ranges from asymptomatic to critically ill, with the majority of patients presenting with mild symptoms and a good prognosis.^{10, 11} However, up to 15% of patients may develop pneumonia, acute respiratory distress syndrome, cardiac injury, renal injury or multiorgan failure around 7–10 days after hospitalisation; a subset of these patients will require admission to intensive care for life-supporting treatment such as invasive ventilation or extracorporeal membrane oxygenation.^{10, 11} In studies of hospitalised patients who originate from the Hubei province of China, intensive care admission rates of up to 32%, non-invasive ventilation requirements in up to 24% and intubation requirements of up to 12% have been reported.^12–14 After intensive care admission, the percentage of fatalities ranges from 20% to 62%, depending on how critically ill patients become.^{15, 16} In terms of surgery, an international multicentre cohort study of 1,128 patients who underwent either emergency (74.0%) or elective (24.8%) operations, confirmed severe acute respiratory syndrome coronavirus 2 infection preoperatively in 26.1% (294/1128) and a 30-day mortality of 21.1% (62/294).¹⁷

As a consequence of these early findings, a prolonged period of healthcare and economic instability continues to present significant challenges to surgical services worldwide, with many healthcare systems having been largely unprepared for the scale of the pandemic. Adaptation is vital to ensure that a successful recovery restores high quality trauma service provision.^{18, 19} There has therefore been a requirement for NHS plastic surgery, trauma and burns centres to rapidly adapt to evolving guidelines, while maintaining crucial cancer, trauma and burns services.²⁰ With respect to hand trauma, joint national guidelines have been produced that emphasise the importance of delivering rapid same or next day, day case emergency operating for complex injuries, and the adoption of a ‘one-stop’ streamlined care model from triage, through to assessment, treatment and discharge, with only minimal face-to-face follow-up as required.²¹ Where possible, a shift towards non-operative management is preferred, otherwise local or regional anaesthesia techniques are recommended.²¹ It is advised that additional outpatient and minor operations areas are identified to perform relevant manipulations or procedures, with access to a mini C-arm.²¹ More specific recommendations, such as using absorbable sutures, leaving Kirschner wires unburied and giving patients removable splints and dressings packs with clear postoperative instructions, are given to minimise in-hospital follow-up requirements; where possible, remote video or telephone appointments are recommended.²¹

St Andrew's Centre for Plastic Surgery and Burns is among the largest of specialist centres in Europe; in 2019, there were 5,240 new tertiary acute hand trauma referrals to the Centre for Hand Surgery, with 3,556 acute operations undertaken for these patients. The UK has been among the countries worst affected by COVID-19; at the end of this study period (June 2020), there had been approximately 280,000 confirmed cases and 44,000 deaths since the UK outbreak in March 2020.⁹ The primary aim of the St Andrew's COVID-19 surgery safety hand trauma study is to prospectively evaluate patient safety during the peak of the UK COVID-19 pandemic; in particular, the purpose is to evaluate the COVID-19 related risk to patients when undergoing management within a tertiary referral centre that rapidly implemented significant service safety adaptations according to national guidelines.²¹ Secondary aims include investigating any risk differences between non-operative and operative management.

Materials and methods

A prospective cohort study was undertaken, using Strengthening the Reporting of Observational Studies in Epidemiology guidelines, in all patients referred to the integrated hand trauma service during the UK COVID-19 pandemic peak (April–May 2020); Clinical governance board approval was granted (CA20–012).²² Patients were prospectively registered on the electronic trauma referral and hospital database. ‘Real-time’ 30-day death data were collected from the hospital database; this database updates in line with local and national registration information.

Random selection was undertaken for patients with hand trauma who either underwent non-operative (control group) or operative (surgery group) management; these groups were also prospectively followed-up within a controlled cohort study design and telephoned at 30 days following the first intervention (control group) or postoperatively (surgery group). Demographic data and clinical outcomes were recorded as patients progressed through treatment; details of the integrated hand trauma service pathway, created specifically to address the COVID-19 related risk posed to patients, are outlined below. Data relating to service and treatment outcome satisfaction, in-hospital or virtual clinic attendance numbers, details regarding pre- and postoperative contact with COVID-19 positive individuals, isolation status, COVID-19 symptoms, formal testing, postoperative hospital/intensive care admissions and ventilation requirements were collected.

Data were analysed using SPSS^®. Categorical variables were compared with the chi-squared test (Fisher test for expected numbers less than five). Continuous variables were compared with the t-test (parametric data) or Mann–Whitney U test (non-parametric data).

Integrated hand trauma service pathway

Patients presented to the Centre for Hand Surgery, Integrated Hand Trauma Service; this service provided immediate, same-day access to surgeon assessment, nurse-led dressing clinic and hand therapy as appropriate. Prior to entering the St Andrew's outpatient department, patients answered a screening questionnaire and had a temperature check. Patients with a temperature less than 37.8 degrees and no active COVID-19 symptoms were assessed by one of two teams depending on the patient referral route. Team members wore surgical masks, aprons and gloves throughout clinical contact. Patients not meeting these criteria were assessed in a designated room by a surgeon wearing a filtering face piece level-3 (FFP3) mask; this room was cleaned before and after the consultation. Plastic surgery and orthopaedic accident and emergency minor injuries were also relocated to separate rooms within the same department; a second team, consisting of an emergency nurse practitioner and plastic surgery dressing clinic nurse supported by a hand trauma consultant and fellow/registrar grade provided a means of bypassing the traditional internal referral route from accident and emergency minor injuries, thus minimising patient appointments and movements within the hospital. All injury patterns were assessed by both teams such that separate ‘open injury (hot) or closed injury (cold)’ clinics were not created.

The first team assessed patients in a designated clinical open plan area within the St Andrew's outpatient department, capable of accommodating six patient beds in curtained bays and six patients at consultation tables at any one time, with at least four metres between each assessment space. Two large rooms adjoining the main clinical open area were allocated; one room for the hand therapists, the other for the surgeons and nurses, with access to relevant equipment, computer systems and patient notes. After initial assessment, patient notes were either given to the hand therapy department for non-operative management or to the hand trauma coordinator in preparation for surgery. Patients with life/limb threatening presentations or severe infections were admitted.

In terms of surgery, two routes to operation were implemented for patients. First, a minor operations room within the St Andrew's outpatient department was reassigned for ‘see and treat’ wide-awake local anaesthetic non-tourniquet (WALANT) cases, with mini C-arm support and full staffing. Second, an all-day trauma list was allocated for regional and general anaesthesia; where theatre time allowed and the patient was appropriately starved, ‘see and treat’ operating was arranged, otherwise patients returned on a scheduled surgery date. All procedures under general anaesthesia and metalwork instrumentation cases were treated as high risk, such that full protective equipment including FFP3 masks and visors were worn. Twenty minutes of theatre downtime was allocated either after extubation (general anaesthesia procedures) or after any high-risk aspect of a procedure had finished (procedures not under general anaesthesia). The choice of surgery using regional anaesthesia or WALANT techniques was influenced in part by the surgeon's preference; however, when regional anaesthesia was used, the injury pattern was complex and involved multiple structures or tissue types (eg multi-digit combinations of neurological, vascular, tendon or fracture injuries). General anaesthesia was more likely to be reserved for paediatric patients, life- or limb-threatening injuries, bilateral injuries or patients with phobias of being awake during surgery.

Face-to-face consultant outpatient follow-up was not routinely arranged postoperatively, but was available by appointment in the clinical open plan area, delivered by the first hand trauma team. The postoperative hand therapy and plastic surgery dressing clinics ran concurrently, also from within the St Andrew's outpatient department. For patients who required follow-up by a specific team member, this was arranged according to the rota. This integrated service therefore streamlined patient follow-up care while also facilitating immediate review by relevant team members as required. Virtual clinics were subsequently implemented to provide further follow-up where necessary. These initially consisted of telephone consultations with or without emailed photographs, but by the end of the study period video consultation access was implemented and remains in use.

Results

There were 731 patients (566 operations) referred to the integrated hand trauma service (April–May 2020), who were all included within the prospective cohort study; there were no 30-day COVID-19 related deaths. Of these patients, 3.7% (27/731) were excluded from further analysis as they were non-hand trauma cases (4 non-operative, 23 operative); 543 hand trauma operations were performed (Figure 1). While we recognise that the indications for non-operative compared with operative management are numerous and must be individually tailored to the patient's functional requirements, an example overview is presented (Table 1). There were 350 hand trauma patients (238 male, 112 female) included within the prospective controlled cohort study design; patient demographics, treatment details, service satisfaction and treatment outcomes are presented (Table 2). The average patient age was 48.53 years (standard deviation, SD, 17.4) and body mass index was 27.51 kg/m², (SD 5.66; Table 2). Overall, 22.6% (79/350) of patients were smokers and 39.4% (138/350) had a median of 1 comorbidity (interquartile range, IQR, 1–2; Table 2). The median patient service satisfaction score was 10/10 (IQR 10–10) and treatment outcome rating was 10/10 (IQR 9–10; Table 2).

Figure 1 .

Prospective cohort study primary operative diagnosis for hand trauma cases performed during April/May 2019 (blue) and 2020 (red). There were 731 patients referred to the integrated hand trauma service during the prospective cohort study period, resulting in 566 operations of which 543 were for hand trauma; there were no 30-day COVID-19 related deaths (0%, 0/731). This represents a 34.3% decrease in referrals and 3.9% decrease in operations, compared with the 1,112 referrals received and 589 operations performed during the same period in the previous year; therefore, the proportion of referred patients who required operative management, was significantly greater compared with the previous year (77.4% compared with 53.0%; p < 0.001). Overall, when grouped by primary operative diagnosis, the numbers of operative cases performed during the study period were similar.

Table 1 .

Example overview of indications for non-operative and operative management. This table is only intended as a guide for the reader, as we recognise that the indications for non-operative compared with operative management are numerous and must be individually tailored to the patient's functional requirements.

Non-operative management example indications	Operative management example indications
Minor fingertip, nailbed or skin laceration without associated neurological, vascular or tendon injury	Life, limb or digit threatening injury (eg replant, revascularisation, compartment syndrome, necrotising fasciitis, high-pressure injection injury)
Minor infection (eg cellulitis)	Major infection (eg septic arthritis, flexor sheath, abscess)
Closed and stable fracture pattern without deformity	Contaminated or complex wound with tissue loss, neurological, vascular or tendon injury
Closed and well-reduced joint dislocation	Bite injury with infection or high risk thereof
Some closed soft tissue injuries (eg mallet, partial collateral ligament, volar plate)	Foreign body retrieval (eg glass, thorn)
	Open fracture or joint injury
	Closed and unstable fracture pattern with deformity
	Irreducible joint dislocation
	Some closed soft tissue injuries (eg jersey finger, complete collateral ligament)

Table 2 .

Controlled prospective cohort study patient demographics, treatment details, service satisfaction and treatment outcomes

Variables	Patient total (n = 350)	Controls (n = 100)	Intervention (n = 250)	p-value	CI
Sex, n (%):				0.131a	–
Female	112 (32.0)	38 (38.0)	74 (29.6)
Male	238 (68.0)	62 (62.0)	176 (70.4)
Age, mean (SD)	48.53 (17.39)	50.14 (17.11)	47.89 (17.49)	0.274b	[–1.79, 6.30]
Ethnicity, n (%):				0.137c	–
White	320 (91.4)	96 (96)	224 (89.6)
Black	6 (1.7)	0 (0)	6 (2.4)
Asian	24 (6.9)	4 (4)	20 (8.0)
BMI, mean (SD)	27.51 (5.66)	27.36 (6.27)	27.61 (5.41)	0.576b	[–1.71, 0.95]
Comorbidities present, n (%)	138 (39.4)	40 (40)	98 (39.2)	0.890a	–
Number of comorbidities, median (IQR)	1 (1–2)	1 (1–2)	1 (1–1)	0.634d	–
Smoker, n (%)	79 (22.6)	25 (25.0)	54 (21.6)	0.492a	–
Surgery type, n (%):				–
day case	NA	NA	224 (89.6)		–
Inpatient	NA	NA	26 (10.4)
Anaesthetic modality, n (%)				–
Local	NA	NA	187 (74.8)		–
Regional	NA	NA	58 (23.2)
General	NA	NA	5 (2.0)
Postoperative/first-assessment hospital visits, median (IQR)	1 (0–2)	1 (0–1)	2 (0–3)	<.001 d	–
Hospital postoperative/first-assessment appointments, median (IQR):
PDC	0.5 (0–2)	0 (0–0)	1 (0–2)	<.001 d	–
OPD	0 (0–0)	0 (0–0)	0 (0–0)	0.187d
HT	0 (0–2)	0 (0–1)	0 (0–2)	0.076d
Remote postoperative/1st assessment appointments, median (IQR):					–
PDC	0 (0–0)	0 (0–0)	0 (0–0)	0.142d
OPD	0 (0–0)	0 (0–0)	0 (0–0)	0.003 d
HT	0 (0–0)	0 (0–0)	0 (0–0)	0.829d
Service satisfaction score (/10), median (IQR)	10 (10–10)	10 (10–10)	10 (10–10)	0.067d	–
Treatment outcome rating (/10), median (IQR)	10 (9–10)	10 (9–10)	10 (9–10)	0.961d	–

^a Chi-squared test

^b independent t-test

^c Fisher test

^d Mann Whitney U test

CI, confidence interval; HT, hand therapy; IQR, interquartile range; LA, local anaesthetic; NA, not applicable; OPD, surgeon outpatient department consultation; PDC, plastic surgery dressing clinic; SD, standard deviation

Controlled prospective cohort study COVID-19 related patient data are presented (Table 3). Overall, 3.1% (11/350) of patients reported contact with a COVID-19 positive individual prior to first assessment (control group) or preoperatively (surgery group). Of these patients, 72.7% (8/11) had positive contact with a family member at a median of 21 days (IQR 21–49.5; Table 3). There were 4.3% (15/350) of patients who reported symptoms prior to first assessment/preoperatively, at a median of 30 days (IQR 5–90), which lasted for a median of 7 days (IQR 3–30; Table 3). Overall, 2.0% (7/350) of patients reported contact with a COVID-19 positive individual after first assessment (control group) or postoperatively (surgery group); of these patients, 42.9% (3/7) had positive contact with a family member at a median of 9 days (IQR 7–20; Table 3). There were 0.9% (3/350) of patients who reported symptoms after first assessment/preoperatively, at a median of 21 days (IQR 14–), which lasted for a median of 10 days (IQR 7–; IQR upper limits not calculated due to low patient numbers; Table 3). There were 17.1% (60/350) of patients who isolated for a median of 28 days (IQR 14–28) in the preoperative/first assessment period and 17.1% (60/350) who isolated for a median of 21 days (IQR 14–29.5) after this time (Table 3). Overall, 106 patients (30.3%) received COVID-19 testing and 2.8% (3/106) of these tested positive; only 1/350 patients (0.3%) was admitted to hospital, for 35 days, and required 5 days of ventilation during a 7-day intensive care admission (Table 3).

Table 3 .

Controlled prospective cohort study COVID-19 related patient data

Variables	Total (n = 350)	Controls (n = 100)	Intervention (n = 250)	p-value
Preoperative/first-assessment positive contact, n (%)	11 (3.1)	1 (1.0)	10 (4.0)	0.146a
Family contact, n (%)	8 (72.7)	1 (100)	7 (70)	1.000b
How many days? median (IQR)	21 (14–28)	28c	19.5 (12.75–23.25)	0.337d
Preoperative/first-assessment isolation, n (%)	69 (19.7)	18 (18.0)	51 (20.4)	0.610a
How many days? median (IQR)	28.00 (21–49.5)	60.00 (22.5–48.75)	28 (18–50)	0.257d
Preoperative/first-assessment symptoms, n (%)	15 (4.3)	1 (1.0)	14 (5.6)	0.055a
How many days? median (IQR)	30 (14–60)	90c	30 (11.25–60)	0.130d
Symptom duration (days), median (IQR)	7 (4–12)	7c	6 (4–12.5)	0.815d
Temperature, n (%)	3 (20.0)	1 (100)	2 (14.3)	0.200b
Chills, n (%)	2 (13.3)	0	2 (14.3)	1.000b
Cough, n (%)	8 (53.3)	0	8 (57.1)	0.467b
Sore throat, n (%)	3 (20.0)	0	3 (21.4)	1.000b
Shortness of breath, n (%)	3 (20.0)	1 (100)	2 (14.3)	0.200b
Body aches, n (%)	3 (20.0)	0	3 (21.4)	1.000b
Loss of taste/smell, n (%)	8 (53.3)	1 (100)	7 (50)	1.000b
Lethargy, n (%)	2 (13.3)	0	2 (14.3)	1.000b
Headache, n (%)	1 (6.7)	0	1 (7.1)	1.000b
Runny nose, n (%)	1 (6.7)	0	1 (7.1)	1.000b
Postoperative/first-assessment positive contact, n (%)	7 (2.0)	3 (3.0)	4 (1.6)	0.398a
Family contact, n (%)	3 (42.9)	1 (33.3)	2 (50.0)	1.000b
How many days? median (IQR)	9 (7–20)	7 (6–)e	15 (9.25–20.75)	< .032 d
Postoperative/first-assessment isolation, n (%)	60 (17.1)	19 (19.0)	41 (16.4)	0.560a
How many days? median (IQR)	21 (14–29.5)	21 (21–30)	21 (14–31.5)	0.758d
Postoperative/first-assessment symptoms, n (%)	3 (0.9)	1 (1.0)	2 (0.8)	1.000b
How many days? median (IQR)	21 (14–)e	14c	26.5 (21–)e	0.221d
Symptom duration (days), median (IQR)	10 (7–)e	36c	8.5 (7–)e	0.221d
Cough, n (%)	2 (66.7)	1 (100)	1 (50)	1.000b
Shortness of breath, n (%)	1 (33.3)	1 (100)	0	0.333b
Body aches, n (%)	2 (66.7)	1 (100)	1 (50)	1.000b
Loss of taste/smell, n (%)	2 (66.7)	1 (100)	1 (50)	1.000b
Headache, n (%)	1 (33.3)	0	1 (50)	1.000b
Diarrhoea, n (%)	2 (66.7)	1 (100)	1 (50)	1.000b
Test performed, n (%)	106 (30.3)	14 (14.0)	92 (36.8)	<.001 a
Positive test, n (%)	3 (2.8)	1 (7.1)	2 (2.2)	0.349b
Hospital admission due to COVID, n (%)	1 (33.3)	0	1 (50)	–
Duration (days), median (IQR)	35c	–	35c	–
Intensive care unit admission due to COVID, n (%)	1 (33.3)	0	1 (50)	–
Duration (days), median (IQR)	7c	–	7c	–
Ventilated, n (%)	1 (33.3)	0	1 (50)	–
Duration (days), median (IQR)	5c	–	5c	–
Mortality at 30 days, n (%)	0	0	0	–

^a Chi-squared test

^a Fisher test

^c Absolute value given due to there being only one patient

^d Mann Whitney U test

^e Upper limit of IQR not calculated due to low patient numbers

IQR=interquartile range

Both the control and surgery groups were matched for sex, age, ethnicity, body mass index, comorbidities, smoking, preoperative/first assessment COVID-19 symptoms, pre- and postoperative/first-assessment isolation and positive COVID-19 contact (Tables 2 and 3). Within the operative group, there were 89.6% (224/250) day case and 10.4% (26/224) inpatient operations performed using local (74.8%, 187/250), regional (23.3%, 58/250) or general (2.0%, 5/250) anaesthetic techniques (Table 2). There were no differences in high service satisfaction (10/10 compared with 10/10; p = 0.067) and treatment outcome (10/10 compared with 10/10; p = 0.961) scores, postoperative/first assessment symptoms (1%, 1/100 compared with 0.8%, 2/250; p = 1.000) or proportion of positive tests (7.1%, 1/14 compared with 2.2%, 2/92; p = 0.349) between the control and surgery groups (Tables 2 and 3).

Discussion

Despite the international implementation of practice modification to address the COVID-19 pandemic, there remains a paucity of prospective patient-centred and controlled studies regarding the safety of continuing surgery for patients.^23–27 By the end of this study period (June 2020), the estimated UK prevalence and death rate were approximately 4400 and 600 per million population respectively; thus, at that time, the UK was among the top five most affected countries in terms of confirmed cases and deaths per million population.⁹ This represents a stark contrast to other highly populated countries, such as India, which at that time was among the top five most affected countries by having 590,000 confirmed cases and 17,000 deaths, yet were among the least affected countries by disease spread through the population. This in part is reflected in a low prevalence (400/million population) and death rate (12/million population).⁹ In a series of 484 elective major cancer surgeries, performed between 23 March and 30 April 2020 at Tata Memorial Hospital, there were no postoperative deaths.²⁶ The authors partly attribute these figures to adopting a ‘COVID-19 centric policy’, but they also acknowledge that the extent of the Indian national lockdown significantly truncated the prevalence of COVID-19 during the study period; as such, these data only apply to countries least affected by the pandemic and where mortality is less than 10/million population.²⁶

It is clear that, internationally, hand surgeons have also modified their practice due to COVID-19.²³ Within the UK, several units rapidly implemented changes according to joint national guidelines.^{24, 25} A study from the university trauma hand centre at the Georges-Pompidou European Hospital (Paris, France), identified 275 urgent upper limb trauma referrals over two months during their lockdown period; this represented a 64.9% decrease compared with the previous year.²⁸ A similar plastic and reconstructive surgery department (Leeds, UK) study reported 109 adult and 6 paediatric patient referrals and scheduled surgeries over one month during the lockdown period; this represented a 56% and 80.6% reduction in adult and paediatric cases compared with the previous year.²⁵ The data presented in our study are in line with these findings, in that we identified a 34.3% decrease in referrals; however, there was only a 3.9% decrease in performed operations compared with the same period in the previous year, and the total number and types of operations performed were similarly distributed (Figure 1). These observations may be explained by the concept that during the UK pandemic peak, patients with less severe injuries were either less likely to present to hospital or were less likely to be referred by peripheral accident and emergency departments.

We identified one patient in the ‘control group’ and two in the ‘surgery group’ who developed postoperative/first-assessment symptoms; none was previously symptomatic (Table 3). The symptomatic patient in the control group tested positive after traceable positive contact one week after the first intervention, then developed symptoms one week later, which lasted for 32 days (Table 3). The two symptomatic patients in the surgery group did not report positive contact; both self-isolated without formal testing after developing mild symptoms. Only one patient had a COVID-19 related hospital admission (35 days), requiring five days of ventilation during a seven-day intensive care admission; her only comorbidity was cardiovascular disease. She sustained an extravasation injury during this admission, following which she recovered with two negative swabs prior to surgery (Table 3). Despite the prospective study design, well-matched and controlled patient groups, routine patient COVID-19 testing was introduced on the 21 May 2020, with only symptomatic patients having been tested prior to this time; as such, some data were driven by symptomatology, although this does represent the true risk to patients.

We did not encounter any issues with respect to personal protective equipment availability for both non-operative and operative team members. All team members were risk assessed. Those who were high risk were removed from direct clinical contact; those who were moderate risk were reallocated to other roles in keeping with this risk assessment level and those who were low risk continued strictly in keeping with the aforementioned implemented departmental service guidelines. Using this approach, team members felt that they were not put at risk due to a lack of personal protective equipment provision.

Conclusion

This prospective cohort study examined 731 referred patients (566 operations) who were managed by the integrated hand trauma service during the UK COVID-19 pandemic peak (April–May 2020); there were no 30-day COVID-19 related deaths (0%, 0/731). Despite being among the most affected countries worldwide, we demonstrate low COVID-19 infection rates and positive patient outcomes. We have further demonstrated that patients with hand trauma who required operations did not incur an increase in this risk. These highly encouraging results were achieved with significant service changes implemented to protect patients and team members.²¹ Healthcare service provision has been significantly limited internationally to mitigate COVID-19 related risk; our findings are therefore vital for healthcare providers when considering service adaptations to reinstate patient treatment.^{6, 27, 29, 30} We continue to adapt according to the literature and national guidelines to maintain a safe and efficient patient service.