Listen to Mr Andrew Duckworth interview the immediate past president of the BOA, Professor Phil Turner, about the recently released BOA guidelines for restarting non-urgent trauma and orthopaedic care.
Click here to view our COVID-19 content
Listen to Mr Andrew Duckworth interview the immediate past president of the BOA, Professor Phil Turner, about the recently released BOA guidelines for restarting non-urgent trauma and orthopaedic care.
Click here to view our COVID-19 content
[00:00:00] Welcome everyone. I'm Andrew Duckworth and I'd like to thank you for joining us for our fourth episode from our second podcast series on the COVID-19 pandemic entitled COVID 19 -The new normal, and how to get there.
As some countries are just sadly going through the peak of the pandemic others are trying to determine the best way forward as we move out of lockdown. However, without doubt, the COVID-19 pandemic continues to weigh heavily over all our healthcare systems across the world. Through this second series of podcasts we have and will continue to reflect on what has happened so far as a consequence of the pandemic for us in our specialty, as well as on our healthcare system as a whole.
We've already heard from a range of colleagues and specialties in how we may move forward as we start to consider restarting or increasing our orthopaedic services around the country. And we've recently discussed the current state of orthopaedic research with regards to COVID with Professor Matt Costa.
There are without doubt, some questions and unknowns which we'll discuss in more detail today with our guest regarding hospital capacities and pathways, patients' safety and prioritization as well as informed consent in light of the COVID-19 [00:01:00] pandemic.
So today I have the pleasure of being joined by the immediate past president of the BOA, Professor Phil Turner, who I know will not only be able to give us an exceptional overview into the effects of the pandemic on our specialty so far. But will also be able to give us some key insights on the recently released guidelines from the BOA entitled Restarting non-urgent trauma and orthopaedic care and how we may try and return to some form of normality in these unusual times.
Many thanks for joining us today Prof. We really appreciate your time.
Thanks Andrew.
So Prof, we start up in terms of, you know, it's now approaching two months since the UK went into lockdown, due to the pandemic and a lot continues to develop and change both in terms of our path through the peak of the virus so far, as well as our understanding of this pandemic and what it means for both us as a country, but also for our healthcare system and specialty. So as we have normally done so far in our series, Prof, can I ask you what has been your experience of the pandemic over the past few months and what do you feel we've learned over that time?
So most of my time has been spent doing remote [00:02:00] clinic and to be honest, I don't think I've ever been busier. It's also given me a real understanding of the issues that face the specialties, particularly the anaesthetics and intensivists, and this has led to much stronger collaboration with other specialties across our unit. But I think the other aspect is that it's given me the opportunity to work with other teams, to essentially fashion a whole new concept of care for musculoskeletal conditions in these new circumstances spreading right the way from self care in the community, primary care, good pathways of management, hopefully safe and if ultimately efficient secondary care. While at the same time ensuring uninterrupted, emergency and urgent care, and then moving on to how to establish remote rehabilitation and follow-up.
Yeah, no, absolutely Prof. I think like we've said before on our podcast, through these difficult times, often you can find a way to move forward and try and take some positives from it. I think [00:03:00] that's right.
In terms of the guidelines though if we come on to those, obviously, you know, the guidance highlights that we should be reviewing and expanding the provision of care for all urgent services. And this should take precedence over starting non-urgent surgery at the moment. How do you feel overall we're going to do this and how well-positioned do you feel we are to move forward with this currently?
Thanks Andrew. It's a difficult balancing act. Isn't it? First of all, I'd just like to say that we have framed our documenters guidance and not guidelines so that we can be flexible ultimately, and take on board new evidence as it comes and new guidelines that do come centrally. So we realise this has to be a document, which is going to change as we get more evidence about the best way forward.
Firstly, as far as trauma is concerned, we've not been practising disaster medicine. We should still be able to [00:04:00] manage trauma appropriately and as the lockdown is eased a little bit in England, certainly from my experience attending the trauma meetings, the trauma is going up. So we're already starting to see more trauma come through.
Absolutely.
I think what I've noticed as well, the early senior input into decision-making and seven-day services have also really supported that. But the other thing that you really notice is the time required to manage these patients in the assumption that they're all COVID-positive.
Yeah.
So the first thing I think that's key to this in moving on is prioritization. So that joint colleges and NHSE produced the documents on prioritization, which gives an outline of the categories of patients, which should be thinking of. The 1A, 1B so the category four. And I think even in the difficult times we've had, we're still managing to cope with the tumours, [00:05:00] the infections, periprosthetic fractures. This type of service has continued, but now we should be starting to think about the level two and ultimately the level three patients.
So to start this, you really have to review your waiting list and classify and prioritize those patients. And you need to, you really need to speak to the patients because their idea of what they want from treatment will have changed and certainly it's my experience and experience from elsewhere in the UK that many patients will no longer want the surgery they've been listed for. And another group of patients want to delay until maybe it's safer to go ahead and they shouldn't be disadvantaged by simply being removed from waiting lists.
Yeah, absolutely. Absolutely, Prof.
In terms of the other guidelines that are out there, we [00:06:00] will come to a bit later though, do you think, you know, we talk about obviously our intensive care colleagues and we've had a podcast with the president of The BOA on this. Do you feel that those services are ready to restart these things as well at the moment? What's your feel for that so far?
Yeah, I think it varies from region to region. I work in the North West where we've been badly hit and we're not as far down the slope as London may be. So certainly from where I am discussing it with our anaesthetists and intensivists, this is some way off.
Yeah.
We can really develop those services. Again, where I work, we've got 700 staff are shielding or are isolating. And when you do want to start providing this type of service again, you need to increase numbers of nursing staff and you need the most experienced staff. So that's going to be a real challenge.
Absolutely. Absolutely.
I think with PPE again, [00:07:00] things are getting better for what we're doing now. But whether the supply can cope with the increase that you need, when you're going to start up on doing more planned surgery is another matter.
Sure.
Even just thinking about bed capacity, for example, you really need to at all possible to have single rooms or four bedside wards, you are probably going to only be able to get two patients in those to keep the distancing you require.
So I think we really do have to start thinking now about developing those green COVID-free pathways, but I think it's still early in terms of capacity. Capacity is going to be key.
Absolutely Prof. No, I agree. So you just touched on it a bit there, in terms of the guidance, it describes establishing these COVID-green or COVID-free and green pathways. And COVID-managed or blue pathways. Can you just sort of expand on that for our listeners and how the categorization of those facilities will be done or are suggested to be [00:08:00] done?
Yeah, I think we've got a sort of plethora of colors, which has led to quite a bit of confusion, I think. So that what we've stuck with as far as The BOA Guidance is concerned is that green and blue are used basically to describe pathways. They don't really describe facilities particularly, but it's the pathway you want to achieve in the facilities you have.
So a green pathway is one that is as COVID-free as you can possibly make it. And I think we have to accept that you can never make it 100% guaranteed COVID-free. There is always going to be a risk. So we could come to the plan of how you manage that perhaps later, in terms of individual patients experience of that, but you need your pre-op assessment, 14 days isolation, antigen testing, 48 hours pre-surgery, again, screening, surgery, early [00:09:00] discharge. The most dangerous period for these patients is immediately post-op so I think that we really should be recommending 14 days isolation post-op as well, so they don't get contact. So you really need to avoid contact with any COVID risk on any pathway you have.
The bigger challenge still I think, is developing a green team to operate your green pathway in terms of surgeons and all the other staff that are involved with it. And again, there's no real clear evidence on the safest or best way to do this so I think this is going to be difficult.
As you're setting up your green pathway you do have to remember that we are clearly, you know, most interested in the patient to staff and staff to patient transfer, but you have to remember we also have to still go out again staff to staff and patient to patient infection.
So you have to have [00:10:00] really good infection, prevention and control at the heart of everything we do. The blue pathway is essentially anything else. So this is where you have to manage your COVID risk.
The other colours that we mentioned in the documents are gold, silver and bronze. And these really come from some work being done in London. And these are essentially a way of trying to describe your facilities of what you have. So they vary from the gold level being a standalone hospital, that's completely separate from all of the healthcare facilities with completely cohorted staff. And that is probably your ideal situation, but that's not going to be everyone by a long, long way. So we have to also give advice here at the silver and bronze level as to how a district general hospital may be able to achieve that complete separation of pathways and facilities.
[00:11:00] No absolutely. I think it's interesting like you say the two things that sort of shout out to me there is in terms of, there's gonna be a great regional variation there in our ability to produce that but also our ability to have COVID-green and COVID-blue pathways for our staff with so many surgeons around the country having both trauma and elective practice, it's going to be quite a challenge that dont you think?
Yes, it certainly is. It's going to need to think about whole new ways of working. And I think the pandemic will be a drive to change how we provide elective care. And I think perhaps we should change it to planned or scheduled care as a way of describing it because elective care still has this sort of sign to it as though it's sort of optional. These are patients who are really struggling. So I think planned and scheduled is the way we should describe it.
Yeah, yeah, no, absolutely.
And we do have the girth methodology there to help us to try and drive best [00:12:00] practice and key to this at regional level is going to be development further of those hot cold split sites and that will make it easier also to achieve the blue-green split. And we've got to bear in mind that it's not just orthopaedic surgeons that want green pathways. All the other surgical specialties equally want green pathways to be sure that they are not operating on patients who are going to develop COVID in the post-op period.
Yeah.
So I think these changes will be some way off, they'll require very strong leadership at the regional level to achieve it. But this is an opportunity to try and change.
I agree Prof. If we just dive into that a bit more, if we move on to sort of just focusing on the planned surgery, you know, the sort of guidance states that we need to consider how non-urgent elective care will be delivered and like we've discussed, obviously there'll be these regional discussions and decision making required. Is there any advice on sort of the referral and the prioritization of those [00:13:00] planned patients at all?
Yeah. So while we've been in the present phases of the pandemic, many of the referrals have just stopped, either by design or just patients wanting to keep away. They've not gone away. They're still there. So we have really had to have two streams in place. You have to have one that continues with a clear pathway in for those patients with red flags for infection, tumours, severe sciatica, perhaps with neurological progression, and then other pathway for those non-urgent problems so that we get some idea of what the demand is going to be. And those still need to be triaged either by your enhanced role practitioners or by another senior decision maker who can make sure that flow is still going through.
But your prioritization needs to be at two levels when you're [00:14:00] starting to think about starting to tackle the category threes and maybe the category fours. First of all you have got your prioritization on the level of, is it a time critical condition? But the other absolute key is the individual risk of that patient based on their age and their comorbidities. And this, we have no clear scoring system yet to try and decide what is the right way to go. And although the patients who are in category three, who may be sick patients as well, in normal circumstances, you would want to get on and get going with your elective work. Realistically, you're probably going to be safer testing out your pathways on those patients who are younger and fitter to be sure that you have a system which is safe.
No, I think that's exactly, I mean, that's something we've actually thought about here in terms of actually [00:15:00] the lower risk patients are often those elective day case personal planned day-case patients. And you think there would be with their lower risk associated with A catching it and B the consequences of COVID. It probably is the safer way to go in some ways, isn't it?
Certainly thats our thoughts Andrew. That is the way we're going to go.
Absolutely.
In terms of, if we move on to that then Prof. For the elective patients, obviously this aim is to manage them at these green sites in a gold centre or facility centre as discussed in the guideline, but what will be the key sort of infection prevention and control measures for planned surgery at these sites? Considering I suppose the patients as we've already talked about, but also the staff as well.
Yeah. So from the patient point of view, I think we've already sort of alluded to it that you need to, first of all, select the right patient for surgery with a careful pre-op assessment, but also consent. And I think this [00:16:00] is going to be a complete change from how we've obtained consent before. There has to be a realistic discussion of the risks, particularly to older age groups who are undergoing reasonably major surgery arthroplasty or revision arthroplasty of what may happen if they develop COVID in the post-operative period. So you certainly would reassure them that the pathways develop this is as safe as possible, but if it should occur, then all the evidence would point to it still being very high risk. So I think we're all sort of horrified really by the results that came from China, where they operated on patients who were COVID positive and were looking at an overall sort of 20, 25% mortality rate. The COVID surge figures from across the world and more recently again, across all the specialties show it's actually pretty much the same. It seems as though those figures were accurate.
It does [00:17:00] doesn't it? Yeah, I agree.
So very difficult. In terms of next steps then I think it does have to be that 14 days isolation. And that will be a big ask because you have to imagine what it would be like in terms of trying to cut down contact with other family members who may have to go out to work. How do you separate from them? So it's going to be a challenge. We need good and accurate testing at 48 hours preop, but preferably not coming into hospital for it.
Then there are concerns about self-administered tests and how accurate those are and whether we have a system in place for community testing. So there's still work to be done. Anonymous admission, the usual screening that needs to go ahead at that time, surgery itself, enhanced recovery protocols, early discharge as quickly as possible, 14 days isolation, and [00:18:00] then remote self-guided rehabilitation and follow-up to avoid coming back to hospital, if at all possible.
As far as staff's concerned, I think this is a really big challenge for your average district general hospital. And there's no really good evidence-based answer to this, but I think you really need to avoid swapping green, blue in the same day, preferably doing blocks of a week at one site or the other. We are uncertain of the role of testing in this situation and how accurate that will be, but certainly daily screenings to go through the questions and temperature checks absolutely vital. And then eventually if we get a quicker, more quickly responding test and particularly antibody tests, then we may be able to move on a little bit further, but at present I think it is going to be quite difficult.
No, absolutely. And as you described Prof, there's a huge amount of sort of [00:19:00] infrastructure and planning required to that, but something which I think you've already mentioned already, which I think is really interesting is obviously the patient perspective for this cause do you get a feel, already you've alluded to it, you mentioned it already I know, but you know, how are patients going to perceive surgery now and how are we going to inform consent them appropriate in the new era with really so little data. I mean, I was just describing some coming through already, but it's going to be a difficult time, really, for both us in providing them with the necessary information but also not really knowing do all these patients still want their operations. It's difficult. Isn't it?
Yeah, no, you're absolutely right, Andrew. And I think from the conversations we've had, or I've had with patients, they really want to avoid coming in for surgery as it stands at present, unless they absolutely have to. And I think a lot of the images that we've seen, you know, through the media early on in this quite rightly were there [00:20:00] realistically to demonstrate, you know, just how bad this problem can be if the NHS gets overwhelmed. But we sort of have to change the message to some extent, I think now and that patient should feel that they can come to the NHS for orthopaedic surgery when they need it. But it's gonna take some time to get that reassurance in place.
The problem with consent is that we, you know, normally we have sort of figures that we can give. We can say what your post-op infection rates likely to be if you have a knee or hip replacement and you can even tailor it to some extent to your individual patient. You can give some idea of what the VTE risk is and what that may mean for the patient. But here we still are very uncertain and hopefully time will tell.
I think the key thing that comes out of that is that when we do get started with any of this planned work is to carefully audit [00:21:00] what happens and where we go with it. I think we cannot be flying blind into this. We really have to record what our outcomes are very accurately. And again, be part of one of the audit's COVID surge, for example would be ideal.
Definitely. Definitely. No. And if, just moving forward Prof, I think to the future, in terms... my first question, just before we go onto the final one, that penultimate one I suppose, is, you know, there's a lot of guidelines out there, there is obviously our BOA guidelines, we've talked about the anaesthetic intensivist guideline, there is the new guidance from NHS England. It can be a bit overwhelming in some ways, how do you feel that they all merged together? And do you think you've just got to take all that information and just take a region based approach? How would you advise our listeners for all that?
Yeah, I think firstly more, not particularly by design, but just by really looking at what's [00:22:00] necessary. Those three documents really come up with the same advice so that they're not conflicting in any way, which is clearly a good thing. The bottom line, I think for all of them is be cautious. This is a time for caution, not for getting carried away and it is going to take some time, I think, to really get started with anything approaching what we think of as being proper planned surgical practice.
There is wide variation across the regions. I know down in the Southwest, they've been minimally hit really in terms of their facilities. So the four SEs are probably all going to be there in their green zones. They will be ready to start. Certainly where I am and in the Northeast this seems some way off and I don't think we're anywhere close [00:23:00] to it yet. And I think what we should be doing now really is looking ahead to be able to plan it. So we plan it properly, use the time that we have before we can really get things set up to make sure it's done correctly. So you need to really know what the demand is from that group of patients that we have on our waiting lists. You need to develop a team dedicated to recovery of those services in your local hospital. And take your time to sort out that green pathway really do the walk through of which doors are they going to come in through when they're admitted to the surgery, where are they going to go? How do you keep away from the blue areas inside your hospital? And ensure that you're safe and ready to go - absolutely vital with all the other people who are involved with this. It really has to be a very close team approach to it.
And on the bigger scale, just use this [00:24:00] opportunity to start thinking about how you provide MSK services and particularly planned orthopaedic surgery on a bigger level, but again, I say, audit your outcomes, audit your outcomes. I think initially where we're looking at 50% productivity, I'm sure.
Yeah. Just to finish Prof. The difficult question. There is no easy answer I suppose. But do you have any feel, you know, from the discussions you have had, you have obviously discussed with a lot of people who've been involved with this. How long do you think it will take?
I think if we avoid a second surge, or at least we get the feeling that the prevalence in community is down at reasonable levels. For most places to get to the level where you're doing your category four cases. I think it's going to be September or October of this year. I think sooner than that for most regions is unlikely to happen.
[00:25:00] That's interesting. And like you say, I think it's a dynamic thing, isn't it? And we always have to be reflecting. If we do get a sudden surge, we have to be able to adapt. Do you think that's true?
Yeah. So you've got to bear everything you put in place, you unfortunately have to be prepared to dismantle again. And I think one of the aspects of running through this and it will be I'm sure worth a podcast of its own is the impact of these changes on training.
Absolutely. Absolutely.
This is going to be very, very difficult. It's going to be senior surgeons doing the operating, it needs to be speedy surgery and just taking every opportunity for the trainees is just going to be so important. Simulation into that, getting the most out of every operation a trainee does.
No, I totally agree, Prof.
I think that's all we have time for, but thank you so much for your excellent overview and insights today, Prof. That was really, really informative. And I really thank you for taking the time to join us today.
Thanks very much [00:26:00] Andrew. I enjoyed it.
And finally, as ever, we'd like to acknowledge and thank our many colleagues around the UK and across the world for their tireless ongoing efforts over the past few difficult months in the delivery of care to our patients during this pandemic. We at the journal thank you and we'll continue to support you in every way we can moving forward and stay safe and well, and thank you for listening.