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Are you torn between the clear and obvious productivity and strategy benefits of reduced distancing and that niggling feeling in your mind that 2m feels significantly safer than 1m? We are too – It is a balancing act; and understanding the scientific evidence and the mechanics of transmission can give you the power to make key, individualised decisions. This is not a one size fits all situation. What should you make of the social distancing rules?

Getting the evidence

When establishing government or organisational policy for something novel e.g. SARS-CoV-2, much of the guidance is initially based on anecdotal reports and expert opinion – rather than data derived. The scientific community also try to apply models for other similar established diseases – notably SARS (the original) and Influenza. Nevertheless, we are gathering more information every day and the statistics we base opinion on are becoming more and more robust.

‘Prevention is better than cure’

Transmission prevention guidance for all diseases is based on the specific disease’s ‘mode of transmission.’ For example; the famous “catch it, bin it, kill it” slogan is based around the respiratory large droplet spread for influenza. On the other hand, “Chlamydia – hard to say, easy to catch – use a condom” is the slogan used in this case, for obvious reasons.

CV-19 transmission theory

The initial assumptions made back in the early days of the pandemic were that contact with contaminated surfaces (fomites) and large droplets were the most significant causes of virus spreading. There are growing calls to acknowledge the greater importance of other airborne particles, and indeed the WHO finally has. Aerosols (much smaller airborne particles) are now thought to also be generated during respiratory secretions – (coughing, sneezing, breathing) as when the droplet evaporates/vaporises they become tiny INVISIBLE aerosols.

Why does this matter? Well, it matters because if we are only protecting against one mode of transmission – for example, stressing the importance of hand washing; and failing to protect against others, for example not socially distancing appropriately then organisations, and indeed the country, will inevitably run into trouble. We should be trying to mitigate against all modes of transmission, where possible, in a non-prohibitive, pragmatic but robust way.

There is a lot more to it than a simple distance. The virus does not just stop and drop at the 2m sign. In fact, if the conditions are right then aerosols can travel for tens of metres and linger in the air for many hours. Organisations must know what the conditions for transmission are like in their environments. For example – a board room with no windows, an air-conditioner that recycles the same air, face to face working, and heated conversation will be risky whatever distance you sit as the particles will linger in the air – so more must be considered.

Conclusion

There is far too much complexity to go into here – and the key message is – Do not rely on the blanket government guidance – it will cost you more in the long run as they inevitably shift their policy to play catch up. You need to analyse your individual environment and apply the science. Then you must make a rational, informed and evidence-based decision on how much risk mitigation you can do and the ways to do it. And if I am being honest – you should just contact us and we can help you out with it – it is what we are trained to do.

 

For more information on return-to-work readiness and preparedness speak to our team today to organise a free 30 minute consultation.

Original publication (click here). 

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.

Introduction – 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 2020.1 The virus initially spread within the Hubei province, where extensive containment measures including lockdowns have led to a decline in new cases.2,3 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 20,465.1 Around 4.4% of cases require hospitalisation and 30% of those require critical care,4 predominantly for mechanical ventilation.5

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 2020.6

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 cases7

 

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”,8 flexibility, teamwork and dynamic leadership are crucial.

This is not a time for the heroic NHS pace-setting leadership of old,9 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.9 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.9,10

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.9

 

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 trauma11 (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,12 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.

 

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.14 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.15,16

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.

 

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 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

The surgical workforce has a key role to play in the current crisis which requires adaptation and cooperation, write Emily A.H. Duggan, Alex C.G. Armstrong, Justin C.R. Wormald and Mark M. Mikhail

Summary: In December 2019 evidence of an emerging highly contagious and virulent pathogen began to surface. Since that time the world has been engulfed in a pandemic which has infected over 1.8 million people. This has drastic changes to our lifestyles and working practices. Surgeons must adapt and contribute to the current crisis as leaders. This article seeks to provide a review of current evidence and impact as well as crisis management plans that are being put in place nationally and internationally. The surgical workload is changing with elimination of elective work but there must be caution to not compromise emergency and cancer care. The Royal College of Surgeons and General Medical Council have given guidance on how surgeons can adapt and the key role workforce planning is playing. There are significant contributions that surgeons can make but they must ensure they are in the strongest position to make them.

The supportive treatment and ventilatory assistance that coronavirus patients require is not in the surgeon’s repertoire. Internationally the trend has been for hospital specialties to become more sub-specialised over the years with many studies showing patient outcomes are significantly improved when surgical patients are managed in a shared care model. Demonstrated in Trauma and Orthopaedics where there has been a dramatic growth in the subspecialty of orthogeriatrics. Guidelines on the management of medical conditions memorised during formative years are unlikely to have remained best practice. As such, surgical colleagues are realising and must openly publicise their shortcomings as well as their skills.

The Royal College of Surgeons has stated that the “overarching principles” for the NHS and the nation to get through the current pandemic are:

i) To triage and deliver healthcare to patients for maximal benefit, as in a mass casualty scenario.

ii) To protect and preserve the surgical workforce.

Managing key services (emergencies and cancer)

Emergency and trauma surgery as well as oncology must continue during any time of crisis. Although not unexpected, it is well documented that key services decline in times of national crisis eg war. During the West African ebola crisis many more people died of malaria than ebola as a result of the diversion of resources. Manpower reduction (surgical and administrative), missed appointments, cancelled operating lists and bed shortages are causing barriers to maintaining a good service. A more flexible approach is needed that allows patients to look after dependants, ensure a safe place to recover and be able to travel to and from the hospital safely.

In order to reduce hospital footfall outpatient appointments are restricted to those that are deemed essential, all others are cancelled or held remotely.

Operative Management

Surgical decisions are being altered, where required, to reduce the burden on critical care, outpatients and primary care. Non-essential operations are being postponed, or non-surgical management options considered. Examples include fashioning a stoma rather than primary anastomosis to reduce risk of requiring a post-operative critical care bed; increasing trials of conservative management of fractures or ligamentous injuries; utilising absorbable sutures for wound closure. Patients are being empowered to change their own dressings and contact the particular service only in the event of an issue arising. These are, at times, uncomfortable decisions for health professions, but needed from surgical leaders at this time.

Elective Work

In the UK the halt of elective work has been mandated within the NHS. Private hospitals have been asked to “donate” their hospital bed capacity to the NHS crisis – with the assurance that the bed, resource and staff usage will be paid at cost price. This is a better commercial position for private hospitals to be in rather than empty wards but will pose problems when starting back up again.

Managing the Team

The Royal College of Surgeons has advised on the priorities that surgical departments should adhere to. There are circumstances where these priorities are achieved with a surplus of time, staff or both. In these circumstances the advice is that individuals should fulfil alternate surgical roles or, if these are already covered, alternate non-surgical roles.

This change in working practices, which may require individuals to work outside of their regular comfort zone, scope of practice and even specialty is troubling to many surgeons should their actions and decisions be called into question in the future. The General Medical Council has released a statement recognising these concerns and confirming that in cases where issues are raised in these challenging circumstances, each case will be considered on an individual basis.

In order for any team to contribute in a meaningful way during a time of crisis, it needs to be in good health, well prepared and present in maximum numbers. One in four NHS doctors are currently off work. In this regard, a major priority and responsibility rests on individuals to try, where they can, to remain well. This means dividing departments and partially deploying employees to keep a healthy staff “reserve”.

Supporting colleagues

The skillset that makes a good surgeon is broader than a good technician. Contributing may be as simple as deploying to the Emergency Department to triage and manage minor injuries. Medical teams are facing an influx of patients and are overwhelmed in a swathe of information and increased duties. Practical help may involve manning phones, contacting patient relatives and even breaking bad news.

Senior surgeons are often respected by their juniors and this is a weight of responsibility in the midst of “fake news” and disinformation. There are many unknowns and all of the modelling we are basing decisions and opinions on is estimation. Many colleagues are joining the workforce, having just finished medical school. As leaders it is a responsibility to project calm and be choice with words and support.

Managing the Fallout

As we emerge from the crisis, a mammoth and complex task of “catch-up” will be ahead. The projected number of cancelled elective procedures is unclear. In the third quarter of 2019 over 2 million elective operations were scheduled and we were already behind target. How and when these operations are allocated will need careful planning and new targets. Many patients’ presenting conditions and co-morbidities will have worsened potentially to inoperable disease; investigations may need repeating. Missed cases will need to be identified and managed. It is during this time, after the panic and dystopian reality has subsided, that the current public support for healthcare professionals internationally may waiver. This influx of elective work may see a boom in the private sector as the NHS struggles to fulfil new targets.

With health systems around the globe in crisis there is innovation occurring in days that has previously taken years. Changes in practice that outlast the pandemic, such as a reduction in follow-up outpatient appointments, will reduce the pressure the health service experiences in normal circumstances. Telemedicine will strengthen its foothold, resulting in improving patient convenience and specialist accessibility. With much of the outpatient delivery of healthcare put on hold or managed remotely there may well be a paradigm shift in patient expectations. More patients may be willing to be educated on their disease and their post-operative course. More importantly, if there is a sustained cohesion and cooperation between specialties, departments and people this could profoundly improve work morale and patient outcomes moving forward. Surgeons should be at the forefront of these changes.

Key Messages

  • The surgical workforce has a key role to play in the current crisis which requires adaptation and cooperation.
  • Emergencies, trauma and oncological surgery must continue with as little disruption as possible, but with vital and considered changes in delivery.
  • Healthcare will not be the same again after the pandemic passes; there will be positives that can be applied for the betterment of the NHS

References and authorship. 

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