This study shows that in a short space of time there was a rapid reorganisation of hand surgery services. As services start to return to the ‘next’ normal, they will need to consider what, if any, changes will be kept and what further adaptations are needed to meet new challenges, such as increased elective waiting lists8. With less than 10% of surveyed units providing an elective service during the initial wave of the pandemic, the backlog of chronic hand conditions and untreated traumatic injuries is likely to represent a substantial burden to health services.
There was a rapid change to remote delivery of care. This was delivered throughout the patient journey from initial triaging of referrals, assessment of the injury and subsequent hand therapy and follow-up. NHS England provided initial guidance on the management of remote consultations and working early in the pandemic9. Whilst there was support for this change in the comments, it will not be suitable for all circumstances. Challenges include IT literacy, access for patients and misdiagnoses. Virtual management of fracture clinics and remote consultations in hand surgery were established in the UK pre-pandemic, but there is limited previous literature10–12. It is likely that better electronic patient information is needed to support this change and research into the effect of remote consultations on patient care and satisfaction.
There was a move towards performing surgery under WALANT before the pandemic for both elective and trauma hand surgery13,14. This appears to have accelerated and was adopted for a broad range of procedures, particularly tendon injuries. There is currently a systematic review ongoing to assess outcomes of flexor tendon injuries when repaired under WALANT compared to regional or general anaesthesia15. WALANT was particularly well suited for the pandemic as it allowed procedures to move out of the main operating theatres and avoid the need for an anaesthetic team, who were largely redeployed to intensive care. Concerns were raised around patient choice for anaesthetic, the additional time taken to inject patients with LA, and quality of the bloodless field. The preferred anaesthesia type for phalangeal and metacarpal fracture fixation moved from general anaesthesia to regional. These would be the next procedures to be increasingly performed under WALANT and has been reported in the literature16,17.
There was a reduction in the use of main operating theatres and increased use of minor operating theatres and clinic rooms. The available evidence suggests that outpatient operating is safe and does not increase the risk of infection18 but it remains uncertain owing to a lack of high quality research. Recommendations have been produced on the minimum facilities required to carry out minor surgical procedures; a naturally ventilated room with easily cleaned surfaces and scrub-up facilities is sufficient19. Further studies are important to establish the infection rate following procedures in outpatient settings.
Changes were often more economically and environmentally sustainable. Delivery of care can be in low-cost settings and potentially delivered closer to patients’ homes. Fewer trips to hospital by both healthcare workers and patients reduce the carbon footprint of services20. Use of WALANT and an outpatient setting consumes significantly fewer resources than a general anaesthesia in main operating theatre, as well as reducing the carbon emissions from the use of anaesthetic gases21–23. There was a move from the use of paper leaflets towards electronic patient information or trust produced leaflets sent via email. Sustainability in Surgery is a current focus for the Royal College of Surgeons of England24.
Many of the changes challenged and accelerated the move away from established dogma. Whilst the safety of LA with adrenaline is well established in hand surgery across the world, it has not necessarily been widely adopted. The British National Formulary still states it should be avoided in digits and anecdotally, medical schools continue to teach this25,26. A recent Cochrane review concluded that further research was needed27.
Absorbable sutures in hand trauma are safe and reduce the need for follow-up28,29. Selected patients can safely perform their own follow-up. Skin cancer patients are already taking increasing responsibility for their own healthcare and show preference for patient-led surveillance and fewer scheduled clinic visits30. NHS England is supporting providers to roll out patient-initiated follow-up moving forward31.
At least three quarters of the units reported providing antibiotics for simple open hand wounds, at least until definitive treatment. The routine use of antibiotics has not been shown to reduce the infection rate in simple hand wounds requiring surgery32,33 and BSSH does not recommend their use in these injuries34. Antibiotic stewardship must be addressed by units and individuals, to reduce the risk of antimicrobial resistance.
Two previous surveys have examined the impact of COVID-19 on hand surgery worldwide35,36. An initial survey early in the pandemic, carried out in March 2020, showed that the majority of surgeons had already modified their practice; many had stopped elective operations, were performing surgeries in a smaller operating theatre than normal and managing more cases conservatively35. Our survey suggests that these changes were reflected in the UK and Europe and continued throughout the first wave. A survey by the Kleinert Society of members, with responses predominantly from the USA, covered a similar time period in the first COVID-19 wave to our survey. It showed similar reduced clinic and elective surgery volumes36. However, contrary to our findings, telemedicine was not widely used and felt to have multiple drawbacks.
The limitations of this study include those associated with surveys, specifically reporting and selection bias. The service evaluation performed at the same time should corroborate the findings. There was also a predominance of responses from the UK.
Through necessity rapid changes were made to service delivery. Understandably, there was little patient involvement or rigorous evaluation of the changes. Now is the time to formally engage patients and the public in service redesign and assess the clinical effectiveness of new approaches to delivering care.