Trauma Care During the COVID-19 Pandemic: A Canadian Survey

Purpose: The coronavirus disease 2019 (COVID-19) pandemic has placed major limitations on trauma health care systems. This survey aims to identify how Canadian trauma centres altered their processes to care for injured patients and protect their staff during the pandemic. Methods: A survey was distributed to trauma directors at level 1 Canadian adult trauma centres in July 2020. Questions included changes made to the trauma service in preparation for the pandemic, modification to clinical practice and expected lasting modifications after the pandemic. Results: The response rate was 68.4%. All trauma centres modified their treatment and investigation protocols for the pandemic. Most respondents adopted online platforms for meetings and educational activities and used simulation to prepare for COVID-19-infected trauma patients. The approach to who would intubate trauma patients, which trauma patients should be tested for COVID-19 and who should use N95 ventilators, varied among the sites surveyed. Conclusion: All centres modified some of their treatment and investigation protocols for the pandemic but not all modifications were adopted universally. Knowing these steps and comparing them with other global centres will help organize disaster plans for the current and future pandemics.

How Translators Affect the Experience and Healthcare of Primary Spanish-Speaking Patients in the Trauma Department

Background and Objective: The trauma bay is a fast-paced environment where comprehension of medical jargon is difficult even for native English-speaking patients. For Spanish-speaking patients, the presence, and use of the translating tools in hospitals may change the course and/or quality of their care, especially in a trauma setting. Our objective was to gather information and perspectives of Spanish-speaking patients in the trauma bay and subsequent hospitalization. This pilot study determined if there were constant themes. Methods: In this pilot qualitative study, we successfully recruited three adult primary Spanish-speaking patients admitted to the trauma service for at least twenty-four hours in July 2021 at an urban academic level I trauma center. Spanish only in-person semi-structured interviews were used to gather patient’s perspectives, with data supplemented from electronic health records and trauma registries. The interview was transcribed in Spanish, translated to English, coded, and analyzed using thematic analysis. Results: Although recruitment occurred at both hospitals, this study includes only three patients admitted at IU Health Methodist. All three were males aged 22-37 years from Latin America. Blunt injuries occurred in two with injury severity scores (ISS) ranging from 5-11 while the third had penetrating injuries with an ISS of 10. Several themes have emerged. All patients felt they did not have autonomy or empowerment in their care. It was found that the healthcare team decided who received a translator. Two of the patients had a lack of understanding in their traumatic injuries. One patient relied on his partner for translating, even though a translator was provided. Conclusions: These results suggest that Spanish-speaking trauma patients lack autonomy, empowerment, and understanding their medical conditions. Further interviews need to be conducted in order to strengthen the perspective of a Spanish-speaking trauma patient’s care.

P-EGS12 An observational study investigating the differences the COVID-19 Pandemic had on admissions, methods of injury in a tertiary trauma centre in a major UK City

Background During March 2020 the country was plunged into a nationwide lockdown. Despite this, there remained a steady stream of trauma admissions. COVID changed a lot about how many medical specialties worked and we wanted to explore the effects on our patient population, and compare it to the experience of other hospitals. Methods We analysed existing data on admissions to the Emergency Department that were referred to the trauma service between the 12th of March to the 24th of May; encompassing the lockdown and the two weeks either side. This data was compared to that of the year beforehand. We compared ages, sexes, mortality, methods of injury, and disposition. Results Admissions fell, 193, compared to 271 (∼3:1 M:F). Both cohorts featured more younger people, but there was a drop-off in the number of older folk post-COVID; 6 of 9 centiles of the over 60s showed a fall in admissions of at least 14%. Those admitted to the Major Trauma service (ISS 9+) remained the same. Regarding the methods of injury, the most common presentations remained road traffic accidents, stabbings and falls <1m, contributing to 71 and 72% total admissions before and after COVID respectively. However, there were fewer patients falling from heights of > 2m (OR 0.5), and fewer recorded assaults (OR 4.0). Penetrating injuries were separated into “stabbings” and “others”. There was a significant increase in non-stabbing penetrating injuries (OR 4.6), a majority of which were self-inflicted. The rate of self harm during the lockdown showed a similar increase, from featuring in 8% of total presentations to 15% of admissions (OR 1.87). The hospital restructured considerably between the sample dates such that dispositions are not possible to compare meaningfully. Rates of patients sent straight home from the ED were similar (OR 1.0). Conclusions Overall, the lockdown had a moderate impact on patient numbers and demography. The data implies that the measures did small amounts to deter people from the roads and from interacting with each other in assaults and stabbings. Older people were less likely to present traumatically. The isolation may have led to a masking of mental health issues leading to a significant increase in self harm, which may present opportunities for restructuring of services in any the event of further major lockdowns. These conclusions are limited by the data, and next steps would include gathering more detailed mortality data.

Influence of a Stay-At-Home Order on Trauma Volume and Injury Patterns at a Level I Trauma Center in Ohio

Background Changes in injury patterns during the COVID pandemic have been reported in other states. The objective was to explore changes to trauma service volume and admission characteristics at a trauma center in northeast Ohio during a stay-at-home order (SAHO) and compare the 2020 data to historic trauma census data. Methods Retrospective chart review of adult trauma patients admitted to a level I trauma center in northeast Ohio. Trauma admissions from January 21 to July 21, 2020 (COVID period) were compared to date-matched cohorts of trauma admissions from 2018 to 2019 (historic period). The COVID period was further categorized as pre-SAHO, active-SAHO, and post-SAHO. Results The SAHO was associated with a reduction in trauma center admissions that increased after the SAHO ( P = .0033). Only outdoor recreational vehicle (ORV) injuries ( P = .0221) and self-inflicted hanging ( P = .0028) mechanisms were increased during the COVID period and had substantial effect sizes. Glasgow Coma Scores were lower during the COVID period ( P = .0286) with a negligible effect size. Violence-related injuries, injury severity, mortality, and admission characteristics including alcohol and drug testing and positivity were similar in the COVID and historic periods. Discussion The SAHO resulted in a temporary decrease in trauma center admissions. Although ORV and hanging mechanisms were increased, other mechanisms such as alcohol and toxicology proportions, injury severity, length of stay, and mortality were unchanged.

SP9.1.9 Are Tertiary Trauma Surveys a worthwhile use of time and resource?

Introduction Patients sustaining major trauma undergo primary and secondary surveys in the emergency department to rapidly identify and treat injuries. Tertiary trauma surveys (TTS) are performed once the patient has been stabilised, within 24 hours of admission, to assess for further injuries. In December 2019, the major trauma service at our trauma centre was reconfigured to include a larger clinical team. Following this, we have assessed compliance with TTS completion and rate of new injuries identified. Methods Data was prospectively collected via hospital and TARN databases from 100 consecutive major trauma patients admitted over a two-month period from 1/8/20. Demographic data and key measures including, date and time of arrival to the hospital, date and time of TTS, performing clinician, injuries identified, mechanism of injury and ISS were collected. Results TTS was completed on 79/100 patients during their admission with 16.5% (13/79) of TTS performed identifying at least one additional injury. 18 separate injuries were identified which were categorized by AIS score: 22.2% AIS 1, 61.1% AIS 2 and 16.7% AIS 3. Of these injuries, 17/18 required further imaging and 3 required operative management. In 38.5% (5/13) of cases, the additional injuries increased the patients overall ISS. Conclusion This data demonstrates the importance of tertiary survey completion to ensure that all injuries sustained during major trauma are identified and treated promptly. Further development of this project will include expansion to a larger data set over a prolonged period to further evaluate the rate and significance of injuries discovered via TTS.

Management Issues with Infection Control during Trauma Resuscitation in the Era of COVID-19: South African Experience.

Background: This invited short report aims to document the management of trauma and nontrauma ICU patients in one quaternary facility in South Africa during the first two waves of the SARS CoV2 (Covid-19) pandemic in Kwa Zulu-Natal. Content: The setting of the trauma service and the changes made to ensure staff and patient safety are detailed. A brief overview of the clinical experience of caring for both trauma and non-trauma cases is provided along with the management of those cases who were found to be Covid-19 positive. The concerning aspect of increased antibiotic resistance development and the potential roles of antiseptic sanitisers is briefly discussed. Conclusion: Trauma care is essential during the infectious pandemic and there is a risk of increased antibiotic resistance. Doing the basics “right” can prevent staff contamination or adverse patient outcomes. Bangladesh Journal of Medical Science Vol.20(5) 2021 p.72-76

713 Wide-Awake Local Anaesthesia No Tourniquet (WALANT) Procedures During COVID-19: A Single Centre Experience

Aim WALANT procedures are becoming more popular and are particularly useful in the COVID-19 pandemic. Procedures can be performed without needing access to general theatres and anaesthetic support, minimising the number of patient-healthcare interactions and avoiding aerosolisation. Our unit has taken this approach and aim to present a case series that demonstrates the efficacy and safety of WALANT. Method A retrospective analysis of WALANT cases in a single plastic surgery centre during March-August 2020 was performed. All procedures using a WALANT approach were included, that would have otherwise required general anaesthetic or regional block. Data was collected on a number of variables, including patient satisfaction. Results 37 procedures were included in analysis. The majority of the injuries consisted of hand trauma. There were no cases of post-operative complications, although one required completion in main theatres due to technicality. No patients required additional anaesthetic during the procedure and all reported pain score as 0/10. Overall patient satisfaction was 10/10 for 26 patients, 9/10 for 10 patients and 7/10 for one patient. Conclusions Results show the use of WALANT can facilitate an effective plastic surgery trauma service during COVID-19. Most of the procedures were performed in the outpatient department setting, without the need for main operating theatres or anaesthetic support. All procedures were performed within 24 hours of initial presentation and were able to be discharged on the same day. In addition, patient satisfaction remained high and post-operative complications were minimal. We propose that the use of WALANT should continue and increase beyond the current pandemic.

1403 Leadership and Teamwork in The Major Trauma Service – Implementation of A New Approach to Secondary Surveys

Aim Trauma Audit and Research Network (TARN) guidelines at a Major Trauma Centre in Northern Ireland state that all patients admitted with Major Trauma should have a secondary survey completed and documented within 24 hours of admission. Method All patients admitted with major trauma had their medical notes reviewed on discharge to look for evidence of a documented secondary survey. Two audit cycles were completed. The first from January 2018 to April 2018 (n = 38). Following a quality improvement project with specific interventions to improve compliance, including improved communication behaviours and the implementation of a revised trauma booklet, a second cycle was performed from October 2019 to January 2019 (n = 44) Results 58% of group 1 and 75% of group 2 had a documented secondary survey within 24 hours of admission. The interventions therefore resulted in an overall 17% increase in the number of secondary surveys completed within 24 hours. Patients admitted under Orthopaedic care had a significant improvement of 26% between cycles to 89% compliance. Cardiothoracics (33% to 40%), Neurosurgery (14% to 43%) and General Surgery (75% to 66%). Conclusions A quality improvement drive led by the Orthopaedic team involving the education of doctors, improving communication channels and the introduction of revised trauma documentation, resulted in a significant increase in the number of secondary surveys completed within 24 hours. Patients under the care of Orthopaedics were more likely to have a survey completed compared with other specialties. This highlights the need for more education and engagement of other specialities to increase compliance in secondary surveys.

1394 Operation Notes Performa: The Way to Optimise Hand Trauma Service

Aim To assess the effect of the introduction of British Society for Surgery of the Hand (BSSH) guided operation note Performa on the hand trauma service in St. George’s University Hospitals. Method First cycle was done in October 2019. This included retrospective evaluation of accuracy of documentation for closed hand fracture audit. Reassessment was done in September 2020 after introduction of surgical Performa guided by the latest BSSH guidelines. Results 27 patients have been included in the first cycle compared with 81 patients in the second cycle. While 82% of first cycle patients underwent operation, only 40% of second cycle patients were treated surgically. Overall documentation has improved by a mean of 40% in all parameters. This includes documentation of discussion of shared decision making regarding conservative and surgical management, documentation of level of competency of the operating surgeon and mobilisation advice given to patients before their first appointment with a hand therapist. This led to improvement in overall patient outcome including rate of infection falling from 14% to 1% and reoperation rate from 23% to 1%. Conclusions Op notes Performa is a useful tool in the armamentarium of hand trauma management. It helps junior trainees to memorise critical information to document especially in the ones usually missed like detailed post-operative advice.

1465 Anaesthetic Preferences in a Tertiary Hand Surgery Unit & Aetiology of Hand Trauma Presentations During the First UK lockdown: Lessons for the Future

Introduction Our tertiary plastics unit serves a 4.3 million population in the South East, providing a seven-day hand trauma service. Our aim was to assess differences in quantity and aetiology of hand trauma during the April 2020 lockdown compared with the equivalent period in 2019, and our ability to reduce risk by carrying out more procedures under local anaesthetic. Method Retrospective notes review for hand trauma surgery patients in April 2020 (3 weeks in first UK lockdown), with a comparative period in April 2019. Fisher’s Exact Test was applied to assess for difference in method of anaesthetia, injury location (workplace vs home) and DIY versus non-DIY aetiology. Results 2020 group: n = 165. 2019: n = 239. (31% reduction). Mean age 45 during lockdown vs 49 in 2019. There was significant reduction in the proportion of workplace injuries in 2020 (22% vs 29%), but the proportion of power tool injuries was similar (31.6% 2020 vs 26.6%). DIY injuries increased significantly (33.5% versus 9.2%). Use of local anaeshesia including increased significantly in our unit (84.2% vs 66.1% 2019) with reduction in use of regional and general anaesthesia. Conclusions Caseload somewhat reduced during lockdown. Fewer injuries occurred in the workplace. Our unit made good use of local anaesthetic techniques to avoid regional anaesthesia (and risk of need for GA conversion) wherever possible. Public safety warnings existed (BAPRAS and BSSH), but perhaps were less publicly available than desirable. Improving awareness further could reduce trauma surgery burden as we enter a third wave of the pandemic.