In the initial phase of rapid change, this juxtaposition of conflicting advice (central vs on-the-ground) was difficult to manage and presented a major source of anxiety. The importance of clear, well considered, centrally driven directives cannot be overstated in any crisis and hospital leadership consistently struggled to support guidance from governing bodies with the real-time feedback from clinicians at ground level. This was amplified by local variations of how guidelines were interpreted, something that often did not resonate with front-line clinicians. These constantly shifting sands made it difficult for clinicians to remain up-to-date and well informed. Guidance was provided/updated on a daily and sometimes hourly basis, giving steer on everything from clinical decision-making, risk stratification and use of personal protective equipment (PPE). Top–down communicationĭuring the first weeks of the pandemic there was a deluge of information from a variety of governing bodies, which was often inconsistent and prompted confusion. However, the emerging situation enabled instigation of new modes of communication that would previously have seemed too disruptive to apply and embed. The traditional morning trauma meeting remained pivotal to the efficient and coordinated delivery of reconfigured services. Overall, social lockdown measures dramatically reduced trauma numbers allowing safe, effective major (and minor) trauma services to be maintained despite resource limitations. Despite delayed introduction, the availability of COVID-19 testing for staff and family numbers made a positive impact on staff retention, although the lack of test reliability has subsequently eroded this confidence. The actual staff sickness rate was much lower than expected and was, on average, closer to 10% at any given time. They provided off-site support in terms of rota co-ordination, communication with satellite hospitals and virtual out-patient consultations, a critical part of shutting down elective services. Colleagues considered ‘high risk’ due to medical co-morbidities who had been advised to stay away from patient-facing duties were well-utilised. High infection rates within healthcare highlighted the vulnerability of the workforce. It also allowed movement between teams in the event of staff absence, along with recovery time after periods of deployment. ![]() Smaller teams allowed agile, senior led responses, particularly in the polytrauma situation. Senior leaders were then allowed to focus on strategic responsibilities. Daily managerial and clinical decision-making could be shared among highly visible and readily available leaders at ground level. The workforce was reorganised into smaller teams each with designated leaders and with a full spectrum of subspecialties represented (pelvis, upper/lower-limb etc.). There were many common themes between centres and, as ever, high-level leadership and clear communication were often the hardest elements to get right. We anticipated that up to 30% of our workforce may be infected and confined to self-isolation at any given time. Each centre adapted individually but the problems faced were identical continuing to provide high quality sub-specialist orthopaedic and trauma care on the unstable platform of inevitable staff illness, redeployment and concerns around safety. Reconfiguration of the trauma service was the first critical element. ![]() In this article we reflect on the changes introduced and the lessons learned at London’s four Level-1 Major Trauma Centres, in maintaining a reduced but functional service for trauma and urgent musculoskeletal pathology, in the midst of the COVID-19 pandemic. Very few aspects of the patient journey or health workers’ roles have remained unaffected but many of the adaptations have already become established practice, with transformative service change emerging. The resulting reconfiguration has had dramatic effects on normal healthcare provision. Major operational changes increased capacity for medical and intensive care while downscaling capacity for major trauma-the polar opposite response to the mass casualty scenario that we prepare for. Recently, this traditional model of the ‘major incident’ has been redefined, with trauma services becoming marginalised to prioritise treatment for patients with viral pneumonia. London is unfortunately accustomed to terrorist attacks, triggering short-lived mass-casualty major incidents where all resources are directed towards the provision of trauma care. Although major incident protocols are well-rehearsed at Level-1 MTCs, the challenges posed by COVID-19 have been very different. These 4 hospitals were the first in the UK to admit large numbers of seriously ill patients affected by COVID-19 infections. ![]() London’s population of approximately 9 M is served by 4 Level-1 Major Trauma Centres (MTCs) with surrounding trauma networks of Level-2 community centres.
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