Abstract
Background
Due to the devastating and far-reaching impact of the novel COVID-19 pandemic, hospital resources have been redirected to protect patients and health care staff, thereby vastly reducing the capacity for outpatient follow-up within a busy Plastic Surgery and Hand Trauma center. Through the use of telephone and video technology, virtual clinics were rapidly introduced to reduce hospital footfall.
Methods
This retrospective cohort study analyzed patient experiences in virtual and traditional face-to-face clinics through the month of April 2020, from the second week of the government-imposed lockdown. A 5-point Visit-Specific Satisfaction Questionnaire was used to subsequently collect patients’ feedback regarding their appointments.
Results
A total of 107 hand injury–related follow-up appointments were recorded during the 4-week period. Sixty (56.0%) appointments were performed as a virtual consultation, and 47 (43.9%) face-to-face consultations were carried out on site. It was possible to discharge 43.3% from the virtual clinic group and 57.4% from the face-to-face group. We identified no significant difference in patient satisfaction (P = .368, Mann-Whitney U test) between the 2 cohorts.
Conclusion
Virtual clinics appear to be safe and effective for the follow-up of patients with traumatic hand injuries during the COVID-19 pandemic. This approach may prove beneficial in terms of workforce organization, reducing waiting times, and providing an alternative for patients unable to attend physical appointments.
Introduction
The coronavirus SARS-CoV-2 (COVID-19) was declared a pandemic on March 11, 2020, by the World Health Organization. 1 By May 15, more than 30 000 deaths were reported within the United Kingdom and more than 300 000 deaths globally. 2 In attempts to curtail the spread of the virus and its impact on communities, the UK government promoted social distancing by imposing restrictions to work and social interactions across the country.3,4 The National Health Service (NHS) was forced to adapt to cater for the increasing pressure on intensive care capacity, due to a proportion of patients severely affected by SARS-CoV-2 requiring long-term ventilatory support. 5 Hospitals in London responded by increasing intensive care unit capacity by over 30% to accommodate the increased demand. 6 By redirecting hospital resources and bolstering efforts to protect patients and health care professionals, the protocols regarding the treatment of non-COVID-19 conditions were drastically modified. The vast majority of elective surgical procedures were postponed, and facilities catering to emergency and trauma care were reduced.7-9
Surgery for traumatic hand injuries has been significantly affected. Although there has been a reduction in the overall volume of cases, this has been offset by a reduction in staffing and operating capacity. The types of trauma injuries referred to Plastic Surgery departments have shifted, with an increase in household trauma and do-it-yourself (DIY) injuries (while undertaking DIY manual work such as building renovations), in comparison with workplace trauma. 10 The Royal London Hospital Plastic Surgery department serves one of the busiest major trauma centers (MTCs) in Europe while also accepting referrals from 4 other regional hospitals, within Barts Health NHS Trust. Typically more than 1000 hand trauma operations are performed per year, with injuries ranging from closed phalangeal and metacarpal fractures, to tendon injuries and mangled hands. Following fracture fixation, patients are followed up for 1 week postoperatively for a repeat radiograph and again 3 to 4 weeks postoperatively for removal of wires in clinic in cases with Kirschner wire (K-wire) fixation. Soft tissue injuries are reviewed by the hand therapists 3 to 5 days postoperatively and are reviewed by the surgical team 6 weeks postoperatively. With such an immense volume of cases, it was imperative to streamline the service to avoid delays in surgery and follow-up appointments.
Despite the huge impact of the COVID-19 pandemic, one of the greatest successes stems from the implementation of virtual clinics (VCs). Carried out via telephone or through video consultations, recent research has shown that this digital approach to patient appointments is both safe and effective.11-13 In accordance with the British Society for Surgery of the Hand and British Association of Plastic, Reconstructive and Aesthetic Surgeons updated guidelines,14,15 to reduce the necessity for face-to-face (F2F) hospital visits and follow-up appointments for patients with hand trauma, a significant proportion of urgent elective and trauma follow-up clinics were undertaken virtually.
In this study, we aim to evaluate the use of these VCs for the follow-up of hand trauma cases and develop a protocol for their potential implementation in the new societal landscape following the COVID-19 pandemic. Our primary objectives were to assess patient satisfaction and to compare the outcomes following follow-up appointments between VC and F2F clinic types. To the best of our knowledge, this is the first study assessing the potential use of VCs in hand trauma.
Methods
Our sample population for this study included all patients with hand trauma, presenting to the Royal London Hospital MTC for a follow-up appointment in the month of April 2020. This period began from the second week of the government-enforced lockdown.3,4 The patients were allocated to 2 distinct groups, with the control group attending a F2F clinic appointment and the intervention group participating in a VC. Those requiring a physical intervention, such as the removal of K-wires, were automatically assigned a F2F consultation. Patients deemed safe for VC review alone were sent a text message with the time and a link to the consultation, 48 hours before their appointment. They then received a second text message as a reminder on the day.
Institutional approval was gained prior to commencing the study. For both groups, patient satisfaction was assessed using the 9-item Visit-Specific Satisfaction Questionnaire (VSQ) with a 5-point Likert-type response. The VSQ is a validated scale created by the American Medical Group Association as part of an adaptation to the Visit Rating Questionnaire used in the Medical Outcomes study. 16 An overall VSQ score per patient was calculated by assigning the values 1 to 5 to the options poor, fair, good, very good, and excellent, respectively, before summing the total. Further data regarding age, sex, operation, diagnosis, reason for follow-up, outcome, and time to follow-up were all recorded and analyzed.
For statistical analysis, the Shapiro-Wilk test was performed to assess normality, before a Mann-Whitney U test was used with the total VSQ scores to evaluate statistical significance.
Results
Patient Cohort
A total of 107 hand injury–related appointments were recorded during the 4-week period. Table 1 displays the patient demographics and the purpose of their appointments.
Patient Demographics and Reasons for Review.
Sixty appointments were performed as a virtual consultation, consisting of 70% telephone (n = 37) and 30% video appointments (n = 16). Forty-seven F2F consultations were carried out on site. In all, 43.3% of the virtual consultations (n = 26) resulted in the discharge of the patient, compared with 57.4% of the F2F appointments (n = 27). Patients who were reviewed over video conferencing were almost twice as likely to be discharged (62.5%) when compared with those having only a telephone consultation (35.7%). In total, 11.7% of patients (n = 7) could not be contacted for their virtual appointment, despite a minimum of 3 attempts spread across the time frame for the session, whereas 17.0% did not attend or canceled their F2F appointment (n = 8).
Purpose of Review
The reasons for follow-up ranged from previous tendon and digital nerve repairs to fractures managed operatively and nonoperatively. Table 2 shows the types of injuries and postoperative cases that were reviewed within each clinic modality. Most VC appointments served as a 6-week follow-up for soft tissue injuries that had been treated by hand therapists postoperatively. Conversely, F2F consultations largely consisted of 1-week postoperative follow-ups after fracture fixation and 4-week appointments for removal of K-wires. Only 23.3% of the appointments (n = 14) in the VC group dealt with patients who previously required K-wires, compared with the 59.6% (n = 28) recorded in the F2F consultation group. Conversely, VCs had a greater proportion of tendon and nerve injuries compared with F2F clinic: 29% and 6%, respectively.
Injuries and Operations, by Clinic Modality.
ORIF = open reduction internal fixation.
Patient Satisfaction
Patients were contacted by telephone and asked to complete the Visit Rating Questionnaire following their appointment. Patients who canceled or did not attend their clinic appointments were not contacted for a satisfaction questionnaire as all questions were deemed irrelevant to this minority subgroup of patients (14.0%). We have therefore excluded these patients from the Patient Satisfaction analysis.
We obtained a 61.7% (n = 37, VCs) and 75.6% (n = 31, F2F clinics) response rate, respectively. The remaining patients were not contactable by telephone or declined to participate in the questionnaire, despite a minimum of 4 attempts to contact the patient. An average total VSQ score of 38.0 (range, 29-45) was obtained from the VC group and a score of 38.9 (range, 15-45) from the F2F group. The small difference in patient satisfaction observed was found not to be statistically significant (P = .368, Mann-Whitney U test). The final question of the VSQ assessed the patient’s overall opinion regarding the VC or F2F consultation, where an average score of 4.2 and 4.5 was recorded, respectively, both corresponding to the value of very good.
Discussion
Literature shows a number of examples of VCs being used within surgical specialties in recent years, including in hand trauma for the purpose of reviewing nonemergency referrals.17-23 A randomized controlled trial (RCT) has demonstrated the safety of video-assisted consultations for the purpose of follow-up in patients having undergone orthopedic surgery; however, it is important to note the presence of a trained nurse at the remote location. 21
Within this department, soft tissue injuries are reviewed 6 weeks postoperatively by the surgical team, after a period of hand therapy starting from 3 to 5 days following surgical repair. Patients are taught set protocols to exercise their hands for the purpose of improving strength and range of motion. This simplifies the surgical consultation as patients have been educated thoroughly regarding their condition and expected outcomes by therapists, and this lends itself well to a virtual surgical review.
Standard practice within the department is to review hand fracture cases 1 week postoperatively with a repeat radiograph to ensure a stable reduction. A proportion of patients are situated closer to 1 of the 4 regional hospitals from which the department takes referrals, and radiographs can more conveniently be obtained at the nearest site. This makes VC clinics suitable for 1-week postoperative fracture cases, helping to reduce the necessity for patient travel and potentially reducing exposure to the COVID-19 virus. In the case of K-wire fixation, the wires are typically removed 3 to 4 weeks postoperatively, and the patients are required to attend an F2F clinic for such an appointment; however, cases with internal fixation can usually be discharged to Hand Therapy after the 1-week appointment unless any complications are identified.
In the current setup, F2F clinic appointments can be reserved for cases in which a physical examination is required or when the patient requires further intervention such as the removal of metalwork. However, lessons can be learned from the RCT published by Buvik et al 21 in which nurses were trained in clinical examination techniques and were with the patient at the time of the virtual appointment. Similarly, it may be feasible to train nurses in examination techniques for common presentations and to remove K-wires, perhaps at the time of the VC consultation, which would allow additional cases to be followed up remotely. The safety and efficacy of such an intervention would require testing prior to implementation.
In the studied month, virtual follow-up clinics were performed by experienced clinicians within the department (Consultants or senior Registrars), and results displayed in Table 3 demonstrate that the outcomes were comparable to those of F2F clinics. It was possible to safely discharge a similar proportion of patients (43.3% vs 57.4% in the F2F group), and there were no adverse outcomes following virtual consultation. Only 2 cases (of 60) within the VC group were deemed to require an F2F appointment following their virtual review, and an additional 2 patients had been incorrectly booked when they had been triaged to require an F2F appointment from the outset. It can be anticipated that the process for allocating patients to the correct clinic type can be quickly optimized following audit of this novel application of technology within the department.
Outcomes, by Clinic Modality.
In the studied patient population, there does not appear to be a significant difference in patient satisfaction following a virtual hand clinic review in comparison with a traditional F2F consultation, with an average total VSQ score of 38.0 (cf. 38.9 in the F2F group). This corroborates findings of multiple studies in the literature, demonstrating no detriment to patient satisfaction following telephone or video consultations.24-26 The mean age of patients in the VC group was 35 (range, 17-82) years, and such a young population, quite typical in hand trauma presentations, may be well suited to this telemedicine approach to consultation.
Feedback obtained from clinicians suggested this was a convenient and safe way to review patients postoperatively, with the main limitation being an inability for physical examination. The necessity for physical examination could be overcome in many cases, provided adequate patient cooperation and engagement could be obtained. This was particularly feasible in video consultations and less so in telephone consultations. Although virtual consultations are likely to be a safe method of patient follow-up, sufficient time has not passed to assess for any potential late complications. We recognize this limitation and present the results in this article without long-term follow-up data.
The additional benefit in the context of the COVID-19 pandemic was that staff members who were self-isolating were able to continue working from their homes and helped reduce the workload for staff members on site.
Although government-imposed lockdown measures have had the desired effect of slowing transmission of the COVID-19 virus, it is predicted that without the development of an effective vaccine or effective new treatment strategies, the virus will continue to affect the public and put pressure on health care resources. 27
Lessons learned in the early stages of adaptation of health services can be continued into the future if enduring patient benefit is demonstrable. In addition to the benefits of promoting the strategy of social distancing, VCs may also benefit patients by reducing their cost of travel to attend clinics, obviating the need to arrange childcare, and potentially preventing them from taking time from employment to attend hospital-based clinics.
We propose the following inclusion and exclusion criteria to form the foundation of a protocol for the continuation of VCs for hand trauma follow-up (Table 4).
Suitability Criteria for Virtual Clinics.
F2F = face-to-face.
A scoping study performed in the West Midlands looked to estimate the potential efficiency gains that can be made by the NHS by the use of virtual outpatient clinic appointments. 28 The study suggested that this approach had potential to improve efficiency and cost-effectiveness of an existing service while providing additional convenience to patients and reducing nonattendance. Indeed, multiple Scandinavian studies have demonstrated cost minimization by use of telemedicine clinics, with quoted reduction of up to 45% in some instances in Finland.29-31 To achieve cost savings, these studies showed a requirement of a case load of above 150 per year, which is far below the volume of cases reviewed in our department. Similar other research has shown the potential for cost savings in this way, when targeted to suitable patients and cases.32,33 To best enable trusts to combat the COVID-19 crisis, NHS England put in place a national contract for payment encompassing many acute and community services, 8 which also centralized the payment for the platform used by this department to conduct VCs. As such, cost savings can be easily anticipated as physical clinic space, and nursing resources were not used; however, a more detailed and long-term cost analysis could not be conducted due to this payment structure.
The platform used to conduct VC appointments is compliant with government privacy policies in the United Kingdom and run according to a System Security Policy approved by NHS National Services Scotland. This incorporates General Data Protection Regulation–complaint and UK Data Protection Act 2018–compliant controls and policies. It does not retain patient-identifiable information, meaning that patients using the service leave no digital footprint. While the COVID-19 pandemic provided the impetus to allow for this system to be efficiently implemented, the implementation protocol states that ongoing regular audit and monitoring is required, from a cybersecurity point of view.
Conclusion
Following the lessons learned during the COVID-19 pandemic, and having demonstrated no detriment to patient satisfaction or outcomes, we suggest the implementation of VCs as part of the routine follow-up protocol for patients with selected soft tissue and bony injuries to the hand. This approach may prove beneficial in terms of workforce organization, reducing clinic waiting times, and providing convenience for patients who may otherwise struggle to attend F2F clinic appointments.
Footnotes
Author Contributions
D.P. was involved in manuscript preparation, drafting and revision of article, data collection, and study design. K.Y. was involved in drafting of the article, data analysis, data collection, and study design. D.H. was involved in data collection. T.W. was involved in revision of the article and study design. G.S.P. was involved in revision of the article and study design.
Ethical Approval
Institutional approval was obtained.
Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.
Statement of Informed Consent
Informed consent was obtained from all individual participants included in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
