Postgraduate Medical Journal | 2021
Orthopaedic surgical prioritisation: can it be made fairer to minimise clinical harm?
Abstract
The current COVID-19 pandemic (SARSCoV-2) has had a profound effect on the provision of healthcare across the National Health Service (NHS) with suspension of all nonurgent elective surgery including orthopaedic procedures to deal with the surge of inhospital admissions and reduce viral transmission. The COVID-19 surge in January 2021 due to the second wave has led to an unprecedented rise in Consultantled Referral to Treatment Waiting Times (RTT) with more than 300 000 patients awaiting more than a year for treatment— compared with 1600 before the pandemic began. The Federation of Surgical Specialty Associations comprising of 10 Surgical Specialty Associations including the Royal College of Surgeons and British Orthopaedic Association have recently updated the ‘Clinical Guide to Surgical Prioritisation during the Coronavirus Pandemic’ for restarting nonurgent and orthopaedic care. This guidance describes levels of surgical priority, covering all surgical specialties except for obstetrics and gynaecology and ophthalmology (table 1). Surgical prioritisation is a decisionmaking process ranking patient referrals in a particular order based on various criteria with the aim of improving fairness and equity in the delivery of surgical healthcare. In a publicly funded NHS deciding who receives which level of care is dependent on the availability of resources and risk stratification process. The novel coronavirus SARSCoV-2 outbreak has added an additional risk factor in the management of waiting lists with the need of further infection control strategies to minimise the chance of viral transmission and reduce associated morbidity including mortality in the perioperative period. Elective orthopaedic surgical procedures such as total hip arthroplasty and total knee replacements (TKA) have been proven to be costeffective health interventions in relieving pain, restoration of joint function and improving quality of life (QoL) outcomes in patients disabled due to underlying arthritis. 7 The current RTT statistics may not reflect the human face behind the numbers, with many in considerable pain and others with restricted mobility affecting activities of daily living. Traditional methods for surgical prioritisation of elective care are based on time waited, for example, RTT and may not account for dynamic deterioration during the period the patient is on the waiting list. This may result in inadvertent harm or is likely to negatively impact on longer term outcomes due to clinical deterioration. A recent UK multicentre, crosssectional nationwide survey across 10 orthopaedic departments (IMPACTRestart Collaboration) has reported alarming findings. Over a third of patients waiting for THA and nearly onequarter awaiting TKR described their health state as worse than death (WTD with a decline in QoL). Patients expected their health QoL to deteriorate with increasing time spent on the waiting list. Apart from the physical consequences of pain, chronic musculoskeletal (MSK) pain is known to affect psychological, psychosocial and mental health of patients. Consequently, these essential factors need to be taken into consideration during surgical prioritisation. The ‘Shared Decisionmaking process’ between the consultant/operating team and the patient with their relatives will be a discussion during which ‘Risks vs Benefits’ of the orthopaedic surgical procedure would be discussed. This would include the benefits of intervention and effects if no intervention is undertaken. An enhanced consent process would be necessary which acknowledges risk of perioperative COVID-19 infection. The challenge with current surgical prioritisation is to explore and consider the associated medical risks associated with a procedure. If a highrisk procedure is performed, one is often faced with a restriction in backup critical care facilities. A ‘surgical urgency’ needs to be balanced against the higher medical risk of surgery during the resumption of elective surgical procedures. Table 1 Current representative Clinical Guide to Surgical Prioritisation During the Coronavirus Pandemic—The Federation of Specialty Surgical Associations 2021 and suggestions to minimise clinical harm