Development of the Manchester wide-awake hand trauma service in 2020: the patient experience

Abstract

Our regional plastic surgery department, based at Wythenshawe Hospital, Manchester University, provides tertiary hand trauma service to 2.8 million people. This is one of the highest population densities in UK. Recently the unit established a regional upper limb orthoplastic service and a regional complex limb multidisciplinary team. The unit is also the regional provider for paediatric hands, spasticity and brachial plexus reconstruction. Prior to March 2020, hand trauma was managed through the primary acute hospital site at Wythenshawe Hospital. Patients would undergo general anaesthetic surgery with use of an arm tourniquet. This limited the daily capacity to between four and six patients. If the list overran there was the possibility of patients needing admission for anaesthetic recovery. On the 23 March 2020, the COVID-19 (C-19) pandemic led to a national lockdown, forcing the closure of normal hospital services in order to provide anaesthetic and intensive therapy unit (ITU) capacity for C19-infected patients (van Klei et al., 2020). The need for hand trauma surgery continued, however, as people faced a prolonged lockdown. The propensity for hand trauma endured and shifted from workrelated to more home do-it-yourself and alcoholrelated injuries (Park et al., 2020). The wave of injuries led to a national campaign to warn individuals of this additional pandemic-related risk (Sephton et al., 2020). Despite fewer injuries presenting during quarantine, the reduction in anaesthetic cover and theatre capacity, the redeployment of junior staff and the shielding of vulnerable staff resulted in major challenges to the hand trauma service, which necessitated change (Ducournau et al., 2020). There was a need to reduce the footfall in the main acute receiving hospital and minimize the risk to patients who potentially did not have the virus but had hand injuries that required treatment. This led to a systematic move towards a service in a ‘cold’ site, independent of the need for anaesthetic coverage and the ability to provide urgent acute trauma care with streamlined workflow. We adopted an ambulatory hand surgery service at the neighbouring community hospital to manage emergency hand trauma that could be performed using WALANT (wide-awake local anaesthetic no tourniquet). A standard operating pathway was prepared and transfer of services (including C-arms and microscopes), was made to the community hospital, which had previously served as a site for minor surgery (Supplementary Appendix S1). The move freed essential theatre space and anaesthetic staff at Wythenshawe Hospital to manage the increasing number of respiratory cases. The uptake of the WALANT approach in the UK had been limited to a relatively small number of enthusiasts, but has seen adoption in a growing number of applications based on the ability to assess function intra-operatively (Higgins et al., 2010). The pandemic caused a major shift in practice, with many more hand surgery patients being treated using WALANT. This article reports on the rapid shift in the management of acute hand trauma towards a WALANT service and examines the patient-reported experiences regarding this change. We hypothesized that WALANT would offer similar outcomes to previously reported patient experiences (Teo et al., 2013) irrespective of complexity of the surgical procedure.