Provision of Emergency Maxillofacial Service During the COVID-19 Pandemic : A Collaborative Five Centre UK Study

Abstract

The global pandemic of Coronavirus disease (COVID-19) represents one of the greatest challenges to healthcare systems, and has forced medical specialties to rapidly adapt their approaches to patient care. Oral and Maxillofacial Surgery is considered particularly at risk of disease transmission due to aerosol generation during surgical interventions, patient proximity and operating environment. On day 2 (26th March, 2020) of when severe restrictions in population movement were instigated in the United Kingdom, we began a study to prospectively monitor the presentation and management of maxillofacial emergencies at five hospital trusts. Data was collected onto an online live database fed through a smartphone application.

Of the total 529 patients over six weeks, 395 attended for face-to-face consultations and 134 patients received remote consultations via telephone or video link. There were 255 trauma related cases, 221 infection and 48 cases of postoperative complications. Most trauma cases were minor soft tissue injury related to slip, trip or fall at home. There were 44 cases of facial fractures with a tendency for conservative treatment. 19 cases were related to domestic violence or self-harm. Of the 216 dental related emergencies, 68% could have been managed in the primary care setting. A quarter of all emergency patients were satisfactorily managed by remote consultations.

There was a significant change in the provision of emergency maxillofacial service during the pandemic lockdown. We discuss the study findings as well as the potential implications in relation to planning for possible further COVID- 19 spikes and future pandemics.

Introduction

An outbreak of the novel Coronavirus disease (COVID-19) originated in Wuhan, China and rapidly spread to multiple countries worldwide, the United Kingdom being one of them. It has been shown to spread via person-to-person transmission as well as being present on aero-digestive mucosal surfaces and in saliva; and may cause severe respiratory complications. Oral and Maxillofacial Surgery (OMFS) as a specialty is considered particularly at risk of disease transmission due to aerosol generation during surgical interventions, patient proximity and operating environment.

In line with the World Health Organisation (WHO) declaration of a Global Pandemic and the evidence of rapid community spread of COVID-19 infection in the population, the UK government instituted strict measures on the 24th of March 2020. These lockdown measures included physical distancing, working from home, closure of non-essential services and closure of schools. On day 2 of the lockdown, we began a study to monitor the provision of OMFS emergency service at multiple National Health Service (NHS) hospital trusts.

The aims and objectives of this study was to analyse the pattern of presentation and management of maxillofacial emergencies during the lockdown. We discuss potential implications of the study findings in relation to planning for current and possible further spikes of COVID-19, and future pandemics.

Methods

This is a muti-centre study involving maxillofacial units based at five NHS hospital trusts: University Hospital Southampton, St. Richard’s Hospital (Chichester), Salisbury Hospital, Poole Hospital and Queen Alexandra Hospital (Portsmouth). Together, these hospitals serve a population of 3.93 million people, representing approximately 6% of the UK population.

We included all patients who were managed by OMFS departments on an emergency basis during the lockdown period. We prospectively collected data over a period of 6 weeks to the date when the UK government announced retraction of some of the strict restrictions imposed.

The data was collected using an online system through a custom built web-based application and stored onto a central database, making data capture and collection as convenient as possible. Several automated algorithms collated and processed the data, presenting the results on a real time ‘Live Whiteboard’. This was readily accessible to all collaborative members of the team so that any learning issues for the department could be picked up quickly and change of practice implemented as necessary in managing their emergency patients flow during the fast moving situation of the pandemic.

Results

There were a total of 529 patients, of which 395 attended for face-to-face and 134 patients received remote consultations via a telephone or video link. The detailed data on a range of parameters examined are listed in Table 1 and Table 2 .

Table 1
Patient data related to face-to-face consultations.
Variables Total number of patients: 395
Number of Patients (%)
Age Median Age : 42
Range : 1-95
Gender
Male 206 (52.2)
Female 189 (47.8)
Source of Referral
A&E 287 (72.7)
Dentist 34 (8.6)
GP 21 (5.3)
Other 53 (13.4)
Care Setting
Inpatient 77 (19.5)
Outpatient 318 (80.5)
Treatment Modality
Local Anaesthetic 201 (51.0)
General Anaesthetic 35 (9.0)
Non-Surgical Management / No Treatment 158 (40.0)
Grade of Treating / Consulting Clinician
Consultant 49 (12.4)
Middle Grade 113 (28.6)
Core/ Foundation Year trainee 233 (59.0)
If Taken to Theatre: Time Waiting (n = 35)
0-1 Hours 15 (42.9)
1-2Hours 7 (20.0)
2-5 Hours 6 (17.1)
5-10 Hours 1 (2.9)
10+ Hours
Patient’s COVID-19 Status
Unknown 373 (94.4)
Positive (tested) 0 (0)
Suspected Positive 6 (1.5)
Negative (tested) 16 (4.1)
Appropriate for Remote Consultation
Yes 67 (17.0)
No 328 (83.0)

Table 2
Patient data related to remote consultations
Variables Total number of patients: 134
Number of Patients (%)
Age Median Age : 48
Range : 1-95
Gender
Male 73 (54.5)
Female 61 (45.5)
Source of Referral
A&E 45 (33.6)
Dentist 21 (15.7)
GP 23 (17.1)
Other 45 (33.6)
Grade of Treating / Consulting Clinician
Consultant 19 (14.2)
Middle Grade 4 (3.0)
Core/ Foundation Year trainee 111 (82.8)
Consultation Outcome
Advice given and discharged 45 (33.5)
Further remote consultation organised 27 (20.1)
Follow up organised – Face-to-face: Same day 8 (6.0)
Follow up organised – Face-to-face: Next day 11 (8.2)
Follow up organised – Face-to-face: 2 days or more 28 (21.0)
Advised to see primary care practitioner 6 (4.5)
Referred to another specialty 3 (2.2)
Other 6 (4.5)
Patient’s COVID-19 Status
Unknown 131 (97.8)
Positive (tested) 2 (1.5)
Suspected Positive 1 (0.7)
Negative (tested) 0 (0)
Appropriate for Remote Consultation
Yes 130 (97.0)
No 4 (3.0)
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Aug 5, 2020 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Provision of Emergency Maxillofacial Service During the COVID-19 Pandemic : A Collaborative Five Centre UK Study
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