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 .
| 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) |
| 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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