Single vs Dual-site service reconfiguration during Covid-19 pandemic - A tertiary care centre experience in hip fractures and a Scoping review

Abstract

Aims and objectives: The Covid-19 pandemic has had an unprecedented effect on surgical practice and healthcare delivery globally. We compared the impact of the care pathways which segregate Covid-19 Positive and Negative patients into two geographically separate sites, on hip fracture patients in our high-volume trauma center in 3 distinct eras - the pre-pandemic period, against the first Covid-19 wave with dual-site service design, as well as the subsequent surge with single-site service delivery. In addition, we sought to invoke similar experiences of centres worldwide through a scoping literature review on the current evidence on "Dual site" reconfigurations in response to Covid-19 pandemic.

Methods: We prospectively reviewed our hip fracture patients throughout the two peaks of the pandemic, with different service designs for each, and compared the outcomes with a historic service provision. Further, a comprehensive literature search was conducted using several databases for articles discussing Dual-site service redesign.

Results: In our in-house study, there was no statistically significant difference in mortality of hip fracture patients between the 3 periods, as well as their discharge destinations. With dual-site reconfiguration, patients took longer to reach theatre. However, there was much more nosocomial transmission with single-site service, and patients stayed in the hospital longer. 24 articles pertaining to the topic were selected for the scoping review. Most studies favour dual-site service reorganization, and reported beneficial outcomes from the detached care pathways.

Conclusion: It is safe to continue urgent as well as non-emergency surgery during the Covid-19 pandemic in a separate, geographically isolated site.

Fig. 1

Study periods 2020 - First surge (12/03/20–15/07/20), Second surge (07/11/20–12/03/21) Blue line indicates volume of Covid-19 in-patients in the trust at any given time. Number of cases in the Y axis, Dates in the X axis.

Fig. 2

The flow of patients during the immediate response phase (First Surge). Leicester Royal Infirmary (LRI) received all acute hip fracture patients in the A&E, where they were isolated in holding bay and tested for Covid-19. The patients were then directed onwards to LGH if tested Covid-19 negative; or stayed in LRI if tested positive. Only those patients that required advanced respiratory input were transferred to the third site, GH. Patients underwent surgery in their respective sites, and were discharged to the community/rehab centre as applicable.

Fig. 3

The number of patients admitted over the previous seven-day period. Red line = 2019, Blue line = 2020 First wave, Green = 2020 Second wave.

Fig. 4

The length of time to theatre in hours by week of admission. Red circles represent individual patients admitted in 2019, blue circles individual patients in 2020 and green circles the second wave. The lines show seven-day rolling mean average, dashed line in 2019, solid line the first wave and dotted line for the second wave. Along the right y-axis the green shaded area show the number of confirmed COVID-19 cases within the hospital trust during the first wave, and red shaded area in the second wave.

Fig. 5

The length of hospital stay in those who survived to discharge in days by week of admission Red circles represent individual patients admitted in 2019, blue circles individual patients in 2020 and green circles the second wave. The lines show seven-day rolling mean average, dashed line in 2019, solid line the first wave and dotted line for the second wave. Along right y-axis and the green shaded area show the number of confirmed COVID-19 cases within the hospital Trust during the first wave, and red shaded area in the second wave.