Shared Learning Awards 2020 highly commended COVID-19 example - Delivering a paediatric elective surgery service during the COVID-19 pandemic

Bedfordshire Hospitals NHS Foundation Trust reconfigured their paediatric elective surgery service in line with recommendations in our COVID-19 rapid guideline on arranging planned care in hospitals and diagnostic services. This allowed them to continue to offer this vital service safely during the pandemic.

Following the pandemic we worked collaboratively in developing a robust pathway, relating to resumption of elective surgeries in children.Whenever faced with a challenge, each step was discussed systematically within our working groups prior to developing consensus.

This workplace inclusion and the rapid implementation of improvements supported thriving at work.

Dr Prabhu Rajendran, consultant paediatrician, Bedfordshire Hospitals NHS Foundation Trust.

Chris Elliott
general manager, anaesthetics, critical care and theatres
Bedfordshire Hospitals NHS Foundation Trust

What was done and why

The aim of the project was to safely restart elective paediatric surgery and to record no incidences of hospital-acquired COVID-19 in patients that were admitted. They also wanted to achieve 100% pre-COVID-19 service cessation capacity at a minimum and to reduce the waiting list.

Following the initial surge in COVID-19 hospital admissions, when the numbers began to decrease, the trust was keen to restart elective surgery for all their patients when it was safe to do so. This led to a new pathway being developed for paediatric patients.

A working group of key stakeholders was established. They liaised with other paediatric surgical centres to understand and share good practice. This group ensured the safe reintroduction of paediatric operating to pre-COVID levels. A COVID-19 clear operating theatre suite was established in the Luton and Dunstable Hospital. This became a standalone facility with its own external access.

All elective paediatric cases were grouped into a dedicated day every 2 weeks. Only elective paediatric cases were operated on within the dedicated theatre suite on this day. This required clinical staff to change their normal job plans to make this work. 

Our guidance recommends that patients who are at a greater risk of getting COVID-19 or having a poorer outcome of getting it may want to self-isolate for 14 days before their procedure. All staff working as part of the low risk (green) pathway have to have a negative COVID-19 swab within the last 7 days. This includes theatre staff, ward staff, anaesthetists and surgeons. 

Patients and their households were asked to do this along with practising social distancing and wearing masks in hospital. Currently, around 30 cases are operated on during each paediatric day.

Outcomes and impact

The working group meets regularly to discuss the pathway, identify problems early and take actions where required. At first, the number of cases were kept low and have increased slowly as they became more confident. Only day case procedures were carried out initially but this has since been expanded to include inpatients

This also helped to reduce the number of caseloads which enabled more patients to be seen when needed and helped when staff were off sick or isolating due to COVID-19. 

An early challenge was that, although the laboratory can get a COVID-19 result back within 24 hours, some surgical cases had to be cancelled because the results had not been prioritised. This was solved by adding a distinctive marking to the specimen boxes. The laboratories also have access to several rapid testing machines which allow last minute swabs to be processed, should this be required.

The new service model started on 7 July 2020 and as of September 2020, the COVID-19 minimal pathway has not had any confirmed cases of the virus. This applies to adult and paediatric patients.

All elective inpatients are swabbed every 5 days following their surgery. This adds further assurance to patients and staff working in the COVID-19 minimal areas of the trust.

Staff feedback has also been positive. Teams have strengthened working relationships and ultimately provide a better service and experience. 

What was learnt

Establishing a working group early to lead on implementation was important to the success of the project. A problem solving attitude, an understanding of national guidance and a desire to make the project work is also key among staff.

Space for standalone self-contained units within the hospital site which can be used as COVID-19 protected areas were identified. It was valuable to learn from and share ideas and ways of working with other trusts with paediatric surgical services.

The team provided patients and families with clear communication about the risks and benefits of attending for surgery. They also provided details about what the trust has already done to reduce the risk of COVID-19 transmission.

They explained why they are being asked to do things differently. To create a continuous improvement culture, regular meetings for front line staff to constructively feedback on ways of working were held.

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