This example describes how Bedfordshire Hospitals NHS Foundation Trust reconfigured their paediatric elective surgery service, in line with recommendations in the NICE COVID-19 rapid guideline: arranging planned care in hospitals and diagnostic services (NG179), to allow them to safely continue to offer this vital service during the COVID-19 pandemic.
Aims and objectives
- To safely restart elective paediatric surgery
- To record no incidence of hospital acquired COVID-19 in paediatric patients admitted for elective surgery
- Achieve 100% pre-COVID-19 service cessation capacity at a minimum
- Exceed 100% of pre-COVID-19 service cessation capacity to reduce waiting list
Reasons for implementing your project
In March 2020, NHS England informed all NHS Trusts that they must significantly reduce the number of planned elective surgery cases (continuing only for clinically prioritised patients) in order to preserve capacity in the NHS for an anticipated surge in demand for patients presenting with COVID-19.
Following the initial surge in hospital admissions relating to COVID-19, the number of admissions for COVID-19 has now reduced and nationally there are significant waiting lists for elective surgery. Bedfordshire Hospitals NHS Foundation Trust were keen to restart elective surgery for all of their patients as soon as it was safe to do so. This case study will focus on how they developed a new pathway and service for their paediatrics patients.
Bedfordshire Hospitals NHS Foundation Trust is a medium sized DGH but with a sizeable paediatric surgical service incorporating General Surgery, Community Dental Surgery, complex Orthopaedics, ENT, Oral and Maxillofacial, Plastics, Ophthalmology and Urology. Prior to March 2020, paediatric patients scheduled for elective surgery (and their families) would be admitted to the dedicated inpatient paediatric ward for their pre-operative checks and would wait there before being taken to theatres on the other side of the hospital. They would then be brought back to the paediatric ward for second stage recovery and discharge. The paediatric ward is a large open plan setting which accommodates planned and emergency admissions. Paediatric patients would commonly be scheduled in between adult patients within a theatre session to fit with the surgeon’s work plan, which meant that every day there would be a small number of paediatric elective surgery cases. Most paediatric elective cases were day cases but there was a small percentage, most commonly the complex orthopaedic patients, who would require an inpatient stay following surgery.
There was concern this service model would increase the risk of COVID-19 transmission especially with different patients and their families being admitted to the open plan inpatient children’s ward on a daily basis and patients moving across the hospital to access theatres. A change was required.
The first step to develop a new paediatric surgery pathway was to establish a working group with representation from key stakeholders. This included microbiology, infection control, theatres, surgeons, anaesthetics, directorate managers, paediatric nursing and clinical teams. The working group also liaised with other paediatric surgical centres to understand and share good practice. This working group was determined to safely reintroduce paediatric operating at 100% of pre-COVID levels of activity and this determination was the key to the project’s success.
How did you implement the project
The resulting service:
- One of the hospital’s theatre suites, which has 8 theatres, 12 first stage recovery bays and a surgical admission / discharge unit (with 24 trolleys, 6 consulting rooms and a large waiting area) was assigned - the Luton and Dunstable Hospital COVID minimal (green) theatre suite. This became a standalone COVID minimal setting with its own external access away from the general through flow of the hospital. This was to be used by paediatric and adult patients.
- All elective paediatric cases are grouped into one dedicated ‘paediatric day’ every 2 weeks. On this day only elective paediatric cases would be operated on within the COVID minimal theatre suite – this required surgeons, anaesthetists and other clinical staff to change their normal job plans to make this work. Their dedication to the success of the new service made this possible. Currently around 30 cases are operated on during each paediatric day through the 8 theatres with plans in place to increase this to 40 from the end of September 2020.
The above steps illustrate how to implement in practice recommendations 4.1 and 4.2 around planning and scheduling care from NICE NG179.
- All elective paediatric patients are admitted to the surgical admissions unit where the paediatric nurses, paediatric medical team and play teams are located for that day. They bring with them decorations and items to make the setting less clinical and more child friendly– these are all cleared away at the end of the respective day ready for the adult patients to be admitted the next day.
- Patients can only attend with one carer to ensure social distancing is maintained. The patient (as appropriate) and carer are required to wear masks whilst in the hospital right from the moment they are admitted into the admission unit up until discharge (excluding whilst in theatre and 1st stage recovery).
- Patients who require an overnight inpatient bed (estimated to be 3-4 of the 30 cases) are taken back up to the paediatric ward at the end of the day. This is a very small proportion of all patients and by taking the patients up to the paediatric ward at the end of the day it allows the ward to prepare and re-organise staffing to ensure these cases are admitted to a COVID minimal area of the ward.
- There is a concerted effort to keep the number of staff working in the area to a minimum and reduce the through flow of staff and visitors within the unit. Theatre staff (including anaesthetists, surgical teams and theatre nursing teams),are assigned to only work in green areas on respective days and will have a COVID-19 test every 7 days along with their temperature being taken every time they work in the COVID minimal theatre suite. Staff who are at higher risk of complications from COVID-19 are prioritised for working in this green area. If staff are required to move between red and green areas, on a single day, they cannot move from red to green (only from green to red).
The above demonstrates how to implement recommendations in sections 5 and 7 of NICE NG179 regarding steps to take during planned care and in regard of managing the risk to healthcare workers.
- Medical staff attend the COVID minimal areas of the hospital (dedicated theatres, critical care, inpatient wards) first thing each day before moving on to other areas of the hospital to review patient’s etc. A dedicated doctor (FY2 or above) is rostered to cover the adult COVID minimal post-operative inpatient ward each day to ensure the surgical teams aren’t required to make numerous visits to the ward after reviewing patients in other areas of the hospital. Video enabled devices also allow senior decision makers to have a video consultation / review of the patient without being required to return to the respective COVID minimal ward.
- If a surgeon who isn’t rostered to be in the COVID minimal theatre suite on a respective day but is required in theatre for whatever reason, they would be asked to shower and change into clean scrubs before entering the COVID minimal theatre suite.
- The operating theatres are cleaned in line with national guidance between cases and PPE is used by all staff in line with national guidance. Patients are extubated in the operating theatres in order to keep the risks of an aerosol generating procedure contained within the most appropriate setting.
- Preoperatively patients and their households have to self-isolate for 14 days irrespective of their planned procedure. For the paediatric pathway, the child and two carers are swabbed 72 hours prior to their admission date just in case one carer could not attend for whatever reason (based on recommendations 3.7 and 3.8 of NICE NG179). All swabs would be checked 24 hours prior to admission and any patients cancelled if any of the respective swabs come back positive.
- A centralised process was put in place for all elective swabbing across the Trust (elective theatres, endoscopy, clean room procedures, cardiac cath lab etc). A daily automated report sends through the patients personal and procedure details from the respective booking system to a dedicated swabbing team 5 and 3 days prior to a planned admission date. The report on the 5th day allows the team to pre-book patients for their swab to ensure as much notice is given as possible and on the later report, booking details are cross checked to ensure no one has been cancelled for whatever reason. All patients would then have their swab carried out via a drive through service based on the hospitals estate with results being checked by the pre-assessment team 7 days a week.
The working group regularly meet to discuss what is working well and what could be improved. It is a continual service improvement process which has allowed the working group to identify problems early and take remedial actions where required. During the early implementation phase, the team kept the number of cases low and have increased slowly as they became more confident, initial teething problems had been solved and the new working model was functioning well. At first, only day case procedures were carried out following the paediatric pathway, however, this has since been expanded to include inpatients.
One of the early challenges this process identified was that although the laboratory can get a COVID-19 result back within 24 hours from a sample being received, some cases had to be cancelled because the results had not been prioritised in the laboratory. This was due to the laboratory staff not being aware of which swabs were urgent apart from what had been included on the original request form (which was inserted inside the respective sample box). The project team liaised with the laboratory department to implement a simple yet effect process which enabled the specimen boxes to be easily identified (a distinctive sticker / tag was added to the specimen boxes). The laboratories also have access to a number of rapid testing machines which could allow last minute swabs to be requested and reported on should this be required for any reason to ensure a patient wasn’t cancelled if not necessary.
The new service model started on the 7th July 2020 and to date, the COVID minimal (green) pathway has not had any confirmed cases of COVID-19 whilst patients have been admitted into hospital for elective surgery – this applies to adult and paediatric patients. All elective inpatients are COVID swabbed every 5 days following on from their respective surgery to add further assurance to patients and staff working in the COVID minimal areas of the Trust.
Staff feedback has been really positive to date with plans to continue with this model moving forward. It has allowed a number of teams to strengthen working relationships and ultimately provide a better service and experience to the paediatric elective patients and their next of kins. This model has also helped to reduce downtime within theatres which is helping with elective recovery plans due to increased theatre utilisation.
Patients’ and families’ feedback has highlighted the benefits of all services being co-located as opposed to spread across the hospital’s estate.
Key learning points
- Establishing a working group early to lead on the implementation which includes all key stakeholders including microbiology and infection control teams
- A collaborative desire amongst all the staff involved in the service, to make it work for our patients
- Identifying opportunities for stand-alone self-contained units within the hospital site which can be used as COVID-19 protected areas
- A problem-solving attitude amongst the project team who strive to overcome challenges and hurdles
- A good understanding among the project team about the relevant national guidance including guidance
- Learn from and share ideas / ways of working with other NHS Trusts with paediatric surgical services
- Providing patients and families with clear communications about the risk and benefits of attending for surgery and details about what the Trust has already done to reduce the risk of COVID-19 transmission and why they are being asked to do things differently
- Facilitate regular meetings / opportunities for the front-line staff to constructively feedback on ways of working which is turn will create a continuous improvement culture.