Obtaining Informed Consent in Orthopaedic Trauma in the Wake of the COVID-19 Pandemic
Obtaining informed consent from patients has always been a crucial and necessary procedure before surgery is performed. However, the COVID-19 pandemic has radically altered care pathways and introduced new elements into the consent procedure. It is vitally important that patients are made aware of the implications of these so that they can make proper decisions about their care. Mr Aswinkumar Vasireddy, Consultant Orthopaedic Trauma Surgeon, discusses the importance of obtaining informed consent in the wake of the COVID-19 pandemic.
For instance, the rates and variety of postoperative complications and the rate of mortality have been affected, even after routine procedures, and this increase in risk must be conveyed to the patient. The main implications of the COVID-19 pandemic on orthopaedic trauma fall into one of two categories: changes to the care offered and the risk of developing COVID whilst in-hospital.
Due to the pressure on resources, many aspects of urgent orthopaedic care are stretched, and surgeons will need to consider alternative forms of treatment. Thus, non-operative treatment options need to be considered more readily in order to minimise a patients’ exposure to the hospital setting. Furthermore, complications may be treated more slowly, and in different locations, than would previously have been the case.
For example, most fractures of the upper limb have a high rate of union and will heal well on their own after immobilisation, so an operation may not be necessary. However, patients need to be made aware that good union of the bone will not be achieved in every case and surgery for late reconstruction may be necessary.
Surgery for complex fractures should be planned to minimise the length of hospital stay. If surgery is staged, patients may be discharged and then readmitted. The use of splints or casts that can be removed by the patient at home will become more common. Patients also need to be aware that access to follow-up appointments and imaging, and rehabilitation services, is likely to be very limited and will almost certainly be delivered remotely.
As well as changes to treatment plans, there is now an inherent possibility of contracting COVID-19 while attending hospital. Emergency admissions for orthopaedic trauma can often involve older, frail individuals with co-existing morbidity, a group particularly at risk from COVID-19 infection. Thus, attendance for treatment is now much riskier than it was, particularly for patients in vulnerable groups, and the potential benefits of treatment in hospital may not outweigh the risks. The British Orthopaedic Association suggests that factors such as increased age, chronic lung disease, diabetes mellitus, obesity, heart disease, cirrhosis and immunosuppression all contribute to a patient’s risk of contracting COVID-19. Clearly, pertinent risk factors will need to be assessed on a case-by-case basis.
At the start of the pandemic, infections acquired in hospitals were relatively common, but more recent surveys indicate that the rate of infection in hospitals is similar to, or lower than, that seen in the community at large. Public Health England estimates that only around 20% of inpatient infections actually originate in hospital. This risk is unlikely to be uniform across the country and may change quickly, as infection ‘hotspots’ develop and are controlled. Therefore, communication between infectious disease specialists and surgical teams is vital to ensure that patients are provided with facts relevant to any decision about admission.
There is little available information on the consequences of surgery in patients who are already positive for COVID-19. The risk of transmission from surgical patients is unclear and little is known about the course of the virus in this patient group. Furthermore, a lack of data on surgical outcomes in this group means that patients cannot be provided with accurate information. Worryingly, there have been reports of very high rates of both complications and mortality in COVID-19 patients undergoing surgery, although many of these patients were at high-risk.
With the advent of effective vaccines, the end of the COVID-19 pandemic appears to be in sight. However, we are still a long way away from herd immunity. While there has always been a need to balance optimum treatment against available resources and clinical safety, this has now become paramount. Best practice dictates that patients should be made aware of all the risks of a procedure, however small. Given the increase in mortality now seen in orthopaedic patients, the procedures used to obtain informed consent need to be updated to reflect the recent changes and increased risks posed by this potentially fatal virus.
About Mr Aswinkumar Vasireddy
Mr Vasireddy is a full-time fellowship-trained Orthopaedic Trauma Surgeon at King’s College Hospital. He specialises in the management of complex open/closed pelvic, acetabular, upper limb and lower limb fractures and amputations in his clinical and expert witness work. He is also one of a small group of surgeons, and the only contemporary Orthopaedic Surgeon, in the UK who works as a HEMS (Air Ambulance) Pre-hospital Care Doctor.
His medico legal practice includes those who have sustained high-energy injuries. With his training, he’s able to provide comprehensive reports and review all aspects of a patient’s treatment. Read his full biography and download his CV here.
British Orthopaedic Association. (2021). COVID-19 BOASTs. British Orthopaedic Association. https://www.boa.ac.uk/standards-guidance/boasts/covid-19-boasts.html [Accessed 15th January 2021].
Davies, A., Heaton, T., Sabharwal, S., Fertleman, M., Dani, M., & Reilly, P. (2020). Consent for surgery during the COVID-19 pandemic. British Orthopaedic Association. https://www.boa.ac.uk/resources/knowledge-hub/consent-for-surgery-during-the-covid-19-pandemic.html [Accessed 18th January 2021].