Table 2

Changes in service types done by HRM before and after DORSCON orange

Service typePrepandemicChanges during COVID-19 pandemic (DORSCON orange level)Changes during COVID-19 pandemic (circuit bBreaker)
Clinics
  • Monday, Tuesday, Wednesday and Thursday.

  • Accepting both elective and emergency referrals

  • Operated by HRM staff and Hand occupational therapists

  • Same working days as prepandemic but:

  1. Reduced to postsurgery, postinjury cases and urgent referrals only.

  2. Triage of elective referrals to be rescheduled after lowering of the national alert level.

  • Monday to Friday clinic

  • Cancellation of specialist hand clinic, all orthopaedic subspecialties are managed through the general orthopaedic clinic.

Operative service
  • Dedicated HRM operative theatres as follows:

  1. Monday: one operative theatre

  2. Wednesday: one operative theatre

  3. Friday: two operative theatres

  • Both elective and emergency surgeries were performed.

  •  Same Operative days with the following changes:

  1.  Only emergency cases

  2.  Cancellation of all elective surgeries

  3.  Tele counselling of all cancellations by HRM staff

  4.  Registry of cancelled cases maintained.

  •  Removal of dedicated HRM operative theatres.

  •  Prioritisation of emergency cases done by the theatre management team.

  •  Same policy as DORSCON orange level but with following add-ons:

  1.  General emergency hand cases were managed by general orthopaedic staff.

  2.  Complex cases were operated by HRM staff.

  3.  Listing of patients monitored closely by operating theatre management team.

  4.  Strict penalties imposed by the Ministry of Health for failure to adhere to the policy

Emergency service
  •  Hot hand clinics in ED Monday to Friday.

  1.  8:30 to before 17:00 cases screened by ED doctors before referring to HRM staff.

  2.  5:00–10:00 all cases are referred directly from triage nurses to HRM staff on site.

  3.  Minor procedures (simple debridement and stitches) performed in ED.

  4.  Complex cases managed by P4 system (a day care semiemergency) delivered Monday, Wednesday, Friday.

  •  Hot clinics in ED Monday to Friday:

     8:30 till 22:00 cases screened first by ED doctors before referring to HRM staff or teleconsultation done by ED doctors using TigerConnect* software.

  1.  Cancellation of minor procedures in ED.

  2.  All simple and complex cases are managed by P4/system and operated on Monday to Friday.

  •  Hot hand clinic cancelled.

  •  All hand cases are managed as a part of the general orthopaedic emergency call.

  •  All simple and complex cases are managed and operated 24/7.

Audit/CME Thursday, multidisciplinary team, Lunch time meetingUse of TigerConnect software, face-to-face ward rounds and during performing surgeries.Same as DORSCON orange level policy
Conference attendance Attendance (FESSH, APFSSH, Local and regional meetings)Cancellation, use video conferencingSame as DORSCON orange level policy
Undergraduate teaching Regular tutorials NUS and NTU year 3 and final yearsCancelled (use available online resources)Same as DORSCON orange level policy
Postgraduate teaching
  •  Friday PM face to face teaching

  •  Daily residence work-based teaching

  •  Friday PM teleconferencing teaching

  •  Daily work-based teaching in small groups face-to-face teaching with social distancing

  •  Friday PM teleconferencing only.

  •  Cancellation of all face-to-face meetings.

Multicentres meeting and research projects
  •  Monthly face to face meetings.

  •  Cross-site collaborative research.

  •  Weekly research clinic to review patient included in projects.

  •  Cancellation of all face-to-face meetings

  •  Digital messaging and teleconferencing.

  •  In order to comply with physical distancing measures, all research projects involving our off-site biomechanical laboratory partners and prospective studies have been consolidated.

  •  Conduct retrospective studies or literature and systematic reviews.

  •  Cross-site physical collaborative research cancelled.

  •  Weekly research clinic cancelled.

Same as DORSCON orange-level policy
External meetings
  • Organ transplant ethics

  • National medical ethics

  • Academic/exams

  • Organ transplant committee teleconference.

  • National medical ethics meeting Cancelled

  • Held by teleconferencing.

  • Same as DORSCON orange-level policy

Manpower
  • HRM team consists of 2 consultants, 2 resident physicians, 1 senior resident, 1 junior resident or medical officer, 1 house officer and one clinical fellow.

  • Manpower was planned based on a monthly roster.

  • The team were segregated into two groups, alternating between operative theatre duties and inpatients and clinics duties weekly

  • Manpower was planned based on a weekly roster.

  • Cessation of specialty HRM team

  • Single general orthopaedic service

  • Implementation of two BCP teams: alternating between active duties on-site and standby 2 weekly.

  • Some staff were deployed for COVID 19 screening or other essential services in ED and wards.

  • *TigerConnect: it is an online text messaging and media application which is accessed only using the institutional email account. It is used as an official way of handling patients details specially those containing personal data.

  • APFSSH, Asian Pacific Federation of Societies for Surgeries of The Hand; BCP, Business continuity plan; DORSCON, Disease Outbreak Response System Condition; ED, emergency department; FESSH, Federation of European Societies for Surgery of the Hand; HRM, hand and reconstructive microsurgery; NTU, Nanyang Technological University; NUS, National University of Singapore.