NOFF prevalence and demographics
In 2020, there were 33 NOFF patients eligible for the NHFD database compared to 45 in 2019. Although an overall absolute reduction by a quarter, the percentage of referrals that were NOFF increased in 2020 to 30% of all referrals from 19% in the preceding year, representing a greater share of the departmental workload during the COVID era. As expected, there was no substantial difference in the NOFF demographics between years including the risk stratification scoring systems (NHFS and CFS). Furthermore, the median age and the gender split were similar, as was the ASA identical pre- and post-COVID further supporting the homogeneity of the cohorts. The majority of patients were admitted from their own home in both periods, and their pre-injury mobility, fracture configuration, and type of operative intervention were well matched between both periods.
Impact of COVID on patient surgical pathway and treatment
The COVID-19 pandemic has necessitated the reconfiguration of resources and pathways to treat patients with COVID-19 and also to protect highly vulnerable patients and healthcare workers [13, 14]. Despite these radical changes, those with NOFF during the COVID period did not see a deterioration in their time to treatment. As per standard procedure, all NOFF patients in this study were still discussed in the daily trauma meeting in the presence of surgeons, anaesthetists, and orthogeriatricians who come together in a multidisciplinary approach to provide individualized and judicious evidence-based treatment.
Although there was a 24% increase in the time to admission from the emergency department to the orthopaedic ward (p = 0.02), this could reflect on the decline in the number of the allied healthcare professionals and hospital staff while also dealing with the concurrent pressure of COVID with an unprecedented demand of side rooms in any suspected COVID-19 patients. The time to theatre was not significantly changed in both periods (Fig. 1).
The SHiFT study  envisaged a scenario whereby they would require a tight triage of patients undergoing operative intervention for NOFF. Fortunately, this has not occurred, with a small but insignificant decrease in median times to theatres and number of breaches during the pandemic. This finding is likely due to the overall reduction of trauma workload found during this period leading to an overall decrease in operative demand. There has also been a recognition that these patients, often elderly with existing comorbidities, represent the most vulnerable to COVID-19, and therefore would be prioritized for operative intervention in a timely manner even in the midst of the pandemic. The more prompt the surgical intervention, the quicker patients would be able to recover and mobilize to reduce the risk of immobility-related complications including pneumonia.
The risk of COVID-19 transmission is increased in any aerosol-generating procedures (AGP), such as intubation, and there are stringent infection control measures for the anaesthetic process [15,16,17,18]. Surprisingly, the risk of AGP such as general anaesthetic with intubation was not reduced between both groups. The expectation would be to reduce the use of AGPs as much as possible to minimize the risks, but this has not been the case with 50% continuing to have AGP for the operative procedure, which has not significantly changed from 2019 (51%). This may represent the medical complexity of these NOFF patients and the limitation in the use of non-AGP anaesthetic such as the anticoagulation status of patients or accounting for the reduced baseline median AMTS in 2020 leading to reduced compliance during regional anaesthetic and the operation.
Whereas all operations were led by consultant anaesthetists, the odds of a consultant surgeon leading the operation during the COVID-19 period was increased by a factor of 4.48 in spite of an identical median ASA grade (ASA 3) between both years. This was due to redeployment of senior surgeons to the trauma theatre since all elective and private practice was compelled to cease, thus increasing their availability as the primary surgeon in the main trauma theatre.
Quality of post-operative assessment
The multi-disciplinary approach to the treatment of NOFF patients is paramount. NOFF patients often have complex medical needs, and all should be reviewed by an orthogeriatrician within 72 hours and also assessed by a physiotherapist to encourage mobilization on day 1 post-op. This is to help facilitate earlier safe discharge from the acute site, more importantly during the pandemic to reduce the patient’s risk of contracting COVID-19.
A total of 97% of patients were reviewed by an orthogeriatric team member in 2020, and 85% of the reviews were at consultant level (p < 0.000001), compared to only 29% in 2019 representing the odds of a consultant-led orthogeriatric review was 13.8 times higher in the COVID-19 period. There was a reduction in the time taken to orthogeriatric review too, which improved by over 20% to under 20 hours. There was no statistical difference in the number of breaches over 72 hours. This represents a greater degree of senior-led care in the management of NOFF patients during the pandemic who were reviewed sooner to provide the gold-standard care to ensure swifter (but safe) discharge from the acute setting.
This care has meant that during the COVID-19 period, there has been a statistically significant improvement in the time to discharge from the trust to support this in 2020. This is comparable at 6.5 days in 2020 compared to 14 days in 2019. By minimizing the time in hospital, it is hoped that the chances of an adverse outcome due to COVID-19 is reduced.
Mortality and morbidity
The recent COVID-Surg study has found a mortality of nearly 25% in patients undergoing operative intervention during the COVID period, with age over 70 years being a significant risk factor . This places patients presenting with NOFF fractures during the COVID-19 pandemic into a high-risk stratification by default. Maniscalco et al.  found a mortality rate of 18% in NOFF patients within the Italian experience, with 82% of mortality associated with a positive COVID-19 status.
In our experience, the 30-day mortality of NOFF patients during the pandemic was 15% compared to 9% in 2019 and significantly greater than the mortality rate nationally at 6.7% published by the NHFD . Traditionally, the 30-day mortality rate has been cited as high as 10% . Of those who died in 2020, one patient died from a confirmed diagnosis of COVID-19. This patient was discharged home with a package of care 9 days following admission, but 6 days following discharge was readmitted with new respiratory symptoms and was confirmed PCR positive for COVID-19 on readmission. She died 11 days later with primary cause of death being COVID-19. Due to the known incubation period for COVID-19, it cannot be said for certain if this patient contracted COVID-19 during their inpatient stay or following discharge. Her operative intervention however was prompt, and her care met all the best practice tariffs with an intramedullary nailing being performed within 15 hours of diagnosis. In the worst-case scenario as suggested in the SHiFT study, this patient had a score of 10 which would have been triaged to potential surgery. Therefore, operative intervention may have been delayed by up to 7 days and this was unlikely to have improved her outcomes.
Another patient had a positive COVID PCR test whilst an inpatient, but this was 3 days after their operative intervention. They were discharged home on day 22 from admission following a subsequent negative COVID PCR test. Again, one can only speculate where this patient contracted COVID-19 (although was felt to be suffering with symptoms of COVID-19 on initial assessment), but this patient again did not breach their time to surgery, and despite a SHiFT score of 14, benefitted from their prompt time to theatres. Whilst this is only a snapshot across a 5-week period, it does warrant further study to investigate the ongoing impact of the pandemic on NOFF mortality, how this compares to the figures suggested by other studies and show a true national representation.