Question: My father’s hip replacement surgery was postponed because of the COVID-19 pandemic. He’s in a lot of pain. When can he expect to have his operation?
Answer: Canadian health care providers are putting much thought into the question of when and how to resume non-emergency, or so-called “elective” surgeries.
But they readily acknowledge it will be a delicate balancing act. The health care system must be able to cope with a potential wave of new COVID-19 activity while, at the same time, dealing with the growing backlog of delayed medical procedures.
“Lots of creative thinking is going to be required,” says Dr. David Naylor, a professor of medicine at the University of Toronto and former chair of the National Advisory Committee on SARS – another pandemic that crippled parts of the Canadian health care system in 2003.
Dr. Naylor compares the bulging caseload to an iceberg. “We see the surge on the system and the tragic deaths occurring but, boy, under the waterline the delayed health care impact is massive.”
About a month ago, as the pandemic gained momentum around the globe, Canadian health care leaders concluded that hospitals had to put all non-emergency operations on hold.
This extraordinary step was taken to prepare for the expected deluge of COVID-19 cases, and to conserve limited health-care resources such as personal protective equipment (PPE) – masks, gloves and gowns – needed to shield health-care workers from the coronavirus.
That meant doctors proceeded with only the most urgent surgeries in which a delay could result in the death or permanent disability of a patient.
“There was general agreement that the vast majority of people could wait safely for their procedures,” says Dr. Chris Simpson, Vice-Dean (Clinical) of the School of Medicine at Queen’s University in Kingston.
“But what happens if weeks of waiting turns into months,” he adds. “A patient’s status could change. Their condition might worsen and that would bump them up into the urgent and emergent category.”
Indeed, the term “elective surgery” simply means that the procedure can be scheduled in advance, and it is based on the assumption that the case is not an emergency that requires almost immediate treatment. But if you delay an elective procedure too long it will eventually require prompt attention.
Dr. Simpson points out that the various medical specialities – such as cancer and cardiovascular care – have well-established protocols for triaging patients so that the most urgent cases are given priority.
And, at this time, doctors are doing their best to make sure their patients in greatest need are put on the list for imminent treatment, he says.
In some parts of Canada, the epidemic appears to be cresting and a lot of health care institutions currently have some extra capacity. So, hospitals are considering increasing the number of procedures that they are doing.
“But we are not going to just turn on a switch and it is going to be normal again,” warns Dr. Avery Nathens, Surgeon-In-Chief and Director of the Trauma Program at Sunnybrook Health Sciences Centre in Toronto.
“With the outbreaks in long-term care homes and some relaxation in physical distancing, we could see another surge in COVID cases. So, we have to ensure we have the capacity to deal with it.”
Dr. Simpson agrees that another jump in cases is highly likely.
“This is far from over. There will be a second wave almost certainly,” he says. “As society opens up again, there is going to be an increased rate of illness that’s going to keep hospitals occupied with COVID for some time.”
Any plans to boost medical procedures – even modestly – must deal with a number of perplexing challenges.
For one thing, the illness is still being transmitted in the general community. This means an asymptomatic infected person – showing no obvious signs of illness – could come into a hospital for a procedure and inadvertently spread the novel coronavirus, which is officially known as SARS-CoV-2.
As a result, health care workers must take extra precautions because any patient they encounter might be harbouring the virus. In some cases, staff will require the full use of PPE.
Dr. Nathens points out that most patients undergoing major surgery are intubated – a tube is inserted down the airway to assist breathing. If a patient has COVID-19, this invasive procedure can “aerosolize” the virus and potentially spread it to those nearby.
So, the anaesthesiologist who intubates the patient should be wearing an N95 mask which is specially designed to effectively filter out virus particles in the air.
As hospitals increase elective surgeries, they will require more and more PPEs, including N95 masks that are in short supply. Yet, if they use up too much inventory, they could be left unprepared for a sudden jump in COVID cases.
Another concern is the potential shortage of drugs required to sedate patients who need to be intubated.
“This limits how much we can ramp up because our supply chains need to be secure,” says Dr. Nathens.
In order to conserve precious resources, doctors are thinking about revising the way they do certain operations. For instance, some cancer surgeries could be performed using a local or regional nerve block, rather than a full anaesthetic which renders a patient unconscious.
With a regional anaesthetic, “the patients are breathing on their own, they don’t need the (intubation) tube – and that saves PPE,” says Dr. Nathens.
He expects hospitals will gradually increase surgeries by expanding the criteria for patients deemed to be immediately eligible for a procedure.
Right now, many hospitals are providing surgical care to the highest risk patients – those who might die or suffer significant disability if they aren’t treated within two weeks.
“The next stage might be a 30-day timeline, and after that it could be three months,” he explains. “By opening up the criteria window, more and more patients will get their procedures.”
However, doing the most time-sensitive cases won’t necessarily put a significant dent in the swelling backlog of “elective” or non-emergency surgeries.
Limited health care resources will continue to put constraints on the system. After all, there are only so many operating rooms.
“What we will have to do is extend the hours of operating rooms way beyond normal and run through weekends,” says Dr. Naylor.
Health care facilities will also need to consider converting additional space into operating rooms.
Ramping up activity will require extra government funding.
“Doctors are advocating strongly for patients. They are not being forgotten,” says Dr. Nathens. “We are working on plans to get them the right care.”
Even so, there’s no doubt that the delays are affecting patients in negative ways – both in terms of their quality of life and mental wellbeing.
“It’s pretty hard to take a measure of what this does to someone who has been waiting six months for an operation and now they have to wait another six months or whatever it turns out to be,” says Dr. Naylor. “But these impacts are real and important.”
It’s also hard to estimate the number of cases that have been postponed by the pandemic. In Ontario alone, about 180,000 elective procedures are performed in a typical year.
“I have been trying to get my head around it, and it worries me a lot,” says Dr. Simpson. “But, in general, the prospect of operating at 120 per cent or 140 per cent of normal volumes for weeks or months, just to catch up with the backlog, is highly problematic from a feasibility point of view.”
He says that the greater use of telemedicine – or “virtual appointments” in which a doctor sees a patient through an online video chat – should help accelerate pre-surgery assessments while keeping people physically out of medical clinics.
“But telemedicine can’t take out a gallbladder or remove a tumour,” he adds.
And the longer non-emergency procedures are postponed, the bigger the backlog becomes. For that reason, many hospitals are making plans to selectively ramp up elective surgeries.
To do this safely, “we must all help keep down the number of COVID cases” says Dr. Nathens. That suggests “physical distancing” will be a way of life for some time to come.