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Prioritizing patients for surgery is becoming more fraught as Canada’s slowdown of non-emergency procedures drags on, doctors warn.

Surgery backlog crisis looming

Doctors and healthcare leaders are worried about Canada’s growing backlog of urgent surgeries as non-emergency procedures have been dramatically scaled back or delayed due to COVID-19 for almost two months now.

Since early March, Sunnybrook Hospital in Toronto has reduced the number of operating rooms available for scheduled surgeries from about 25 to four to free up human resources, medications, equipment, and beds for patients with COVID-19. In the last week, the hospital made available two more operating rooms to keep up with the rising number of patients who need surgery urgently.

“We’ve really been banging the drum about how much danger these patients are under if the slowdown continues at this rate,” says Dr. Shady Ashamalla, a surgical oncologist at Sunnybrook. “The administration has been listening,” he adds.

With less operating space available for scheduled procedures, Sunnybrook has prioritized patients at risk of worse outcomes or death if they don’t get surgery in the next two weeks, Ashamalla says. The hospital will soon expand that window to four weeks.

Patients who can wait longer are being monitored more closely than usual to ensure their conditions don’t worsen. “Every morning, we review our list of patients we believe to be in that two-week window,” Ashamalla says. Patients flagged for urgent surgery typically receive it within 48 hours.

Ashamalla believes his team has “kept everyone safe” so far, but some patients will suffer worse outcomes if provinces move too slowly to resume elective procedures.

Dr. Andrew Krahn, a cardiologist at St. Paul’s Hospital in Vancouver, says the slowdown of elective procedures in British Columbia has led to an uptick in “more complex procedures with more risk” as patients’ conditions have worsened. And delays will continue even after surgeries resume as usual. “There are probably about 15,000 to 20,000 people in Canada who are on a waitlist for cardiac surgeries normally and adding two months [of delayed cases] is going to make that number a fair bit larger,” he explains.

While a patient’s prognosis is the main consideration in prioritizing surgeries, there are many other factors to weigh, Krahn says. For example, it’s easier to fit in patients who won’t require lengthy hospital stays compared to those undergoing cardiac surgery who may be in the hospital for a week and need intensive care beds, some of which hospitals are still reserving in case of a surge in COVID-19 cases. Decisions are also being coordinated across jurisdictions. “In one day, I have the same conversation at all three levels: locally, regionally and provincially,” Krahn says.

According to Dr. Danielle Martin, executive vice president and chief medical executive at Women’s College Hospital in Toronto, one “unintended but welcome consequence” of COVID-19 is the way hospital leaders are collaborating regionally to make the most of limited resources. While Women’s College typically only does outpatient surgeries, the hospital has taken on procedures for complex patients requiring overnight stays. It has also made operating space available for teams from other hospitals.

Martin says prioritization decisions are becoming more fraught as the slowdown continues. In the early days, surgery to remove a recently discovered melanoma cancer could wait, but now those cases are getting to the point where delaying them further is risky.

In a recent CMAJ commentary, Martin and Women’s College Hospital Surgeon-in-Chief Dr. David Urbach warned that returning to “business as usual” will not be acceptable. They called for a switch to a team-based approach, where patients see the first available surgeon in a team responsible for their care, rather than waiting to see specific providers.

Martin adds that many research bodies and organizations, including the Wait Time Alliance and Cancer Care Ontario, are advising hospitals on how to “work down the backlog as quickly and as equitably as possible.”

How quickly will depend on whether Canada sees a drop in hospitalization rates for COVID-19. So far, that hasn’t happened, says Dr. Joshua Tepper, president and chief executive officer of North York General Hospital in Toronto. Patients undergoing surgery and those hospitalized with COVID-19 draw on the same resources, including ventilators, intensive care beds, and drugs like propofol, which is now in short supply globally. Many health professionals needed in operating rooms, such as anesthesiologists, have been called to COVID-19 wards. And shortages of protective equipment persist across health systems.

“It’s easy to forget how integrated our healthcare system is,” says Tepper. “Nobody operates without gloves and nobody operates without gowns, and that supply chain is under stress.”

Photo credit: iStock/nimon_t

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