Health-care providers and patients alike are breathing a "sigh of relief" as hospitals across the province start to ramp up scheduled surgeries and procedures during what one health executive is calling a "window of opportunity." This comes as new data show Ontario saw 154,097 fewer surgeries performed during a 99-day period of the COVID-19 pandemic compared to one year prior.
"Our providers of care who have been so focused on wanting to do the right thing for their patients are breathing a sigh of relief that they’re able to access resources to deliver that care," said Dr. Fayez Quereshy, clinical vice-president of the University Health Network (UHN), which includes Toronto General and Toronto Western hospitals and the Princess Margaret Cancer Centre.
However, health teams also recognize that they need to be "thoughtful, careful and cautious that if a second surge emerges in the community, then we have to be able to respond like the way we did the first time and pull back activity" for the safety of patients in hospital and in the community, said Quereshy, who is also a surgical oncologist specializing in gastrointestinal malignancies.
"So people recognize that, but where there is a window of opportunity to help service patients that are in need I think many of our providers are breathing a bit of a sigh of relief," said Quereshy, going on to praise his own patients, some of whom he had to tell that their care would be delayed because of the pandemic.
"Not once did I hear a patient complain; they were incredibly gracious, they recognized that others in the community needed the resources more than they did in the moment," he said.
Now as he starts to perform more surgeries, "just seeing them in the hospitals and on the day of surgery, (you) can see an obvious sigh of relief on their face too, that they were happy to finally get the care that they had been waiting for," he added.
According to Ontario Health, the government's central health-care agency, 113 out of 115 acute care hospitals across the province had begun to restart scheduled surgeries and procedures as of July 10 after getting the green light at the end of May from Chief Medical Officer of Health Dr. David Williams.
Williams first issued a directive, known as Directive #2, on March 19, ordering hospitals to significantly ramp down elective surgeries and procedures, and when he amended it on May 26, he paved the way for this work to begin, provided that hospitals could meet certain criteria. This included a rolling 30-day supply of personal protective equipment and reserving 15 per cent capacity within hospitals.
While hospitals were performing urgent surgeries early on in the pandemic, thousands of scheduled surgeries were deferred since mid-March, with more than 2,000 fewer cancer surgeries being performed during a two-month period.
"Hospitals and their Regional Ontario Health COVID-19 Response Tables have worked collaboratively to determine what’s appropriate in their local context, while maintaining COVID-readiness," Ontario Health said in a statement.
For its part, UHN created a "clinical activity recovery blueprint" that outlines five phases and different volumes of activity in the ambulatory, procedural and surgical areas. Movement between the phases is dependent on things like the supply of personal protective equipment (PPE), in-patient bed and ICU capacity in the hospital and region, and COVID-19 cases in the region and province.
The "pandemic phase" involved emergency activity only, so surgeries that needed to be done within 14 days, said Quereshy. The network started scheduled activity during "Pandemic Phase 1" after Williams amended his directive and stayed in that phase for about one month. On July 6, UHN moved to "Pandemic Phase 2."
As with the "pandemic phase," the latter two have also involved the triaging of patients with the focus being on utility and equity, said Quereshy. The patients receiving surgeries during the recent two phases were expanded to include those who would typically need to have surgery within 28 days.
Surgical volume for the network was estimated to be about 20-25 per cent in the "pandemic phase" compared to the pre-pandemic period, 30-35 per cent during "Pandemic Phase 1" and close to 60 per cent during "Pandemic Phase 2."
"If it happens that the most emergent patient shows up today, well obviously they’re going to be delivered on care tomorrow, but for the most part the volumes, or the activity that we’re doing now, is trying to catch up on some of the patients that have been in queue owing to the pandemic," Quereshy said.
He's noticed a change with his own surgery volumes as well. Normally, he'd operate an average of one-and-a-half times a week, but during a six to eight-week period at the height of the pandemic he operated a total of three times. Now he's operating about once a week.
"My field of practice is cancer surgery, so it is urgent essential care and that’s the magnitude of which we as an organization and we as individual health-care providers pulled back in terms of our volumes," said Quereshy.
Shady Ashamalla, a surgical oncologist specializing in colorectal cancer and head of the division of general surgery at Sunnybrook Health Sciences Centre, told QP Briefing in May that the hospital would typically have 25 operating rooms running at any given time. But due to the COVID-19 pandemic, the hospital went down to 10 operating rooms by March 16 and then four by the end of that month.
There is generally a scaling back during the summer, so 18 operating rooms is the norm around this time, which is what the hospital is currently at, Ashamalla said last week. However, he said that because there is such a backlog, surgeons haven't returned to their "normal summer schedule."
"We’re running to the capacity of a normal summer, but we are still triaging through services," he said. "Cancer is probably doing more than they would normally do in a summer, whereas some benign types of services are doing far less than they would normally do in a summer."
But through this process, Ashamalla said there were "a lot of creative pathways that were established to try to open up (operating rooms) and deal with patients."
"When we opened up (operating rooms), we disproportionately opened up more breast cancer rooms because those patients don’t need to stay in hospital after their surgery," he said. When PPE and N95 masks were an issue, the hospital looked at what surgeries could be done with regional anesthesia instead of intubation — an aerosol-generating procedure that requires N95 masks, Ashamalla added.
"Then we would cluster those cases so ... all the cases in that room don’t need intubation, nobody needs an N95 in that room," he said.
According to Ontario Health information provided to QP Briefing, there were 154,097 fewer surgeries performed this year between March 15 and June 21 (a 99-day period) compared to a similar 99-day timeframe last year — March 17 to June 23.
It shows:
- Cancer surgeries dropped by 28 per cent from 13,922 to 9,963
- Non-oncology adult surgeries dropped by 87 per cent from 157,150 to 20,228
- Pediatric surgeries dropped 87 per cent from 15,171 to 1,955
About 29 per cent of the cancer surgeries performed this year between March 15 and June 21 were done after Williams' directive was amended (a 26-day period from May 27 to June 21). This compares to 55 per cent of the non-oncology adult surgeries and 51 per cent of the pediatric surgeries being performed after the change.
Both Quereshy and Ashamalla said the data reflects their "lived experience quite well."
Quereshy said while the data doesn't present a monthly breakdown, he suspects April and May would have seen a significant drop in surgeries compared to March and June.
"I think what you’re seeing in the numbers here are catch-ups at the beginning part of the pandemic and the end, but most hospitals and our organization as well really reduced activity in the surgical oncology volumes," he said.
As for non-oncology surgeries, the data shows that "there are a lot of people that have non-cancer diagnoses that have essential care needs, and when we talk about urgency and procedures there is a wide variety of patients in need of care, whether it be urologic, neurosurgical, gynecological or ophthalmologic," Quereshy said. "It reflects the issues of hospitals in the region paying attention to health equity and distributing resource towards essential care and where care is needed regardless of specifically the presenting diagnosis."
Ashamalla said the numbers also don't show the number of urgent versus scheduled surgeries, but that they feel "very representative of what we’re seeing subjectively."
"We’re doing less colorectal cancer, but not profoundly less because we operated on people that are presenting with symptoms, whereas something like breast cancer, which really doesn’t present with symptoms ... the differential between last year and this year is far more significant than it would be for colorectal cancer because those will eventually present with symptoms," Ashamalla said. He added that screening plays a role as breast cancer is often discovered through mammograms, which have been significantly reduced during the pandemic.
-Photos courtesy of the University Health Network and Sunnybrook Health Sciences Centre
Leave a Reply
You must be logged in to post a comment.