Provincial directive asking hospitals to ramp down scheduled surgeries and procedures still in place

Even though the resumption of scheduled surgeries and procedures was included in Ontario's Stage 1 reopening plan, a provincial directive in March that ordered hospitals to significantly ramp down this work is currently still in place.

But the directive isn't the only thing holding hospitals back from resuming non-emergency surgeries and procedures during the COVID-19 pandemic. According to some Ontario surgeons, there's been a flurry of activity both within hospitals and at regional levels to create plans for resuming scheduled surgeries and procedures and evaluate whether hospitals meet several criteria outlined by the government in order to do so. This includes having a rolling 30-day supply of personal protective equipment and reserving 15 per cent capacity within hospitals.

"You can’t flip a switch to resume surgery in hospitals, it takes some preparation and some advance notice," said Dr. David Urbach, chief of surgery at Women’s College Hospital, likening the eventual ramping up of surgeries to a "dimmer switch as opposed to a light switch."

Hayley Chazan, spokesperson for Health Minister Christine Elliott, said in an email to QP Briefing last week that there had not been any changes to Directive #2 and "conversations with experts and stakeholders on Directive #2 are ongoing. As a result, the current directive remains in effect." She confirmed on Monday that this was still the case.

The directive, issued by Chief Medical Officer of Health Dr. David Williams on March 19, said "all non-essential and elective services should be ceased or reduced to minimal levels, subject to allowable exceptions, until further notice." As a result, there were 72,392 fewer surgeries performed in Ontario between March 16 and April 26 compared to the number of surgeries performed during the same time period last year.

Ontario's reopening plan announced on May 14 noted the province would be "gradually restarting health care services" in Stage 1, which began on May 19. The plan linked to Ontario Health's May 7 framework document titled "A Measured Approach to Planning for Surgeries and Procedures During the COVID-19 Pandemic," which stressed that the focus was on "planning" and that "no activity should actually be resumed until such time as (Directive #2) is amended or revoked."

"In the interim, we continue to advise hospitals to work with their Ontario Health regional partners to plan for the resumption of scheduled surgeries and procedures," Chazan said in her email.

"Are (hospitals) just waiting for some sort of modification of Directive #2, I think the answer is no, I think that’s obviously necessary to proceed, but there’s much more important work that’s going to be required for hospitals to increase their activity," said Urbach. "I don’t think you’re going to expect people sort of chomping at the bit waiting for the voiding of Directive #2; although people are waiting for that, it’s also some direction from these regional co-ordinating centres as well as the hospitals to figure out how to gradually and safely increase activity."

Dr. Fayez Quereshy, interim vice-president at Toronto General Hospital and a surgical oncologist with the University Health Network, agreed.

"I think all of us are waiting for direction from the minister on this and I think we are all kind of expecting that imminently there will be an amendment," said Quereshy, adding that the ministry is likely trying to evaluate whether "it is the right time."

"Because we’re still working at sorting through some of the plans both at a regional and a local level; even if let's say Directive #2 were amended or...lifted, we’d probably be still working through our plan to make sure we had a systematic and measured approach," he said.

Quereshy said he doesn't think the directive would be "completely lifted," and that instead, some language on the limitations of scheduled activity might be relaxed.

"I suspect there will probably be an amendment and the amendment will provide a bit of additional allowance to do work, but I would suspect that there would still be a caution about increasing scheduled work to the point where our hospital occupancies are back to where they were pre-pandemic," he said.

Quereshy said while UHN has been performing urgent surgeries, it has had to postpone around 2,700 surgeries during the past two months.

The network has set up a clinical activity working group — an interdisciplinary committee Quereshy is part of — that is setting thresholds for resuming scheduled work including the rate of COVID-19 in the region and province, occupancy levels in the hospitals, the availability of in-patient beds along with PPE and drug supply. An oversight committee would then guide the network through the different phases of recovery.

"The recovery process is really a...gradual and incremental ramp-up approach, so it’s not as though we’re going form zero to 100 overnight when these threshold elements have been met, but rather very carefully and in a measured way increasing activity," said Quereshy, noting that hospitals need to maintain some capacity for any surges.

"One of the things that we’re mindful of and some things that I think many of us have had a bit of palpitations about are when people congregate in social environments like they have in the Trinity-Bellwoods Park this past weekend…we worry that if we’re not adhering to social distance, if we’re not wearing universal masks in public spaces, there’s a risk that we’ll see a spike of COVID-19 in the community."

Quereshy, who is also part of an Ontario Health regional table for the Toronto area, said the UHN network has a 30-day supply of PPE and an adequate supply of drugs, but that these are resources they would need to constantly monitor since supply levels could change.

The government outlined in its May framework that hospital committees would complete weekly feasibility assessments to assess the hospital's ability to meet the outlined criteria and would work with regional or sub-regional COVID-19 steering committees. Both would need to sign off on a hospital’s plans to ramp up scheduled surgeries.

UHN's plan is "close to being finalized," Quereshy said, adding that the regional table is also working on providing guidance documents to hospitals.

"What I would expect is that hopefully within the next week or 10 days, we’ll have convergence of the region and hospital-based tables on looking for approval," he said.

Quereshy said while it might be "very challenging" for some hospitals to meet all the requirements outlined by the government, regional collaboration and a system-wide approach in the form of "pooled assets," for example, would be helpful.

Urbach, who is co-chair of the procedure and surgery oversight committee that was struck at his hospital, said while Women’s College Hospital hasn't yet submitted its plan for resuming scheduled surgeries, it would currently be able to meet the criteria outlined by the government.

Urbach, who is also part of the Ontario Health table for the Toronto region, said that "at the worst of it" Women’s College Hospital was doing just 10 per cent of its typical surgical activity.

"The one thing hospitals have done is working within this Directive #2 is providing essential surgery, but much less restrictive than we were in late March," he said. "What hospitals are doing is doing a bit more of the emergency and urgent type of surgeries, so largely those are cancers or conditions that are very debilitating or causing suffering to people for which surgery would make a big difference."

The hospital is now up to about 40 per cent and part of that is providing operating rooms to surgeons from other hospitals who need a space to perform surgeries.

But even when hospitals do resume scheduled surgeries and procedures, Urbach said it's "very unrealistic" to think that they will be able to go back to their normal operating levels.

"One thing that people wouldn’t realize is how less efficient operating rooms are now because of the infection control procedures in place; for example, you can’t have a lot of people around, you can’t move people in and out of operating rooms quickly, you have to give lots of time between cases," he said. "So overall the hospitals as a result of this have become much less efficient and much less able to really ramp up numbers of surgeries just in order to provide a safe environment for patients."

Dr. Wes Stephen, executive vice president of clinical operations at Hamilton Health Sciences, said they recognize "changes to our services in response to the pandemic have impacted many people who rely on our care."

"Presently, all Ontario hospitals are instructed to maintain existing service reductions and the capacity required for the provincial pandemic response effort as we await revisions to CMOH Directive #2," Stephen said. "Once we are approved by the province to start reintegrating services, the process will be gradual and phased over the upcoming weeks. This work will occur in close collaboration with our regional healthcare partners."

Meanwhile, the province's chief medical officer of health said Ontario Health has been reviewing the issue of resuming scheduled surgeries "intensely," and noted that hospitals across the province are facing different circumstances with some, for example, taking in long-term care residents whose homes are experiencing outbreaks.

"It may seem easy just to roll it back, but as the premier said even rolling back is harder than closing down and that’s true in the case of Directive #2 and the surgeries," Williams said. "That is a robust discussion and we hope to have that resolved and those steps taken forward in a process that they’re mapping out at this time."

He said even though he's the one signing off on the directive, it's work that's being done through the province's COVID-19 command table.

"They’re working at that as quickly as they can with adequate consultation with the leadership in the various facilities," Williams said, adding that he's seen many "final versions that have been pulled back."

He said the government wants to resume scheduled surgeries and address the backlog "and especially a hierarchy of less urgent, more urgent, very urgent (cases) and different ways to bring them back into line there and to utilize the resources as best as possible."

"There’s a lot of movement here and already a number of surgeries that were seen as less than essential have been moved up already, so there’s a lot of shifting happening," Williams said.