Mohit Bhandari MD FRCSC PhD
Ayesha Siddiqua Msc PhD
- The COVID-19 pandemic has led to mass cancellation of surgical services around the world.
- Even if the typical surgical volume is increased post-pandemic, it may take a long time to catch up with the backlog of surgeries.
- A wide range of factors influence the capacity of surgical services to keep up with the pandemic, including the spread of SARS-CoV-2 and the duration of societal regulations.
- There is emerging evidence highlighting the importance of weighing the risks of delaying surgery and conducting surgery during the pandemic.
- Guidelines for providing surgical services during the pandemic have contradictory recommendations.
- Moving forward, there is a need for collaboration between governing bodies to develop guidelines, which will have to be further customized to meet the needs of individual countries.
- Collaborative Generated Resources include: OE Best Practices and Resuming Elective Surgery“The team [The COVIDSurg Collaborative (1)] estimated that more than 28 million elective surgeries worldwide could be cancelled or postponed in 2020, based on a 12-week period of peak disruption to hospital services due to COVID-19 — including potentially hundreds of thousands of procedures in Canada.” — Lauren Pelley, CBC News, 2020 (2)
“An estimated 45 000 fewer surgeries were performed in adults with non-cancer-related illness in Ontario in late March and early April 2020, which is a more than 90% reduction compared with the same 4-week period in 2019” — David R. Urbach & Danielle Martin, 2020 (3)
The COVID-19 Crisis in Surgery
The COVID-19 pandemic has placed significant challenges on healthcare systems of many countries around the world. One of the hardest hit areas of care has been surgery – with near-universal disruption and mass cancellation of surgical services (4). In order to accommodate the surge of COVID-19 patients who require critical care, all non-essential elective surgeries have been cancelled or are pending cancellation due to the current high demands for ventilators, hospital space, as well as hospital staff (4). These cancellations can lead to tremendous short and long-term health implications for patients who require surgery, including potential loss of function, risk of adverse prognosis, worsening quality of life, and even death (1,4). As an example, earlier this summer in the midst of the pandemic, we identified 7 key consequences for the growing unmet burden of orthopaedic care, which are likely to amplify the negative implications of the current backlog of surgeries (Exhibit 1).
Countries that were hit particularly hard by the pandemic, and especially countries such as Canada where wait times for surgery were already long even before the pandemic, recovering from the
current public health crisis and catching up on the backlog of surgeries will require plans that are proactive, ethical, and creative (5). While it may be challenging to see beyond the immediate demands on healthcare systems, critical reflection of the current challenges to support constructive preparation for the future will not only allow surgical services to survive post-pandemic, but thrive in a care landscape that will no longer be the same.
Exhibit 1: Consequences for Growing Unmet Burden of Orthopaedic Care
Beware of the second wave of COVID-19
Avoidance: “I’m too scared to go to the hospital right now.”
Complications: “I had non-operative care. but there’s a problem now.”
Kickstart: Summer trauma surge with easing social restrictions
Lest We Defer: ” Doctor, I can’t wait anymore. I need my operation.”
Ongoing Natural History: Diseases don’t stop progressing because we stop operating.
Growing Epidemics within the Pandemic (opioids, IPV, medtal health, job loss)
“If countries increased their normal surgical volume by 20 percent after the pandemic, it would take a median of 45 weeks to clear the backlog of operations resulting from COVID-19 disruption.” — The COVIDSurg Collaborative, 2020 (1)
“Hitting that kind of ambitious target [increasing normal surgical volume by 20 percent after the pandemic] would be challenging…In Canada, we’re already working at or beyond capacity in many ways.” — Dr. Janet Martin, Associate Professor at the Schulich School of Medicine & Dentistry, Western University (2)
Keeping Up with The Pandemic
Soreide et al (2020) described the capability of surgical services to keep up with the pandemic depends on a wide range of factors, including (4):
1. The peak of the pandemic,
2. The spread of SARS‐CoV‐2,
3. The duration of societal regulations, and
4. The duration and temporal epidemic repeats by which the disease burden approaches the threshold of maximum capacity of the critical care resources.
This highlights the complexity of providing surgical services in the midst of a pandemic, which will require different strategies than those most healthcare systems are used to implementing to cope with seasonal disruption and occasional cancellation of surgeries. It is hypothesized that even when the threshold of maximum capacity of critical care resources is not surpassed, the capacity can come close to, or temporarily cross the threshold, before the pandemic ends (4). In this context, capacity building in surgical services to withstand the challenges of a dynamic environment – where demands on the healthcare system can rapidly change – is crucial for moving forward.
“Patients having surgery are a vulnerable group at risk of SARS-CoV-2 exposure in hospital and might be particularly susceptible to subsequent pulmonary complications, due to the pro-inflammatory cytokine and immunosuppressive responses to surgery and mechanical ventilation.” — The COVIDSurg Collaborative, 2020
Surgery During Pandemic: Experience So Far
Despite the mass cancellation of surgical services across many settings, there are reports of surgeries taking place for patients with or without COVID-19. The COVIDSurg Collaborative led an international, multicentre cohort study across 24 countries in 235 hospitals with patients undergoing surgery who had SARS-CoV-2 infection confirmed 7 days before or 30 days after surgery (6). Postoperative pulmonary complications occurred in half of these patients (51.2%) and the 30-day mortality rate was high (23.8%). Additionally, men, individuals aged 70 years or older, those with comorbidities, those having a malignant diagnosis, and those needing emergency or major surgery were more vulnerable to 30-day mortality. The authors noted that the postoperative outcomes observed in SARS-CoV-2 infected patients were much worse than pre-pandemic baseline rates of pulmonary complications and mortality. Taken together, these findings highlight the importance of weighing the competing risks of delaying surgery until patients recover from COVID-19 versus the progression of disease or adverse outcomes in the intervening period (7).
There is now emerging evidence on the impact of COVID-19 on surgeons’ knowledge, attitude, practice, and socioeconomic burden. An international, multicentre cross-sectional study of 781 spine surgeons showed that 70% of surgeons were willing to operate on patients with COVID-19 if needed, while only 23.3% received training or knew another spine surgeon who received training to deal with the pandemic (8). Additionally, being an orthopedic spine surgeon, working in the private sector, and older age of practice were predictors of higher effects of COVID-19 on practice (8). While authors of this study have not provided hypotheses regarding these associations for all the risk factors, they did propose that surgeons working in private hospitals were likely more affected because many of them do not work on a salary basis, unlike most surgeons working in university hospitals, thus losing patients would lead to a loss of income. It is clear that spine surgeons from different regions around the world are ready to face the challenges of the pandemic, even if they may not be ready for them or pay a personal cost for their service. While these altruistic traits are commendable, practicing in this manner in the long term, given the uncertain duration of the pandemic, is neither sustainable nor desirable. In this context, health system capacity building to better support surgeons to survive the pandemic and its aftermath should be a top priority for decision makers.
Although the pandemic has been a cause of much distress, there are also a few silver linings of this crisis. Notably, after the pandemic began, the majority of spine surgeons reported improvement in general and personal hygiene, increased awareness of the importance of medical and scientific research, as well as increased use of telemedicine (8). With continued commitment, these positive changes can have a lasting impact on surgical services and raise the standards for better practices in the field.
Guidance for Surgery During a Pandemic
Times of public health crises not only impose new challenges on healthcare systems, but also reveal many of the inherent limitations of these systems that otherwise remain hidden. There is growing consensus on the need for guidance to navigate through surgical services during a pandemic, and considerable research and guideline formation activities have followed at rapid speed. Earlier in the pandemic on April 15, 2020, the COVIDSurg Collaborative published their findings of a scoping review and key informant interviews that identified key themes to consider in pandemic preparedness plans for surgical services (10). Moreover, since the beginning of the pandemic, our team has taken a leading role in providing recommendations to surgeons through a series of guidance documents, the first version published on April 12, 2020, the second version published on April 22, 2020, and the latest version published on May 30, 2020 (11). For the latest guidance document, we conducted a critical review and proposed a series of evidence-based principles to guide musculoskeletal care decision making in the context of the current resource scarcity experienced around the world. We provided updated peer reviewed recommendations from an ongoing systematic mapping review of the published literature to guide key areas of orthopedic management during the COVID-19 pandemic. These key areas include general considerations for surgery, outpatient care, phased management of elective procedures, urgent/emergent procedures, perioperative care, and steps to restart non-urgent restorative surgery. We have prepared easy to access summary documents with recommendations in each of these areas, while
indicating the strength of evidence these recommendations are based on. Exhibit 2 shows a summary of our recommendations for general considerations for surgery.
Exhibit 2: Surgery Protocols During COVID-19 – General Considerations
(DOWNLOAD FULL PDF)
One of the criticisms of some of the surgical and perioperative guidelines is that many of the recommendations are contradictory and based on anecdotal data (4). While the rapid speed of
guideline development during a public health crisis is necessary, it is still important to ensure recommendations are based on a critical assessment of risks and benefits, if not based on relevant
evidence which may be unavailable during a pandemic. In order to avoid duplication of efforts, one pragmatic strategy can include collaboration between prominent governing bodies to develop some general guidelines surgeons from different countries can refer to. However, given the heterogeneity in the healthcare systems and prevalence of COVID-19 cases across countries, the need to adapt guidelines based on local needs is inevitable. At a broader level, in addition to dealing with the short term challenges in hand, the appropriateness of proposed recommendations to cope with the backlog of surgeries in the long-term should be considered. It may be the case that in addition to proactive planning, increased staff training, and operational changes in hospitals, there is a need for a bigger healthcare system reform. For example, in Canada, there have been calls for a team-based, single-entry approach to deal with the backlog of surgeries in an efficient and ethical manner moving forward (3).
Trade-offs: To Delay Now, is a Crisis Emerging
Given the difficulties of providing surgical services in the midst of a pandemic, it is tempting to take a conservative approach and postpone or cancel surgeries, while promoting non-operative treatment to delay or avoid the need for surgery. Although this approach may be appropriate for some cases of elective surgery, there can be a significant detrimental cost of this approach for both patients and healthcare systems. The current approach of largely deferring surgeries is an unsustainable short-term solution, which will not save us from an overwhelming public health crisis in the near future. An effective way forward will begin with joining forces with leaders around the world to determine common recommendations that can be applicable across countries, with a concerted effort in individual countries to customize recommendations based on their needs.
Mohit Bhandari, MD, PhD
Dr. Mohit Bhandari is a Professor of Surgery and University Scholar at McMaster University, Canada. He holds a Canada Research Chair in Evidence-Based Orthopaedic Surgery and serves as the Editor-in-Chief of OrthoEvidence.
Ayesha Siddiqua MSc, PhD
Ayesha Siddiqua has a Masters and a PhD from the Health Research Methodology Program in the Department of Health Research Methods, Evidence, and Impact at McMaster University.
1. COVIDSurg Collaborative et al (2020). Elective surgery cancellations due to the COVID-19 pandemic: Global predictive modelling to inform surgical recovery plans. The British Journal of Surgery. DOI: 10.1002/bjs.11746.
2.Pelley L (2020, July 23). Ontario hospitals strive to clear surgery backlog as patients remain in limbo due to COVID-19. Retrieved from https://www.cbc.ca/news/canada/toronto/ontario-hospitals-strive-to-clear-surgery-backlog-as-patients-remain-in-limbo-due-to-covid-19-1.5659334
3. Urbach DR & Martin D (2020). Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ; 192(21): E585-E586. 10.1503/cmaj.200791.
4. Søreide K, Hallet J, Matthews JB, Schnitzbauer AA, Line PD, Lai PBS et al (2020). Immediate and long‐term impact of the COVID‐19 pandemic on delivery of surgical services. The British Journal of Surgery. DOI: 10.1002/bjs.11670.
5. Urbach DR (2020). Improving access to health services in Canada. Healthcare Management Forum; 31(6): 256-260. DOI: 10.1177/0840470418776995.
6. COVIDSurg Collaborative et al (2020). Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. The Lancet; 396(10243): 27-38. DOI: 10.1016/S0140-6736(20)31182-X.
7.Myles PS & Maswime S (2020). Mitigating the risks of surgery during the COVID-19 pandemic. The Lancet; 396(10243): 2-3. DOI: 10.1016/S0140-6736(20)31256-3.
8. Khattab MF, Kannan TMA, Morsi A, Al-Sabbagh Q, Hadidi F, Al-Sabbagh MQ et al (2020). The short-term impact of COVID-19 pandemic on spine surgeons: a cross-sectional global study. European Spine Journal; 29: 1806–1812. DOI: 10.1007/s00586-020-06517-1.
9. Osman L (2020, April 29). Doctors concerned over surgery backlog after immediate COVID-19 crisis. Retrieved from: https://www.cbc.ca/news/politics/doctors-fret-surgery-backlog-coronavirus-1.5550028
10. COVIDSurg Collaborative et al (2020). Global guidance for surgical care during the COVID-19 pandemic. The British Journal of Surgery. DOI: 10.1002/bjs.11646.
11. Prada C, Chang Y, Poolman R, Johal H, & Bhandari M (2020). Best practices for surgeons. COVID-19 Evidence-based scoping review. Retrieved from https://myoe.blob.core.windows.net/docs/OE-Best-Practices-for-Surgeons-COVID-19-Evidence-Based-Scoping-Review.pdf