Confronting the COVID-19 surgery crisis: time for transformational change

The capacity to perform elective surgeries amidst COVID-19 has been severely constrained. Urbach and Martin recommend implementing a single-entry model as a solution to optimize waitlist management (1). This model has the potential to reduce wait times by allowing patients to be put in a single queue and receive their operation by the first available surgeon (1). While promising for some procedures, this model is not as likely to be effective for cataract surgery, where patient choice is highly valued. Instead, in the context of cataract surgery, it is important to think about how to better evaluate the appropriateness of referrals, and then prioritize patients in a shared decision-making model. Waitlist 1 (‘referral to consultation’) can be optimized by education and filtering out unnecessary referrals, and then prioritizing referrals for patients with significant comorbidity from their cataracts. Waitlist 2 (‘decision for surgery to surgery’) prioritization is often done on a first-come, first-served basis, although going forward post COVID-19, we should incorporate patient-reported outcomes in determining priority. Previous studies have shown that monocular visual acuity may not be enough to determine the benefit of cataract surgery as it may not represent the day-to-day visual disability for that patient (2). As such, incorporation of patient-reported outcome measures will likely ensure those who stand to benefit most from the surgery receive it in a timely manner.

In addition to optimizing the cataract surgery waitlist, we need to also think about how we can best optimize workflow and patient flow in the COVID-19 era. Although traditionally cataract patients visit their ophthalmologists twice prior to surgery, we should now consider a single preoperative consultation which occurs on the same day as biometry testing. This approach can lead to not only savings in terms of time, but also more efficient utilization of resources and streamlined patient turnover (3). Similarly, postoperative evaluations can also be modified by having ophthalmologists either ask the postoperative questionnaire to low risk patients virtually via telephone on the day after their surgery, or in-person 7-14 days after their surgery (4). As we move towards more electronic care, virtual education through the use of online information and videos delivered in advance can also be useful for teaching and educating patients while reducing the need for an in-person discussion. To further reduce exposure time, ophthalmologists may consider offering immediate sequential bilateral cataract surgery; with careful patient selection and strict adherence to protocol, this can lead to fewer hospital visits, enhanced clinical efficiency, and reduced PPE utilization (5). Although the cataract patient journey is likely to change drastically post COVID-19, the silver lining of this pandemic is that we can come out better equipped to more efficiently and safely serve our patients.

Since COVID-19 was declared as a pandemic by WHO on Mar 11, 2020, many professional societies have recommended elective surgery should ideally be postponed before it seems necessary with the goals to minimize disease spread and maintain healthcare capacity. Even so, the provision of surgery will continue to be an essential part of our healthcare system throughout the pandemic [1]. For patients who need surgeries during the pandemic, what risk will they take if infected with SARS-CoV-2 postoperatively? So far, little is known about the impact of COVID-19 on the fatality of patients during the postoperative period, however. I searched PubMed for articles published up to May 13, 2020, using the search term “novel coronavirus”, “2019-nCoV”, “COVID-19” or “SARS-CoV-2” with no language or time restriction. Three articles including 19 patients who have COVID-19 perioperatively are found [2-4].
Of the 19 patients, 11 are male (57.9%). The mean age is 60.3 years old. The operations include general surgery, gynecology surgery and thoracic surgery. Among them, 12 patients have records about timing of COVID-19 symptoms onset; 9 patients (75%) present pneumonia symptoms within 7 days after surgery and the other 3 have symptoms more than 7 days following surgery. The case fatality rate is 36.8% (7/19).
Data presented here suggest that patients infected with COVID-19 in the perioperative period do have increased risk of fatality. Based on current literatures and statistics, although the current series might bias reporting more severe cases, it is widely believed that the fatality of COVID-19 in the general population is less than 5%. Older age and comorbidity are thought to be the indicators of poor prognosis [5]. Data here suggest that postoperative patients might be another group of patients with poor prognosis of COIVD-19.
In addition, the median incubation period of COVID-19 has been reported to be 4 days, mostly 2-7 days. The fact that 75% of the cases manifest pneumonia symptoms within 7 days after surgery means that most of the infections might occur before surgery. These surgeries could have been delayed safely if SARS-CoV-2 infection could be detected before the operations.
At this moment, there is no vaccine or effective antivirals available. Prevention is, so far, the best way to reduce the impact of COVID-19. Preoperative intensive surveillance for SARS-CoV-2 infection must be done during the whole pandemic period. To avoid nosocomial transmission of the virus, strict isolation and protection measures should be implemented. The visitor policy should be updated simultaneously; each patient can only have 1 visitor at a time. Finally, our surgical communities should adapt to the unprecedented worldwide public health crisis to develop a COVID-19-specified approach for providing the very best care to our patients during the pandemic.

Drs Urbach and Martin highlight the issue of access to elective surgeries during the COVID-19 crisis. However, their solution-- a single-entry care model—is overly simplistic and will do little to address patient wait times for many elective surgeries, such as cataract surgery. Even before COVID-19, surgeons across Canada had unacceptably long wait times, over 1 year in several regions.

A single-entry model would be useful in hospitals where surgeons performing the same procedure have large variations in wait times. But even in this scenario, patients having elective procedures like cataract surgery may want to preserve some choice. A more reasonable solution would be a centralized referral system so that patients can choose either the shortest wait time or a specific surgeon. I perform cataract surgery out of Saint Mary's General Hospital in Kitchener, Ontario, where all 9 cataract surgeons have unacceptably long wait times. To address this, before COVID-19 we worked with regional partners to adopt a centralized referral system that would allow referring providers to see surgeon wait times. We also published periodic hospital newsletters highlighting current surgeon wait times for cataract surgery. These solutions empower the patient and referring provider to use wait-time information to influence their surgeon of choice without removing their autonomy.

An essential COVID-19 issue for elective surgery not addressed in the commentary is the compounding problem of how we are to maintain OR efficiencies. Before COVID-19 my hospital provided excellent and efficient care with 18 cataract surgeries completed per day, but this required patients to congregate in open-concept preoperative and postoperative areas. How can we maintain these efficiencies with the new need for social distancing and repeatedly sanitized surfaces? If we can’t, we may be facing a 2-year average wait for a procedure that patients require to maintain visual function and driving standards.