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

David R. Urbach; Danielle Martin

doi:10.1503/cmaj.200791

Submit a Response to This Article

Compose Response

Title *

References

Author Information

Contributors

First Name and Middle Initial *

First or given name, e.g. 'Peter'.

Last Name *

Your last, or family, name, e.g. 'MacMoody'.

Degrees

Email Address *

Your email address, e.g. higgs-boson@gmail.com

Occupation *

Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Minimum 7 characters.

Affiliation *

Your organization or institution (if applicable), e.g. 'Royal Free Hospital'. Minimum 12 characters.

Address

Your organization, institution's or residential address.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

Vertical Tabs

Jump to comment:

High fatality is expected in patients who have COVID-19 during postoperative period
Gengwen Huang [Ph.D., M.D.]

Posted on: 14 May 2020
RE: Urbach and Martin
Peter Schuringa

Posted on: 06 May 2020
RE: Confronting the COVID-19 surgery crisis: time for transformational change
Chryssa N McAlister [MD, FRCSC, MHSc]

Posted on: 06 May 2020
RE: Central Intake
Craig Stone [MD MSc FRCS(C)]

Posted on: 06 May 2020

Posted on: (14 May 2020)

High fatality is expected in patients who have COVID-19 during postoperative period
Gengwen Huang [Ph.D., M.D.], General Surgeon, Xiangya Hospital, Central South University
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,...
Show More

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.
Show Less

Competing Interests: None declared.
Posted on: (6 May 2020)

RE: Urbach and Martin
Peter Schuringa, Orthopaedic Surgery, Handworx Inc
Regarding the "Who gives a "F" who does my surgery approach to medicine. Good luck with that. Patients care who does their surgery. And this approach assumes that there is even more than one surgeon who can competently perform the procedure - a failed assumption.
And this article completely ignores that there is simply for too little resource to address an over taxed system no matter who does the surgery.

Competing Interests: None declared.
Posted on: (6 May 2020)

RE: Confronting the COVID-19 surgery crisis: time for transformational change
Chryssa N McAlister [MD, FRCSC, MHSc], Ophthalmologist and Co-Division Lead for Ophthalmology at Saint Mary's General Hospital, Saint Mary's General Hospital
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...
Show More

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.
Show Less

Competing Interests: None declared.
Posted on: (6 May 2020)

RE: Central Intake
Craig Stone [MD MSc FRCS(C)], Orthopedic Surgeon, Memorial University/Eastern Health
Drs. Urbach and Martin. Thank you for your timely and well written article. I have an example of how this approach is achievable.
The Orthopedic Service at Eastern Health in St. John's, NL has had a orthopedic central intake (OCI) for all elective referrals for over 10 years now. All 12 surgeons participate in the intake model. We triage all referrals on an urgency scale and assure the patient ends up with the proper subspecialist if appropriate. The referring physicians have provided excellent feedback. They appreciate the one common referral form and the fact we direct the patient to the most appropriate provider. The option still exists for a specific surgeon if the patient or family doctor desires. Often we will suggest more investigations to be completed before the clinic visit, making it much more productive. The list of advantages of our intake model, both predicted and unforeseen, is long.
The efficiency achieved has certainly outweighed the resources invested. Once we had buy in for all stakeholders, the system has provided advantages for all. No one would go back to the old way. Our guiding principle has always been "the right patient, in the right place, at the right time."

Competing Interests: None declared.