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Commentary

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

David R. Urbach and Danielle Martin
CMAJ May 25, 2020 192 (21) E585-E586; DOI: https://doi.org/10.1503/cmaj.200791
David R. Urbach
Women’s College Hospital and Departments of Surgery and Health Policy, Management and Evaluation (Urbach), University of Toronto; Women’s College Research Institute (Urbach); Women’s College Hospital and Department of Family and Community Medicine (Martin), University of Toronto; Women’s College Hospital Institute for Health System Solutions and Virtual Care (Martin), Toronto, Ont.
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Danielle Martin
Women’s College Hospital and Departments of Surgery and Health Policy, Management and Evaluation (Urbach), University of Toronto; Women’s College Research Institute (Urbach); Women’s College Hospital and Department of Family and Community Medicine (Martin), University of Toronto; Women’s College Hospital Institute for Health System Solutions and Virtual Care (Martin), Toronto, Ont.
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  • RE: Canadian Health Care Should Be Better.
    Geddes F O Tyers [MD]
    Posted on: 28 October 2020
  • Transforming Cataract Surgery Practice Post COVID-19
    Bindra Shah [MPH] and Matthew B Schlenker [MD]
    Posted on: 25 August 2020
  • RE: Transformational change in surgery
    Randall W. Friesen [MD]
    Posted on: 25 June 2020
  • 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: (28 October 2020)
    Page navigation anchor for RE: Canadian Health Care Should Be Better.
    RE: Canadian Health Care Should Be Better.
    • Geddes F O Tyers [MD], Subtotally retired cardiovascular and thoracic surgeon, University of BC Hospital

    Because “Wait times for surgery were unacceptably long even before the pandemic”, Urbach and Martin refer to TRANSFORMATIONAL CHANGE (1). By definition this would completely and irreversibly alter current operating structure. Yet they only recommend further depersonalizing Canadian healthcare by centralizing waiting lists, with the probability someone you never met will do your surgery. What if months later the assigned surgeon reviews the case and thinks the risks outweigh the potential benefit (2). Or imagine immediately after a procedure a surgeon meeting a spouse and family for the first time, to inform them their loved one is dead. While there are low risk procedures where who does what may not matter there will be legal risks.

    Shuffling wait lists will not add more nurses or OR time, the bedrock of the system, but will add administration to record and manage individual lists for numerous different procedures, further diverting funds from front line care. The ability to set up reliable computerized systems is also unassured, e.g. the federal pay debacle. Plus preparing for any surgery and recovery can be stressful and very personal, particularly if complicated. Everyone in my COVID-19 bubble wants to meet their surgeon and discuss a number of issues including risks, and the authors’ comparisons to the amusement and airline industries (1) are peculiar as the customer can usually select provider and day of service on short notice.

    In spite of numerous com...

    Show More

    Because “Wait times for surgery were unacceptably long even before the pandemic”, Urbach and Martin refer to TRANSFORMATIONAL CHANGE (1). By definition this would completely and irreversibly alter current operating structure. Yet they only recommend further depersonalizing Canadian healthcare by centralizing waiting lists, with the probability someone you never met will do your surgery. What if months later the assigned surgeon reviews the case and thinks the risks outweigh the potential benefit (2). Or imagine immediately after a procedure a surgeon meeting a spouse and family for the first time, to inform them their loved one is dead. While there are low risk procedures where who does what may not matter there will be legal risks.

    Shuffling wait lists will not add more nurses or OR time, the bedrock of the system, but will add administration to record and manage individual lists for numerous different procedures, further diverting funds from front line care. The ability to set up reliable computerized systems is also unassured, e.g. the federal pay debacle. Plus preparing for any surgery and recovery can be stressful and very personal, particularly if complicated. Everyone in my COVID-19 bubble wants to meet their surgeon and discuss a number of issues including risks, and the authors’ comparisons to the amusement and airline industries (1) are peculiar as the customer can usually select provider and day of service on short notice.

    In spite of numerous commissions and promises, Canadians requiring surgery wait longer than in every other western country according to the London School of Economics/Commonwealth Fund 2017 report, plus only 35% found the overall system adequate (3). Yet per capita funding is on par, except with the only country we consistently out perform - the USA where health care delivery is even more dysfunctional. Being second or third from the bottom should not be good enough when Canadians health, livelihoods and family integrity are at risk.

    Truly transformational improvements are needed, not further additions to already bloated bureaucracies.

    Show Less
    Competing Interests: None declared.

    References

    • Urbach DR, Martin D. Confronting the COVID-19 surgery crisis: Time for transformational change. CMAJ 2020;192:15-18.
    • Raj S, Zachary K, Bheeshma R, et al. Relation between surgeon age and postoperative outcomes: a population-based cohort study. CMAJ 2020;192:E385-E392.
    • www.commonwealthfund.org > 2017 > may > international profiles
  • Posted on: (25 August 2020)
    Page navigation anchor for Transforming Cataract Surgery Practice Post COVID-19
    Transforming Cataract Surgery Practice Post COVID-19
    • Bindra Shah [MPH], Science Associate, Trillium Health Partners
    • Other Contributors:
      • Matthew B Schlenker, Glaucoma, Cataract, & Anterior Segment Surgeon

    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.

    ...Show More

    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.

    Show Less
    Competing Interests: None declared.

    References

    • David R. Urbach, Martin D. Confronting the COVID-19 surgery crisis: time for transformational change | CMAJ. CMAJ. 2020;192(21):E585–6.
    • Zhu X, Ye H, He W, Yang J, Dai J, Lu Y. Objective functional visual outcomes of cataract surgery in patients with good preoperative visual acuity. Eye. 2017 Mar;31(3):452–9.
    • Prasad S, Tanner V, Patel CK, Rosen P. Optimisation of outpatient resource utilisation in cataract management. Eye. 1998 May;12(3):403–6.
    • Grzybowski A, Kanclerz P. Do we need day-1 postoperative follow-up after cataract surgery? Graefes Arch Clin Exp Ophthalmol. 2019 May 1;257(5):855–61.
    • Lam FC, Lee RMH, Liu CSC. ‘Bilateral same-day cataract surgery should routinely be offered to patients’ – Yes. Eye. 2012 Aug;26(8):1031–2
  • Posted on: (25 June 2020)
    Page navigation anchor for RE: Transformational change in surgery
    RE: Transformational change in surgery
    • Randall W. Friesen [MD], General Surgeon, Victoria Hospital

    Kudos to Drs. Urbach and Martin for their courage to speak to fundamental issues affecting delivery of surgical services in Canada. Our regional hospital's General Surgery division began a pooled referral process several years ago. The results: balancing of workload, less variation in practice, a more cohesive team, shorter waits overall and fewer wasted resources.
    As the senior surgeon in the group at the time of transition, I shared concerns about patient willingness to see junior colleagues. However (to my reluctant satisfaction), only 10-20% of patients or referring physicians expressed a preference for a surgeon if it might result in a longer wait for consultation and/or surgery.
    I believe it is also important to bring remuneration into the discussion; fear of loss of income drives much (or most) of the reluctance to change. Thus alternate payment models, especially in an era of reduced efficiency/turnover/volume, hold some promise (and some challenges).

    Competing Interests: None declared.

    References

    • David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;192:E585-E586.
  • Posted on: (14 May 2020)
    Page navigation anchor for High fatality is expected in patients who have COVID-19 during postoperative period
    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.

    References

    • 1. David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;10.1503/cmaj.200791.
    • 2. Aminian A, Safari S, Razeghian-Jahromi A, et al. COVID-19 outbreak and surgical practice: unexpected fatality in perioperative period. Ann Surg 2020 March. 26. [Epub ahead of print]. doi: 10.1097/SLA.0000000000003925.
    • 3. Yang S, Zhang Y, Cai J, et al. Clinical characteristics of COVID-19 after gynecologic oncology surgery in three women: a retrospective review of medical records. Oncologist 2020 April. 7. [Epub ahead of print]. doi: 10.1634/theoncologist.2020-0157
    • 4. Li YK, Peng S, Li LQ, et al. Clinical and transmission characteristics of Covid-19-A retrospective study of 25 cases from a single thoracic surgery department. Curr Med Sci 2020; 40: 295-300.
    • 5. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet 2020; 395:1054-1062.
  • Posted on: (6 May 2020)
    Page navigation anchor for RE: Urbach and Martin
    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.

    References

    • David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;10.1503/cmaj.200791.
  • Posted on: (6 May 2020)
    Page navigation anchor for RE: Confronting the COVID-19 surgery crisis: time for transformational change
    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.

    References

    • David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;10.1503/cmaj.200791.
  • Posted on: (6 May 2020)
    Page navigation anchor for RE: Central Intake
    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.

    References

    • David R. Urbach, Danielle Martin. Confronting the COVID-19 surgery crisis: time for transformational change. CMAJ 2020;10.1503/cmaj.200791.
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Confronting the COVID-19 surgery crisis: time for transformational change
David R. Urbach, Danielle Martin
CMAJ May 2020, 192 (21) E585-E586; DOI: 10.1503/cmaj.200791

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Confronting the COVID-19 surgery crisis: time for transformational change
David R. Urbach, Danielle Martin
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