While the provincial government asked hospitals to start preparing to ramp up scheduled surgeries and procedures Thursday, Health Minister Christine Elliott said it could be "several weeks" before this actually happens.
"Because of the collective efforts of every Ontarian to stop the spread of COVID-19, we are now in the position where we can begin to plan for the gradual resumption of scheduled and elective surgeries and procedures," Elliott said during a press conference on Thursday afternoon as the government unveiled a framework for hospitals to follow for the resumption of elective surgeries.
"No decision was tougher than delaying surgeries, especially cardiac and cancer surgeries," said Elliott, referring to the government's decision to ask hospitals on March 15 to ramp down "elective surgeries and other non-emergent clinical activity."
While urgent surgeries have still been happening, Elliott acknowledged that "tens of thousands" of other surgeries have been postponed. A report from Ontario's Financial Accountability Office on April 28 estimated that about 12,200 medical procedures were being foregone each week.
On Thursday, the framework sent from Ontario Health President Matthew Anderson to hospital heads noted that hospitals responded to the government's March directive in different ways, "with some significantly reducing volumes...to only 'life or limb' surgical procedures accounting for only 10–20 per cent of regular surgical activity, while others maintained 50 per cent or more of regular surgical activity."
The document provided insight into surgery volumes prior to and during COVID-19. It outlined that there were 2,039 fewer adult cancer surgeries, 1,033 fewer adult vascular surgeries, 609 fewer cardiac surgeries and 62,614 fewer adult non-cancer surgeries between March 16 and April 26 compared to the same period last year.
"I’ve spoken with several physicians who are surgeons, they want to get back to doing more procedures but I would say it’s going to be several weeks before we’re able to get to that, before we can actually start performing those surgeries," Elliott said.
The health minister said the timelines for when hospitals resume elective surgeries and procedures — referring to surgeries that can be scheduled in advance — will vary because it depends on when each meets the criteria developed by Ontario Health and health-care experts and clinicians.
Elliott said the framework is "designed to help hospitals take an equitable, measured and responsible approach that prioritizes the health, well-being and safety of patients and health-care workers."
Hospitals will need to have a "stable" number of COVID-19 cases with the community they are in seeing a "manageable level of disease burden" or a continued decline in cases over the last two weeks. Hospitals will also need to ensure they have a "stable supply" of medications and personal protective equipment (PPE), "adequate capacity" of inpatient and ICU beds and availability of post-procedural care outside of the hospital such as rehabilitation or home care.
According to the memo from Anderson to hospital heads, the target for PPE is "a rolling 30-day stock on-hand."
Hospitals will need to set up COVID-19 Surgical and Procedural Oversight Committees. The 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. The government previously announced it was setting up five regional planning and implementation tables — a collaboration between Ontario health and local public health units — to implement plans around testing, supplies, surveillance and communications, with officials saying Thursday that these existing tables would be used.
The government is asking hospitals to reserve 15 per cent of their capacity, meaning either maintaining a maximum 85-per-cent occupancy or being able to "immediately" create more space if needed due to COVID-19. Regional committees are also being tasked with ensuring that even once surgeries ramp up, they maintain an "aggregate 15 per cent of acute care capacity."
Hospitals would also need to ensure that they have staff available.
"This includes consideration of overall workforce availability, as well as health human resources being directed to support long-term care, as this still remains a provincial priority," wrote Anderson. With long-term care homes being hit hard by COVID-19, hospitals have being redeploying staff to help in these facilities.
Ontario Health also outlined considerations for prioritizing surgeries and procedures including a patient's condition and co-morbidities, the options for non-surgery treatments, the risk of delaying a surgery, the resources that might be needed including PPE, ICU beds and medications, factors related to the procedures such as the length of stay or the probability of having to intubate a patient and the risk of transmission of COVID-19.
The framework suggested that hospitals facing resource constraints that are not ready to ramp up surgeries could consider providing "low-resource intensity" surgeries and procedures like an outpatient or day surgeries.
Asked how this aligned with officials' desire to have cancer and cardiac surgeries among the top priorities, Elliott said it's possible hospitals will decide to proceed with cataract surgeries or hip replacement surgeries, but that it will "depend on what the hospital is able to do."
"It’s going to be up to each hospital to figure out how they can proceed, what's the best way for them to proceed, what they’re going to concentrate on and that will be co-ordinated through their regional table," said Elliott, adding that some areas could a "regional approach to surgeries." So some surgeons could be deployed to other hospitals to conduct surgeries, she said.
Premier Doug Ford said the government knew "the potential for our hospitals to be overwhelmed was very real," and this is why the "difficult but necessary decision to stop many surgeries and procedures" was made. But he said Thursday he was hopeful many of these scheduled surgeries would "start soon."
"We're telling hospitals to get ready, we're telling patients to get ready," he said.
When Elliott announced on March 15 that there would be a ramping down of elective surgeries, Ontario had 142 reported cases — on Thursday, the province was reporting 19,121.
Elliott said on March 15 the government was trying to make sure Ontario's health-care system was "ready for any scenario." A memo from public health officials to hospitals that same day stated hospitals should "immediately" start planning for the reduction in non-emergent activity, but that "the trigger to implement such reductions may vary from organization to organization based on capacity, influx of COVID-19 patients, local trends in cases, and other factors."
Anderson noted that the directive from Chief Medical Officer of Health Dr. David Williams on ramping down elective surgeries "remains in force and thus no activity should actually be resumed until such time as the directive is amended or revoked."
Dr. Shady Ashamalla, a surgical oncologist specializing in colorectal cancer and head of the division of general surgery at Sunnybrook Health Sciences Centre, previously told QP Briefing that the hospital moved to a triage system instead of a "scheduled surgery system."
"Everybody that had scheduled surgeries for the end of March and...April, they were told they no longer had a scheduled date and they would be put on our triage list and they would be contacted as they were triaged," Ashamalla said.
Sunnybrook went from 25 operating rooms pre-COVID-19 to 10 and then four by the end of March. For those overseeing cancer patients, an already existing group that would review new cancer cases took on the task of triaging cancer cases.
"At that point, which was sort of the nadir — the lowest point we got to — the goal was anyone that would have a prognostic change or a risk of mortality if they did not have their surgery within two weeks would be triaged for surgery," Ashamalla said of the period when Sunnybrook had four operating rooms going.
Photo Credit: Randy Risling/Toronto Star