How a hospital group is preparing to resume elective surgeries after COVID-19 turmoil

TORONTO — During the pandemic, hospitals closed to all but urgent treatments. Now, with the number of COVID-19 cases dropping and the toll of the disease on the health care system easing, Ontario hospitals are getting ready to move to Phase 2 — where they can perform elective surgeries again.

But the process of starting everything up again after COVID-19 shut it down is a complex and unprecedented juggling act between pent up patient demand created by thousand of postponed surgeries, and the uncertainties of the new coronavirus.

INSIDE PHASE 1

On the surgical floor of Milton Regional Hospital is an unusual site in the history Canadian health care — a bank of operating rooms empty and unused.

This has been the reality during the COVID-19 lockdown. Operations were postponed to clear bed space and redeploy staff for a surge of patients with severe coronavirus infections.

Only emergencies and critical cancer operations have been performed and, more recently, day surgeries that don’t require an overnight stay, as part of Phase 1.

Hospital staff like veteran OR nurse Debbie Szczygelski are anxious to get back to normal patient care.

“We’re definitely feeling a little bit out of sorts,” says Szczygelski. Things “feel very strange,” for her and her colleagues these days.

Halton Healthcare, which operates three hospitals in Oakville, Milton and Georgetown, usually performs 44,000 surgeries a year. But that number has been down with OR operating at 25 per cent capacity.

Meanwhile, the pressure is mounting to help patients waiting for more complex surgeries such as hip and knees, said Judy Linton, Halton Health’s senior vice president of Clinical Programs and Chief Nursing Executive.

“Those people, the longer they wait, the more the chronic pain gets worse, and so there’s definitely pressure from the public, from our surgeons, to increase the volume of cases that we can do,” she said.

The backlog of elective surgeries that have piled up during the pandemic could take well over a year to clear. Officials in B.C. predicted in May that it could take up to two years for the health-care system to catch up.

But hospitals can’t rush back into their old routine. Because no one knows exactly what the new coronavirus holds in store.

“From a hospital system perspective […] I don’t think we’ve seen anything like this before, “ says Dr. Daniel Edgcumbe, vice president of Medical Affairs at Halton Healthcare.

There are new critical issues to keep in mind, he says. How do you ramp up procedures when there is limited supplies of medications and protective equipment like masks and gowns?

“COVID means we’re going to have to do things differently for the foreseeable future,” Edgcumbe said. “It’s unprecedented.”

Moving to Phase 2 in Ontario requires hospitals to return to 90 per cent of occupancy. Some have been as low as 50-60 per cent filled during the past months. Ten per cent must be left free for COVID-19 cases if there is a surge.

Managing this is part of the role of the COVID-19 Emergency Operations Centre Team. 

Every day since late January, team leaders from across the three hospital sites have gathered to sort out the challenges of treating COVID-19 cases.

More recently, their focus is shifting to how to get the hospitals running more normally again, with three key measures:

  • tracking COVID-19 cases, which are dropping in the region;
  • making sure there is a steady supply of medications, in particular, sedatives, needed for surgery patients and for ICU and COVID-19 patients; and,
  • keeping a healthy supply of the critical gloves, masks and gowns needed for COVID-19 protection and for surgery. As hospitals ramp up elective surgeries, they will need more PPE, including masks, to deal with any surge of COVID-19.

In Ontario, hospitals aren’t allowed to resume surgery until there is a secure 30 day supply of medications and PPE.

Scott Etherington, Manager of Logistics at Shared Services West, a not-for-profit organization in Georgetown that helps manage supply chains, said they “have to demonstrate every week to the government that we continue to maintain our supply.”

Because PPE and masks are in such high demand right now, he said they’ve “had to find new and innovative ways in order to keep these things coming in.”

Waiting at the other end of that supply chain are the surgeons like Kevin Kwan, the chief of surgery at the Milton hospital and a urologist who treats cancers. Right now, he’s able to handle the most critical cases, but like everyone else, is stuck waiting for the green light to move into Phase 2 and take on more surgeries.

“We don’t want to just open up the floodgates and not have enough [PPE], and then we’re having to take two steps back,” Kwan told CTV News. “Same thing applies to medication shortages, which have been a pre-existing problem. But when you have more patients that are admitted to the hospital, for example, in a situation where there might be a surge of COVID-19 patients, that does use up a lot more of the medications that we would also additionally use for elective surgery. So we have to prioritize where we can use our fixed supply.”

Another concern is ensuring physical distancing is possible within the hospital. Halton Healthcare, like other hospitals, has redesigned waiting rooms to make sure people are six feet apart.

And in the event of a new surge of COVID-19 cases, the three hospitals have also turned unused wards into makeshift “field hospitals.”

In total, it’s been a system overhaul unlike anything.

“I lived through SARS, and it was a completely different environment,” Linton said. “I have never seen us go down this much, and then have to figure out how to come back up again.”

Edgcumbe agreed, pointing out that the pandemic has significantly impacted the healthcare landscape for physicians.

“I don’t think anyone’s job looks the same as it did before COVID, and of course they’re anxious to do the best thing for their patients in this new world of COVID that we face,” he said.

Despite all the juggling, the hospitals insist they are ready for the province to greenlight the expansion of services.

“Everyone is kind of wanting to get back to normal. So it’s frustrating, but we are doing everything that we can [to have] a safe space,” Szczygelski said.

“The only thing I can say is, yes, it seems like it’s a long wait, but it is with your safety in mind that we are doing it at this pace.”

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