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Updated: December 3, 2020

What is the available evidence regarding how hospitals should manage elective surgeries during waves of COVID-19 infection rates?

Summary

The following is a short summary of the best available evidence from trusted sources that have been rated as providing high quality information on how hospitals should manage elective surgeries during waves of COVID-19 infection rates. Two evidence summaries, one rapid systematic review, one briefing note, and three national guidance were found to answer this question and were used in this REAL Summary. For additional information about each of the sources, see the Table below. For additional information about each of the sources, see the Table below.

The Surgical and cancer patients during the COVID-19 pandemic and  Surgical Practice in the Current COVID-19 pandemic: A Rapid Systemic Review both suggest hospitals to delay elective surgeries when possible [1,3].  In the event where elective surgeries will proceed, it is suggested to follow a strict protocol in the event that elective surgeries will proceed : 1) patients and staff are pre-screened; 2) the number of surgical staff are minimized without compromising  the procedure; 3) surgeries are performed by experienced staff to reduce the overall duration of the surgery; 4) there is a sufficient supply of personal protective equipment (PPE) and/or single-use equipment; and 5) make use of ambulatory care centres or other alternate sites outside of acute care facilities where appropriate [1,2,3,4]. In the Surgical and operating room procedures during the COVID-19 pandemic (multiple reviews), Evidence Aid recommends taking the following precautions: 1) use preoperative planning; 2) patients should self-isolate before elective surgery admission and use surgical masks during admission; 2) use negative pressure ventilation in operating rooms; 3) use regional anaesthesia to minimise the duration of surgery; and 4) limit the use of electro-cauterization within procedures; and (5) limit the use of endoscopic procedures to emergencies only [2].

The New South Wales Government released a national guidance, Elective surgical procedures, non-surgical alternatives and shared decision-making found that shared decision-making interventions had significant implications on increasing knowledge and certainty about completing procedures [6]. This rapid evidence check identified non-surgical alternatives for 151 surgical procedures including  orthopaedic injuries, degenerative conditions, cardiovascular conditions, and cancers [6]. In another report by the New South Wales Government’s guidance, Resuming elective surgery – Post-surgery innovations: enhanced recovery after surgery, early mobilisation and discharge, they state that evidence-based protocols  — that standardize care to improve surgical consequences  and to expedite post-surgery recovery —  was shown to reduce length of stay and decreased post-surgery complications across various surgeries (see table for this list) [5]. An emphasis on early mobilisation, nutrition and discharge were shown to be effective as well [5]. The New South Wales Government in the Resuming elective surgery – Post-surgery innovationsguidance. states that telerehabilitation leads to positive health outcomes such as reduced pain, reduced uncertainty and anguish, improved mood and physical functioning, and increased quality of life [7]. Evidence also supports the feasibility of telemedicine without compromising clinical outcomes [7].

Evidence

What‘s Trending on Social Media and Media

Published on July 1st, 2020, the Chief of Surgery at Milton Hospital states in the CTV news article that due to fixed supply of medications and PPE, the hospital must prioritize allocation of resources and poses as a barrier to resuming elective surgeries. The article reports that in Ontario, hospitals are only allowed to resume surgeries when they have a secure 30-day supply of mediations and PPE. Physical distancing must be implemented when possible. Halton Healthcare has managed this by re-designing waiting rooms to ensure patients are 6-ft apart.

Organizational Scan

On June 15, 2020, Ontario Health published their expectations for hospitals to resume surgeries and care procedures. Under the updated guideline, hospitals must reserve at least 10% of acute care capacity including personnel and resources for any emergencies. At least 15 days of supply of PPE and medication must be reserved by the hospital inaddition to 30-day backstock of PPE in the region that can be distributed readily. Hospitals must perform a weekly feasibility assessment published by Ontario Health and develop a plan for rapid ramp-down of elective surgeries and procedures in case of change in future circumstances. The region and the hospital must co-sign the hospital’s plan for resumption of elective surgeries and procedures when all the above conditions are met.

Since healthcare is under provincial jurisdiction, protocol for elective surgeries is not standardized across Canada. On May 21, 2020, BC Centre for Disease Control published protocol for surgical procedures during the COVID-19 pandemic. Prior to the surgery, patients must complete an assessment to be categorized into green, yellow, or red groups in order to apply appropriate PPE and precautionary measures (including air exchange).

Review of Evidence

Resource Type/Source of Evidence Last Updated
Surgical and cancer patients during the COVID-19 pandemic
— Evidence Aid
Evidence Summary

The following is recommended: 

·    Pre-operative management strategies: 1) postponing elective surgeries; 2) routine screening of patients; 3) using PPE; 4) scheduling longer shifts to minimize COVID-19 exposure; and 5) screening of healthcare workers.

·    Support of the use of telemedicine in postoperative follow-up of patients is also recommended.  

Last Updated: September 14, 2020
Surgical and operating room procedures during the COVID-19 pandemic (multiple reviews)
— Evidence Aid
Evidence Summary

This evidence summary recommends:

·    Screening and self-isolation of patients before elective admission and the use of surgical masks during admission. 

·    Infection control measures: 1) using negative pressure ventilation in operating theatres; 2) limiting personnel; 3) using single-use equipment; 4) using regional anaesthesia to minimise duration of surgery; and 5) limiting the use of endoscopic procedures to emergencies.

Last Updated: August 23, 2020
Surgical Practice in the Current COVID-19 Pandemic: A Rapid Systematic Review
— Hojaij et al.
Rapid Systematic Review

·    Any elective surgery that can be postponed should be delayed considering that it may take 2–3 months for the healthcare situation to return to normal. 

·    High-risk surgeries should not be postponed, but measures should be taken to reduce transmissibility — all surgical patients should be screened for COVID-19, with preference given to PCR tests. 

·    Surgical staff should be reduced to the minimum, without compromising the procedure and any operation should be performed by the most experienced surgeon, so that the procedure time is reduced.

Last Updated: May 10, 2020
Resumption of Elective Health Services Amid COVID-19
— CADTH: Canadian Agency for Drugs and Technologies in Health
Briefing Note

Safe resumption of elective services amidst COVID-19 should include: 

·    Use triage strategies to prioritize most urgent cases.

·    Ensure a sufficient availability of resources (e.g. PPE, post-acute care etc.).

·    Have clear procedures for patient and staff cohorting and infection control practices.

·    Screen and test patients undergoing elective procedures as available

·    Communicate safety measures clearly with patients, families and staff.

·    Make use of ambulatory care centres or other alternate sites outside of acute care facilities where appropriate.

Last Updated: May 4, 2020
Resuming elective surgery – Post-surgery innovations: enhanced recovery after surgery, early mobilisation and discharge
— The New South Wales Government
National Guidance

·     Enhanced recovery after surgery (ERAS) are recommended for consideration by hospitals as elective-procedures resume since outcomes for various types of surgery were generally consistent in reducing length of stay with either similar or decreased complications post-surgery when employing ERAS.

·    Early mobilisation, nutrition and discharge were effective in reducing length of stay and/or improving outcomes after certain types of surgeries including pancreatic, breast, knee, hip, bladder, liver, gastroesophageal, and colorectal.  

Last Updated: July 12, 2020
Elective surgical procedures, non-surgical alternatives and shared decision-making
— The New South Wales Government
National Guidance

·    Non-surgical alternatives were found for 151 surgical procedures.

·    Conditions reporting non-surgical alternatives to elective surgery were orthopaedic injuries and degenerative conditions, cardiovascular conditions, and cancers.

·    Shared decision-making was found to have significant implications on increasing knowledge and certainty about going through with procedures. 

·    The brief includes a list of suggestions for interventions to promote or integrate shared decision-making for elective surgical treatments and procedures.

Last Updated: October 6, 2020
Resuming elective surgery – Post-surgery innovations
— The New South Wales Government
National Guidance

·    Telerehabilitation can lead to positive health outcomes such as reduced pain and improved function after total knee or hip replacement in patients with osteoarthritis, and increased quality of life for patients undergoing physiotherapy post-surgery. 

·    Virtual follow-up shows similarly beneficial patient outcomes including reduced uncertainty and anguish for prostatectomy patients, and improved quality of life, mood and physical functioning for patients who have undergone myocardial revascularization.

·    Evidence also supports the feasibility of telemedicine without compromising clinical outcomes.

Last Updated: July 15, 2020
Updated―A Measured Approach to Planning for Surgeries and Procedures During the COVID-19 Pandemic
— Ontario Health
Organizational Scan Last Updated: June 14, 2020
Protocol for Surgical Procedures During COVID-19: Adult
— BC Centre for Disease Control
Organizational Scan Last Updated: May 20, 2020
Disclaimer: The summaries provided are distillations of reviews that have synthesized many individual studies. As such, summarized information may not always be applicable to every context. Each piece of evidence is hyperlinked to the original source.

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