In the early stages of the pandemic – amid fears that surges of COVID-19 cases might overwhelm hospital bed capacity – surgical departments across Canada responded quickly by postponing or cancelling thousands of scheduled surgeries. (We avoid the term “elective surgeries” because it implies that these surgeries are of lower priority than other medical interventions.) For many patients the consequences of the delayed surgeries were severe.

This initial pandemic response created a large amount of capacity very rapidly, but also resulted in extensive surgical backlogs. With the benefit of hindsight, we know that a more nuanced approach of targeted restriction of surgical activity – easily modelled using length-of-stay data –could have allowed a more dynamic balancing of the needs of COVID-19 patients and the much larger number of patients harmed by surgical delays.

Now, as scheduled surgeries resume, healthcare organizations are facing significant challenges in their efforts to clear the backlogs while maintaining sufficient capacity to cope with future waves of the pandemic. This is not a matter of working harder to get back to normal. Before the pandemic began, hospitals were already running at or near capacity, and operating room (OR) management is now more complicated due to COVID-related restrictions, such as physical distancing and infection control. Many health systems are already rethinking their processes and developing new strategies based on knowledge gained during the course of the pandemic.

With all that in mind, a group of 19 surgeons – representing diverse specialties and healthcare organizations across Canada – recently took part in an online Health Leaders’ Forum with the theme, “COVID-19 Response: Clearing Surgical Backlogs and Adapting Surgical Care Delivery.” Sponsored by Medtronic Canada, the forum was part of the Health Professionals’ Roundtable for Strategy, a program of the Canadian College of Health Leaders (CCHL n.d.).

The discussion focused on six topics considered essential to the development of successful responses to COVID-19. Key comments and insights for each topic included:

• Patient prioritization. In an effort to ease backlogs, leading organizations are developing centralized systems to prioritize patients and schedule surgeries in a way that increases efficiencies and capacities. The approach is patient-centered, not surgeon-centered. Some organizations are coordinating services and sharing resources to support centralized patient prioritization. The ability to ramp up OR capacity is limited by factors such as competition for resources and the difficulty of increasing staffing levels at a time when all hospitals face similar challenges.
• OR efficiency. With COVID-19 control measures in place, moving patients in and out of the OR takes more time than in the past. Several hospitals are experimenting with regional anesthetics (rather than general anesthetics), when appropriate, as a way of reducing OR and recovery times. Patient preparation time and PPE use can potentially be reduced through improved pre-operative testing for COVID-19, or by requiring patients to self-isolate for two weeks before hospital admission. Innovations in OR utilization of time and space, such as extended hours and alternating ORs between patient preparation and surgical procedures, are also being tested. 
• Protecting OR capacity. After giving up beds for COVID-19 cases early in the pandemic, surgical departments now need them back. As hospitals adjust to the new realities, surgeons should collaborate more broadly on advocacy efforts to ensure that beds and other resources will be available for surgical patients. Surgical departments have shown they can shut down services very quickly, so idle capacity doesn’t have to be maintained for long periods in the event of a future COVID-19 wave. The pandemic has also revealed that surgical resources are limited, so investments are required.
• Extrinsic factors affecting surgical planning. Cancer care offers a number of examples of how a pandemic alters extrinsic factors that are beyond the control of surgical teams but have a significant impact on surgical planning and patient care. In the UK, a six-month delay in surgery schedules led to a 30% reduction in cancer survival rates (Maringe et al. 2020). During the pandemic, cancer diagnostic rates, such as endoscopies and biopsies, fell and that can have a long-lasting impact on surgery schedules. During the pandemic, many medical patients did not go to the hospital for ER visits or as scheduled, and this had major implications for managing wait lists (Jackson 2020). Coordinating with ORs to help address extrinsic factors is important, particularly for smaller hospitals.
• Teaching in a hospital in a COVID-19 environment. The pandemic has majorly impacted teaching by limiting opportunities for students and residents to be present in hospitals and engage with teachers. Various measures are now being taken to accommodate students and residents, but more work and advocacy is needed in this area.
• Virtual care. One silver lining of COVID-19 is that it has forced rapid adoption and adaptation of virtual care technologies that were previously underutilized in Canadian health systems. Investments in these technologies have accelerated, resulting in substantial savings of time for patients as well as improved efficiency and convenience for both patients and providers. Support for these technologies should continue, but the limitations of virtual care need to be understood.

In addition to the discussion points and recommendations outlined above, several recurring themes emerged over the course of the forum:

• Need for better data. Improved data collection and analysis will be required to enable more informed decision-making in any future pandemic waves. For example, data related to length-of-stay and clinical resources can support centralized systems for patient prioritization; data demonstrating the risks associated with surgical delays can protect OR capacity as well as patient prioritization; and data on regional variations in the impact of COVID-19 or any future pandemic will help organizations respond to local circumstances.
• Ambulatory care.  Whenever possible, patients should be moved to ambulatory care where they are easier to manage due to reduced infection control needs. This will facilitate patient prioritization, improve OR efficiency and protect OR capacity.
• Regional coordination and planning. Regional approaches to patient prioritization and OR management can help ensure ample COVID-19 care delivery without shutting down ORs in all area hospitals.

Despite its challenges, the COVID-19 pandemic has shown how everyone in healthcare can work towards a common goal. It has also been a trigger for important changes in areas such as communication technology and virtual healthcare. The lessons learned to date can be applied toward planning for future waves and pandemics. The surgeons participating in the forum noted that they share many of these lessons even though they represent different specialties and healthcare organizations across Canada. They recommended that dialogue on these issues should be continued, and expanded to include anesthesiologists, nurses and other members of surgical teams.

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