COVID-19 and the challenges of the surgery backlog: the greatest healthcare innovation would be to do what we know

Describing primary care patterns before and during the COVID-19 pandemic across Canada: a quasi-experimental pre-post design cohort study using national practice-based research network data

OBJECTIVE

The objective was to analyse how the pandemic affected primary care access and comprehensiveness in chronic disease management by comparing primary care patterns before and during the early COVID-19 pandemic.

DESIGN

We conducted a quasi-experimental pre-post design cohort study and reported indicators for the 21 months before and after the onset of the COVID-19 pandemic.

SETTING

We used electronic medical record data from primary care clinics enrolled in the Canadian Primary Care Sentinel Surveillance Network from 1 January 2018 to 31 December 2021.

POPULATION

The study population included patients (n=919 928) aged 18 years or older with at least one primary care contact from 12 March 2018 to 12 March 2020, in Canada.

OUTCOME MEASURES

The study indicators included three indicators measuring access to primary care (encounters, blood pressure measurements and lab tests) and three for comprehensiveness (diagnoses, non-COVID-19 vaccines administered and referrals).

RESULTS

67.3% of the cohort was aged ≥40 years, 56.4% were female and 53.5% were from Ontario, Canada. Fewer patients received an encounter during the pandemic (91.5% to 81.5%), while the median (IQR) number of encounters remained the same (5 (2-1)) for those with access. Fewer patients received a blood pressure measurement (47.9% to 31.8%), and patients received fewer measurements during the pandemic (2 (1-4) to 1 (0-2)).

CONCLUSIONS

Encounters with primary care remained consistent during the pandemic, but in-person care, such as lab tests and blood pressure measurements, decreased. In-person care indicators followed temporally to national COVID-19 case counts during the pandemic.

Critical care and pandemic preparedness and response

Critical care was established partially in response to a polio epidemic in the 1950s. In the intervening 70 yr, several epidemics and pandemics have placed critical care and allied services under extreme pressure. Pandemics cause wholesale changes to accepted standards of practice, require reallocation and retargeting of resources and goals of care. In addition to clinical acumen, mounting an effective critical care response to a pandemic requires local, national, and international coordination in a diverse array of fields from research collaboration and governance to organisation of critical care networks and applied biomedical ethics in the eventuality of triage situations. This review provides an introduction to an array of topics that pertain to different states of pandemic acuity: interpandemic preparedness, alert, surge activity, recovery and relapse through the literature and experience of recent pandemics including COVID-19, H1N1, Ebola, and SARS.

Integration of functional capacity to medically necessary, time-sensitive scoring system: A prospective observational study

OBJECTIVES

To evaluate 2 new modifications to medically necessary, time-sensitive (MeNTS) scoring systems integrating functional capacity assessment in estimating intensive care unit (ICU) requirements.

METHODS

This prospective observational study included patients undergoing elective surgeries between July 2021 and January 2022. The MeNTS scores and our 2 modified scores: MeNTS-METs (integrated Duke activity status index [DASI] as metabolic equivalents [METs]) and MeNTS-DASI-5Q (integrated modified DASI [M-DASI] as 5 questions) were calculated. The patients' ICU requirements (group ICU+ and group ICU-), DASIs, patient-surgery-anesthesia characteristics, hospital stay lengths, rehospitalizations, postoperative complications, and mortality were recorded.

RESULTS

This study analyzed 718 patients. The MeNTS, MeNTS-METs, and MeNTS-DASI-5Q scores were higher in group ICU+ than in group ICU- (p<0.001). Group ICU+ had longer operation durations and hospital stay lengths (p<0.001), lower DASI scores (p<0.001), and greater hospital readmissions, postoperative complications, and mortality (p<0.001). The MeNTS-METs and MeNTS-DASI-5Q scores better predicted ICU requirement with areas under the receiver operating characteristic curve (AUC) of 0.806 and 0.804, than the original MeNTS (AUC=0.782).

CONCLUSION

The 5-questionnaire M-DASI is easy to calculate and, when added to a triage score, is as reliable as the original DASI for predicting postoperative ICU requirements.

Getting operating theatre metrics right to underpin quality improvement: understanding limitations of NHS Model Hospital calculations

The Model Hospital is an NHS online resource summarising performance data for, amongst other things, operating theatres categorised by NHS Trust and specialty. As an official source of information, it might be assumed that metrics, such as 'average late start time', 'average early finish time', and 'average late finish time', are calculated in a way to reflect performance in these domains, but this is not the case. These values are, respectively, only for those lists that start late, finish early, and finish late, with the number of lists in each category unreported. The Model Hospital reports utilisation appropriately as 'touch time' (the time delivering anaesthesia and surgery) but prefers a 'capped' measure, in which any touch time occurring in late finishes is ignored. The Model Hospital aggregates utilisations across lists in a mathematically invalid way, which leads to the assumption that small aliquots of unused time on lists can be combined to create larger time blocks, in which to complete more operations. We present alternative, more intuitive, and mathematically conventional methods to derive performance metrics using the same data. The results have implications for hospitals developing their own dashboards and international organisations seeking to create national databases for operating theatre performance.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Reimagining health preparedness in the aftermath of COVID-19

Efficiency is an essential part of sustainable healthcare, especially in emergency and acute care (including surgical) settings. Waste minimisation, streamlined processes, and lean principles are all important for responsible stewardship of finite health resources. However, the promotion of efficiency above all else has effectively subordinated preparedness as a form of waste. Investment in preparedness is an essential part of resilient healthcare. The ongoing COVID-19 pandemic has exposed the gap between efficient processes and resilient systems in many health settings. In anticipation of future pandemics, natural disasters, and mass casualty incidents, health systems, and individual healthcare workers, must prioritise preparedness to be ready for the unexpected or for crises. This requires a reframing of priorities to view preparedness as crucial insurance against system failure during disasters, by taking advantage of lessons learnt preparing for war and mass casualty incidents.