Bass, Juan

Beaudry, Paul

Corsten, Gerard

Drake, James

Evans, Mark

Farmer, Jean Pierre

Flageole, Helene

Keijzer, Richard

Mau, Elke

Mayer, Sandeep

Prasil, Pascale

Price, David

Scott, Leslie

Skarsgard, Erik D.

Venne, Dominic

English

Scholarship@Western

Western University Scholarship@Western Paediatrics Publications Paediatrics Department 10-13-2020 Prioritizing specialized children’s surgery in Canada during the COVID-19 pandemic Erik D. Skarsgard The University of British Columbia Erik D. Skarsgard The University of British Columbia Juan Bass Children's Hospital of Eastern Ontario, Ottawa Paul Beaudry University of Calgary Gerard Corsten Dalhousie University See next page for additional authors Follow this and additional works at: https://ir.lib.uwo.ca/paedpub Citation of this paper: Skarsgard, Erik D.; Skarsgard, Erik D.; Bass, Juan; Beaudry, Paul; Corsten, Gerard; Drake, James; Evans, Mark; Farmer, Jean Pierre; Flageole, Helene; Keijzer, Richard; Mau, Elke; Mayer, Sandeep; Prasil, Pascale; Price, David; Scott, Leslie; and Venne, Dominic, "Prioritizing specialized children’s surgery in Canada during the COVID-19 pandemic" (2020). Paediatrics Publications. 2380. https://ir.lib.uwo.ca/paedpub/2380 Authors Erik D. Skarsgard, Erik D. Skarsgard, Juan Bass, Paul Beaudry, Gerard Corsten, James Drake, Mark Evans, Jean Pierre Farmer, Helene Flageole, Richard Keijzer, Elke Mau, Sandeep Mayer, Pascale Prasil, David Price, Leslie Scott, and Dominic Venne This article is available at Scholarship@Western: https://ir.lib.uwo.ca/paedpub/2380 All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Can adian Medical Association or its subsidiaries.E1212  CMAJ  |  OCTOBER 13, 2020  |  VOLUME 192  |  ISSUE 41 © 2020 Joule Inc. or its licensorsO n Mar. 11, 2020, the World Health Organization declared coronavirus disease 2019 (COVID-19) a global pan-demic, and our provincial and territorial governments began preparing hospitals for an expected surge of COVID-19–related hospital and intensive care unit admissions. This included cancellation of elective surgeries; by the end of March, Canadian hospitals were cancelling surgeries at an estimated rate of 33 000  per week.1 How have hospitals’ surgery cancella-tion policies affected subspecialty children’s surgery in Canada and how should we deal with the backlog? Subspecialty-trained pediatric surgeons, anesthesiologists, pediatricians, pediatric nurses and other health care profession-als, supported by child-focused infrastructure, provide surgical care in 15 children’s hospitals in Canada. Children’s hospitals are referral centres for tertiary and quaternary surgery, includ-ing surgery for congenital heart disease, brain and solid organ tumours, scoliosis, hearing and vision preservation, and surgery in children with complex medical conditions. Cardiac and solid organ transplant surgery is regionalized to eastern and western Canada. Children aged up to 17 years account for about 5% of inpatient surgical procedures, according to data from the Can-adian Institute for Health Information.2 About half of these sur-geries — which include appendectomy, hernia repair, ear tubes, and tonsillectomy and adenoidectomy — are performed in older, generally healthy children outside of children’s hospitals by surgeons who primarily treat adults, and are not the prime focus of this article.Surgery in children has traditionally been overlooked in Can-ada.3 Scheduled (elective) children’s surgery is informed by national-consensus wait-time targets (ranging from < 24 h to <  12  mo), which allows for robust performance measurement and reporting on completed surgeries.4 Data from 2018 showed that only 65% of elective surgeries in Canadian children’s hospi-tals were completed “within window,” suggesting insufficient national capacity even before the pandemic.5Canada’s early COVID-19 surge planning considered the poten-tial for diverting adult patients to children’s hospitals. This was not needed, except for 3 adults with COVID-19 treated at pediatric facilities in Quebec, 2 of whom required mechanical ventilation (Pramod Puligandla, Department of Pediatric Surgery, The  Montreal Children’s Hospital, McGill University Health Centre, Montréal, Que.: personal communication, 2020). Care of these adults did not interrupt service delivery for children and had no negative effects on the hospital’s health care workforce. However, although emergency (unscheduled) pediatric surgery was uninter-rupted during the pandemic, scheduled surgery was restricted to urgent procedures from the week of Mar. 16, 2020, until late May or early June, depending on the province. This resulted in a pre-cipitous decline in pediatric surgical volumes across Canada. Urgent surgical priorities for children included cancer and car-diac surgery, and within a few weeks, solid organ transplant sur-gery; procedures with short wait-time targets; and surgery for symptomatic patients and those requiring developmentally timed surgery for which delay impairs functional outcome (e.g., spinal fusion for scoliosis). Although nearly 9000 emergency and urgent surgeries were completed in Canadian children’s hospitals between mid-March and June, there were an estimated 7600 sur-gery postponements with an additional estimated 4000 children COMMENTARY    HEALTH SERVICESPrioritizing specialized children’s surgery  in Canada during the COVID-19 pandemicErik D. Skarsgard MSc MD; for the Pediatric Surgical Chiefs of Canada*  n Cite as: CMAJ 2020 October 13;192:E1212-3. doi: 10.1503/cmaj.201577; early-released September 1, 2020*A complete list of the members of the group appears at the end of the article.KEY POINTS • Children requiring elective, specialized surgery in Canada are treated by subspecialized surgical teams in 1 of 15 children’s hospitals but, like adults, are required to wait for their surgery. • As part of an overall health system response to the coronavirus disease 2019 (COVID-19) pandemic, children’s hospitals in Canada — like adult hospitals — cancelled elective surgeries and immediately prioritized urgent surgeries and developed policies and protocols to reduce the risk of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among patients and staff. • As hospitals restore elective surgical services, the backlog of children waiting requires a prioritization and implementation framework for surgery that reflects the unique needs of children compared with adults and supports access for families who are already disadvantaged by social and economic inequality.COMMENTARY CMAJ  |  OCTOBER 13, 2020  |  VOLUME 192  |  ISSUE 41 E1213not wait-listed owing to reduced access to consultation (Helene Flageole, McMaster Children’s Hospital and Pediatric Surgical Chiefs of Canada, Hamilton, Ont.: personal communication, 2020).Addressing this backlog will require additional scheduled sur-gical capacity (such as longer weekday and weekend slates and extra rooms) supported by additional human resources (nurses, anesthesiologists and surgeons), a commitment to workplace well-ness, specialized equipment, drugs, diagnostic services (especially laboratory and radiology), and a sufficient supply of personal pro-tective equipment. Pediatric nursing and anesthesiology shortages already exist in a number of provinces, making targeted physician recruitment and retention and hospital-based nurse training crit-ical to the ramp-up. Priority should be given to surgeries postponed owing to COVID-19 and procedures with shorter wait-time targets, for which delays increase the risk of harm (e.g., infant hernia incar-ceration). Certain patients (e.g., those with scoliosis and epilepsy) experience disease progression at different rates and may need to jump the queue. Wait-list analytics should drive operating room allocation to specialties with long wait-lists, especially those with procedural wait times beyond Canada’s national targets.The pandemic has lengthened perioperative processes (which should be factored into case volume projections) and has reduced ambulatory clinic access. Addressing the surgical backlog assumes sufficient access for pre- and postoperative assessments as well as new referrals, many of which can likely be performed virtually. Ambulatory clinic redesign that reduces waiting, enables physical distancing, integrates screening and patient optimization, and uses virtual care for follow-up when appropriate can lead to a more patient-centred experience that should be sustained beyond the pandemic.Although the COVID-19 burden among children initially seemed low, emerging evidence has suggested that one-third of children infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were asymptomatic,6 and the sensitivity of RNA poly-merase chain reaction testing from swabs taken from children was less than 80%.7 Given the perceived higher likelihood that an adult household member would transmit the virus than a child, children’s hospitals restricted the number of adults accompanying children to hospital. Even hospitals that routinely encourage parental presence in the operating room during anesthesia induction allowed it only selectively, and this practice largely continues. However, special consideration for surgical access is required for fam ilies disadvan-taged by geographic remoteness, economic instability and other disparities, for whom existing virtual and outreach clinics will need to continue or be expanded. Culturally sensitive engagement, including with Indigenous communities, will be essential.In Canada, interprovincial mobility is necessary for patients to access cardiac or transplant surgery, as well as some spinal and minimally invasive surgeries that are not available in every prov-ince. This means that travel-associated public health risks must be mitigated and requires an ethical framework, currently in use in several provinces, for resolving conflicts in prioritizing children from different provinces. Children waiting for surgery in general hospitals may become lost in the large backlog of adult surger-ies. We must engage our adult surgical colleagues in advocating for these children, and in finding solutions that could include bringing some to children’s hospitals for surgery.As Canada moves into a pandemic recovery phase, there is a danger that adult patients will be favoured by efforts to address the impact of disrupted access to surgery and to reduce the backlog of surgery. Children are not small adults and they are not less deserving. Children have unique surgical needs that require prioritization within our health systems.References1. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg 2020 May 12 [Epub ahead of print]. doi: 10.1002/bjs.11746.2. Table 4: Number, percentage* and average acute length of stay for top 10 high-volume inpatient surgeries by province/territory, HMDB, 2017–2018 [table]. Ottawa: Canadian Institute for Health Information. Available: www.cihi.ca/sites/default/files/document/dad-hmdb-childbirth-quick-stats-2017-2018-en.xlsx (accessed 2020 May 17). 3. Blair GK. Children are waiting for care and answers. CMAJ 2008;179:983-4.4. Wright JG, Menaker RJ; Canadian Paediatric Surgical Wait Times Study Group. Waiting for children’s surgery in Canada: the Canadian Paediatric Surgical Wait Times Project. CMAJ 2011;183:E559-64.5. Paediatric surgical wait times report. FY 2018. Canadian Paediatric Decision Sup-port Network. Available: https://ken.childrenshealthcarecanada.ca/xwiki/bin /view/Canadian+Paediatric+Decision+Support+Network+%28CPDSN%29 (accessed 2020 July 17). 6. Bai K, Liu W, Liu C, et al. Clinical analysis of 25 novel coronavirus infections in children. Pediatr Infect Dis J 2020;39:e100-3.7. Yuan C, Zhu H, Yang Y, et al. Viral loads in throat and anal swabs in children infected with SARS-CoV-2. Emerg Microbes Infect 2020;9:1233-7.Members of the Pediatric Surgical Chiefs of Canada group: Erik D. Skarsgard* MSc MD (pediatric surgery), University of British Columbia and British Columbia Children’s Hospital, Vancouver, BC; Juan Bass† MD (pediatric surgery), University of Ottawa and Children’s Hospital of Eastern Ontario, Ottawa, ON; Paul Beaudry† MD, pediatric surgery, University of Calgary and Alberta Children’s Hospital, Calgary, AB; Gerard Corsten† MD (pediatric otorhinolaryngology, head and neck surgery), Dalhousie University and IWK Health Centre, Dalhousie, NS; James Drake† MD (pediatric neurosurgery), University of Toronto and SickKids Hospital, Toronto, ON; Mark Evans† MD (pediatric surgery), University of Alberta and Stollery Children’s Hospital, Edmonton, AB; Jean-Pierre Farmer† MD (pediatric neurosurgery), McGill University and Montreal Children’s Hospital, Montreal, QC; Helene Flageole (chair)† MD (pediatric surgery), McMaster University and McMaster Children’s Hospital, Hamilton, ON; Richard Keijzer† MD (pediatric sur-gery), University of Manitoba and Children’s Hospital of Winnipeg, Winnipeg, MB; Elke Mau† MD (pediatric urology), University of Sas-katchewan and Jim Pattison Children’s Hospital, Saskatoon, SK; Sandeep Mayer† MD (pediatric surgery), Université de Sherbrooke and Centre Hospitalier de l’Université Sherbrooke, Sherbrooke, QC; Pascale Prasil† MD (pediatric surgery), Université Laval and Centre Hospitalier de l’Université Laval, Ste. Foy, QC; David Price† MD (pedi-atric surgery), Memorial University of Newfoundland and Janeway Children’s Health and Rehabilitation Centre, St. John’s, NL; Leslie Scott† MD (pediatric surgery), Western University and London Health Sciences Centre – Children’s Hospital; Dominic Venne† MD (pediatric neurosurgery), Université de Montréal and Centre Hospitalier de l’Université  Sainte-Justine, Montréal, QC. *author; †contributor. Competing interests: None declared.This article has been peer reviewed.Affiliations: Department of Surgery, University of British Columbia; Department of Pediatric Surgery, British Columbia Children’s Hospital, Vancouver, BC Correspondence to: Erik Skarsgard, eskarsgard@cw.bc.ca

Prioritizing specialized children’s surgery in Canada during the COVID-19 pandemic

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Prioritizing specialized children’s surgery in Canada during the COVID-19 pandemic

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