Modelling the backlog of COVID-19 cases for a surgical group

A reinforcement learning-based optimal control approach for managing an elective surgery backlog after pandemic disruption

Contagious disease pandemics, such as COVID-19, can cause hospitals around the world to delay nonemergent elective surgeries, which results in a large surgery backlog. To develop an operational solution for providing patients timely surgical care with limited health care resources, this study proposes a stochastic control process-based method that helps hospitals make operational recovery plans to clear their surgery backlog and restore surgical activity safely. The elective surgery backlog recovery process is modeled by a general discrete-time queueing network system, which is formulated by a Markov decision process. A scheduling optimization algorithm based on the piecewise decaying [Formula: see text]-greedy reinforcement learning algorithm is proposed to make dynamic daily surgery scheduling plans considering newly arrived patients, waiting time and clinical urgency. The proposed method is tested through a set of simulated dataset, and implemented on an elective surgery backlog that built up in one large general hospital in China after the outbreak of COVID-19. The results show that, compared with the current policy, the proposed method can effectively and rapidly clear the surgery backlog caused by a pandemic while ensuring that all patients receive timely surgical care. These results encourage the wider adoption of the proposed method to manage surgery scheduling during all phases of a public health crisis.

Patient, family and professional suggestions for pandemic-related surgical backlog recovery: a qualitative study

BACKGROUND

Surgical shutdowns related to the COVID-19 pandemic have resulted in prolonged wait times for nonemergency surgery. We aimed to understand informational needs and generate suggestions on management of the surgical backlog in the context of the ongoing COVID-19 pandemic through focus groups with key stakeholders.

METHODS

We performed a qualitative study with focus groups held between Sept. 29 and Nov. 30, 2021, in Ontario, with patients who underwent or were awaiting surgery during the pandemic and their family members, and health care leaders with experience or influence overseeing the delivery of surgical services. We conducted the focus groups virtually; focus groups for patients and family members were conducted separately from health care leaders to ensure participants could speak freely about their experiences. Our goal was to elicit information on the impact of communication about the surgical backlog, how this communication may be improved, and to generate and prioritize suggestions to address the backlog. Data were mapped onto 2 complementary frameworks that categorized approaches to reduction in wait times and strategies to improve health care delivery.

RESULTS

A total of 11 patients and family members and 20 health care leaders (7 nursing surgical directors, 10 surgeons and 3 administrators) participated in 7 focus groups (2 patient and family, and 5 health care leader). Participants reported receiving conflicting information about the surgical backlog. Suggestions for communication about the backlog included unified messaging from a single source with clear language to educate the public. Participants prioritized the following suggestions for surgical recovery: increase supply through focusing on system efficiencies and maintaining or increasing health care personnel; incorporate patient-centred outcomes into triage definitions; and refine strategies for performance management to understand and measure inequities between surgeons and centres, and consider the impact of funding incentives on "nonpriority" procedures.

INTERPRETATION

Patients and their families and health care leaders experienced a lack of communication about the surgical backlog and suggested this information should come from a single source; key suggestions to manage the surgical backlog included a focus on system efficiencies, incorporation of patient-centred outcomes into triage definitions, and improving the measurement of wait times to monitor health system performance. The suggestions generated in this study that may be used to address surgical backlog recovery in the Canadian setting.

Development of a decision analytical framework to prioritise operating room capacity: lessons learnt from an empirical example on delayed elective surgeries during the COVID-19 pandemic in a hospital in the Netherlands

OBJECTIVE

To develop a prioritisation framework to support priority setting for elective surgeries after COVID-19 based on the impact on patient well-being and cost.

DESIGN

We developed decision analytical models to estimate the consequences of delayed elective surgical procedures (eg, total hip replacement, bariatric surgery or septoplasty).

SETTING

The framework was applied to a large hospital in the Netherlands.

OUTCOME MEASURES

Quality measures impacts on quality of life and costs were taken into account and combined to calculate net monetary losses per week delay, which quantifies the total loss for society expressed in monetary terms. Net monetary losses were weighted by operating times.

RESULTS

We studied 13 common elective procedures from four specialties. Highest loss in quality of life due to delayed surgery was found for total hip replacement (utility loss of 0.27, ie, 99 days lost in perfect health); the lowest for arthroscopic partial meniscectomy (utility loss of 0.05, ie, 18 days lost in perfect health). Costs of surgical delay per patient were highest for bariatric surgery (€31/pp per week) and lowest for arthroscopic partial meniscectomy (-€2/pp per week). Weighted by operating room (OR) time bariatric surgery provides most value (€1.19/pp per OR minute) and arthroscopic partial meniscectomy provides the least value (€0.34/pp per OR minute). In a large hospital the net monetary loss due to prolonged waiting times was €700 840 after the first COVID-19 wave, an increase of 506% compared with the year before.

CONCLUSIONS

This surgical prioritisation framework can be tailored to specific centres and countries to support priority setting for delayed elective operations during and after the COVID-19 pandemic, both in and between surgical disciplines. In the long-term, the framework can contribute to the efficient distribution of OR time and will therefore add to the discussion on appropriate use of healthcare budgets. The online framework can be accessed via: https://stanwijn.shinyapps.io/priORitize/.

Cardiovascular Outcomes in Nova Scotia during the Early Phase of the COVID-19 Pandemic

Background

This study sought to determine the impact of the pandemic response to healthcare delivery on outcomes in patients with cardiovascular disease.

Methods

This is a population-based cohort study performed in the province of Nova Scotia (population 979,499), between Pre-COVID (March 1, 2017 - March 16, 2020) and in-COVID (March 17, 2020 - December 31, 2020) periods. Adult patients (≥18 years) with new onset or existing cardiovascular disease were included for comparison between periods. The main outcome measures included: cardiovascular emergency department visits or hospitalizations, mortality, and out-of-hospital cardiac arrest.

Results

In the first month of the in-COVID period, emergency department visits (n=51,750) for cardiac symptoms decreased by 20.8% (95% CI 14.0% - 27.0%, p<0.001). Cardiovascular hospitalizations (n=20 609) declined by 48.1% (95% CI 40.4% to 54.9%, p<0.001). In-hospital mortality rate increased in patients with cardiovascular admissions in secondary care institutions by 55.1% (95%CI 10.1%-118%, p=0.013). A decline of 20.4% - 44.0% occurred in cardiovascular surgical/interventional procedures. Out-of-hospital cardiac arrests (n=5528) increased from a monthly mean of 115±15 to 136±14, beginning in May, 2020. Mortality for ambulatory patients awaiting cardiac intervention (n=14,083) increased from 0.16% (n=12501) to 2.49% (n=361) in the in-COVID period (p<0.0001).

Conclusion

This study demonstrates increased cardiovascular morbidity and mortality during restrictions maintained during COVID-19, in an area with low burden of COVID-19 disease. As the healthcare system recovers or enters subsequent waves of COVID-19, these findings should inform communication to the public regarding cardiovascular symptoms and policy for delivery of cardiovascular care.

Reducing Setup and Turnover Times in the OR With an Innovative Sterilization Container: Implications for the COVID-19 Era Military Medicine

Introduction

The global 2019 coronavirus pandemic (COVID-19) is setting unprecedented demands on the nation and the military and surgical services. Surgical demands include a large backlog of surgical cases, strain on available resources, and the need for additional measures to prevent exposure. The purpose of this project was to evaluate the feasibility, duration, adverse events, and potential gains associated with using a Turbett Sterilization Pod (TSP) for total joint replacements.

Materials and Methods

A multidisciplinary team used the Plan–Do–Study–Act model to guide this project. A time–motion study was completed in the operating room (OR) to measure the average time required to set up surgical instrumentation for total joint replacement cases that required 12 or more instrument trays. We compared the amount of time it took to complete the setting up of instrumentation using the traditional method versus the TSP method. The traditional method consisted of unwrapping each surgical tray, checking for holes in the blue wrapper, and placing the tray on the back table. In the case of the TSP, the door of the pod was opened, and the instrument trays were transferred directly to the back table. We measured the time the staff took to perform the task using each of these methods.

Results

When compared to the traditional method, the use of the TSP resulted in improved turnover time, decreased room setup time, reduced environmental waste, and eliminated both the effect of damage to wrappers and the time previously spent wrapping surgical trays.

Conclusion

The TSP minimizes the time needed by the staff to set up an OR suite for a total joint replacement, therefore permitting them to focus more on direct patient care. This time improvement suggests that all surgical specialties, including those requiring greater than 12 traditional instrument sets, may experience reduced turnover time between cases. The use of the TSP is one means to help rectify the OR backlog brought on by COVID-19.