Hospitals May Put Off Elective Surgeries Until After COVID-19 Peaks
Mumbai: The central government, in its advisory released on March 20, had directed hospitals and medical institutions to postpone non-essential elective surgeries upto March 31, 2020, and this was to be reviewed “as per evolving situation”. It has been more than two months since then and COVID-19 cases are showing no signs of abating. With just four days left for the fourth phase of the lockdown to end on May 31, 2020, resuming elective surgeries is critical, as delay could lead to a spike in diseases and deaths in the coming weeks, health experts say.
To avoid overburdening hospitals already struggling to deal with the rising pandemic load, doctors suggest waiting until the COVID-19 peak is past, and then restarting with surgical day procedures such as for small ear-nose-throat procedures and removal of small lumps.
An elective surgery is one that can be scheduled in advance but is not necessarily optional. Emergency surgeries are lifesaving procedures that have continued through the lockdown.
Here are some examples of elective surgeries that should not be postponed indefinitely, according to surgeons we spoke to for this story:
- Hernia, appendix, kidney or gallbladder stone surgeries can be rescheduled for a later date but could have severe outcomes if the delay is prolonged.
- Cardiac surgeries, which can be planned in advance for angiography or stenting, could be fatal if delayed over months.
- Early-stage cancer that is curable through surgery could worsen with delays.
- In a diabetic patient with an infection or a wound, delayed treatment could push the infection closer to the bone, necessitating amputation.
An estimated 505,800 non-emergency surgeries, 51,100 cancer surgeries, and 27,700 obstetric surgeries could have been delayed across India during the three-month period before and after the peak of the viral outbreak, Mint reported on May 18, 2020.
The number of operations cancelled in India is estimated at 48,728 per week or about 585,000 over 12 weeks, as per a report published in the British Journal of Surgery on May 12, 2020. The global figures stand at 28.4 million cancelled or postponed elective surgeries during the “12 weeks of peak disruption” caused by COVID-19--around 2.4 million a week--the report estimated.
Elective surgeries such as bariatric (for severe obesity) and metabolic (for type-2 diabetes) procedures are being postponed worldwide during the pandemic, said a report published in The Lancet on May 7, 2020. "Because of the progressive nature of obesity and diabetes, delaying surgery increases risks for morbidity and mortality, thus requiring strategies to mitigate harm," the report said. There will be a backlog of those seeking these surgeries as the outbreak abates.
Elective surgeries should be suspended during COVID-19 outbreak in affected areas “unless the risks of the disease impose a potential risk, morbidity or organ failure in the patient”, said a report in the International Journal of Surgery on April 14, 2020.
The postponement of elective surgeries was to protect patients and health workers from the risk of COVID-19. With another four days to go for the end of the lockdown and the pandemic still raging, surgeons told IndiaSpend that elective surgeries must be resumed at the earliest to prevent a backlog of cases in hospitals that are already burdened by the pandemic.
‘Critical to resume elective surgeries’
“It is important to start elective surgeries and our routine work because these cases are going to pile up,” said Satish Dharap, professor and head, department of surgery at the TN Medical College & BYL Nair Hospital, Mumbai, and secretary of the Maharashtra chapter of the Association of Surgeons of India.
There could be a rise in morbidities too, said Kranti Vora, obstetrician and additional professor at the Indian Institute of Public Health (IIPH), Gandhinagar. “If elective surgeries do not start for long, then these will become emergency surgeries and survival rates will go down, putting extra burden on the health system,” she said. “Complications tend to worsen when preventive procedures are delayed.”
Dharap cited the example of hernia where the intestine is stuck inside a sac, and if the patient is not operated in time, he/she may end up with complications.
Curative surgeries such as those for cancer wherein delay could lead to disease spread, or a coronary bypass that needs timely intervention, need to be resumed soon, Dharap said. “Surgeries for functional improvement such as joint replacement may not affect survival but their delay will lead to deterioration in the quality of life,” said Dharap.
Transplant surgeries are the other area of concern for surgeons. “A transplant patient waiting for an organ will need to be operated on once he gets a matching organ,” said Shalin Dubey, consultant, laparoscopic and robotic surgery, Apollo Hospitals, Navi Mumbai. “It is critical for society’s overall health that healthcare facilities start to cater to non-COVID patients who have faced major issues in accessing healthcare during this lockdown.”
At the Tata Memorial Hospital, Mumbai, cancer out-patient departments (OPDs) and surgeries have been continuing, though with fewer patients, as per Pankaj Chaturvedi, professor, department of surgical oncology, head and neck services. “Under my department we are offering services to around 6-7 cases every week which is otherwise double the figure,” he said. “These are all planned surgeries and not emergency surgeries.”
Cancer surgeries can be planned, but for patients who have been diagnosed, it is emotionally imperative to be treated fast. “For a cancer patient, the surgery is an emergency but from the medical perspective it can be elective,” said Chaturvedi.
Elective surgeries also need to be resumed to help hospitals become viable, said Sanjay Oak, a surgeon who heads Maharashtra’s COVID-19 task force. “This will bring the health sector to normalcy, and will also help hospitals regain financial stability,” he said. “Most health units have become financially sick and retaining workforce at designated remuneration has become a challenge in itself.”
- Every patient is considered COVID-19 positive till tested and declared otherwise. Surgery can be planned only if the test proves negative; healthcare workers are at greater risk from asymptomatic positive patients.
- Reliability and accuracy are issues with COVID-19 tests; also adds additional cost.
- In cancer surgery, the treatment lasts days and weeks. If the patient is asymptomatic and no precautions are taken it could lead to problems. The incubation period for the virus is 14 days and health workers might later find the patient infected.
- During intubation--while providing general anaesthesia, wherein a sterile tube is passed into a patient's mouth--the anaesthetist is at a risk from the patient's breath and risks being exposed to potentially infected droplets. (To address this issue, an intubation box, which is transparent and has two holes, is placed on the patient’s head and it reaches up to his shoulders. The anaesthetist's hands go in, avoiding direct contact with the patient’s breath. This gear might not be available everywhere.)
- If an operation theatre is air-conditioned, it requires 20-25 air changes per hour, which many operation theatres may not have. The exhaust should have a high-efficiency particulate filter so that the air released is not infected.
- Performing surgeries while wearing personal protective equipment (PPE) is uncomfortable and face shields often fog up, affecting visibility. It is also hot, humid and dehydrating inside the PPE.
- The operation theatre has to function with limited staff due to the lockdown.
Source: Interviews with surgeons
Mumbai faces biggest challenge
India has had 145,380 COVID-19 cases of which Maharashtra accounts for the most (52,667 or 36%), as on May 26, 2020. Mumbai, the country’s financial capital, with more than 31,900 cases, accounts for 61% of cases in the state and 22% in the country. This crisis could lead to a shortage of doctors and health workers in the coming days, which could further impact the resumption of elective surgeries in the city.
“There is a need for additional doctors round-the-clock to manage fever clinics--set up to test people--and isolation wards,” said Anil Gvalani, general surgeon and former head of surgery at Seth Gordhandas Sunderdas Medical College and the King Edward Memorial Hospital, Mumbai. “Healthcare workers are required for patients found positive and speciality doctors are required for seriously ill COVID patients, those who are on ventilators and having comorbidities.”
The rule of thumb in medical facilities today is that every patient is COVID-positive unless tested otherwise, Gvalani said. Therefore, “elective surgeries risk the spread of the virus adding complications if the patient is positive and more so if asymptomatic--if not tested”, he added.
When to resume surgeries
Oak recommended caution before resuming non-essential surgeries, suggesting a delay of another couple of weeks, especially in Mumbai. “The case doubling time should rise further,” Oak said. “That will give an indication that the infectivity has become less; otherwise you read of anecdotes that the entire surgical team has become COVID-positive after operating a case. By restarting routine electives, we should not go two steps forward and four steps back.”
A careful start would be to concentrate on day surgeries where the patient does not need to stay at the facility for recuperation, Oak said. “The moot question is whether a COVID test would be made mandatory,” he said. “It may not be an official guideline but many hospitals may include this test in their mandatory preoperative work-up. Any postoperative fever would get investigated for COVID. So in my opinion let's go slow and in a prudent manner.”
At Nair Hospital, a COVID-19 facility, the one surgery that is being conducted often is the caesarean-section delivery, Dharap said. “For most emergency surgical problems wherever possible we are treating patients conservatively i.e. with medication,” he said. “Many of these patients will subsequently need surgeries. If they are COVID positive, the surgery can be planned after complete recovery which is expected to occur in about four weeks.”
Even if elective surgeries resume in two weeks, there will be a delay of one to three months in performing these given the backlog. “There will be a prolonged waiting period, adding to the burden on hospitals and healthcare facilities,” Dharap said. “In our country we are not used to this [delay] because the waiting time for elective surgeries is relatively short, say one to three months at the most,” he pointed out. “In the United Kingdom, it may take at least three months for a hernia or gallbladder operation, and in very busy hospitals there can be a waiting period of more than a year. People will have to get used to such waiting periods in India.”
To ease the burden on government hospitals, the Maharashtra government has declared that 80% of beds in private health facilities across the state would be temporarily taken over to deal with the contagion, The Indian Express reported on May 22, 2020. Charges for the treatment of COVID-19 and other illnesses have been capped at these facilities. The central government too had to issue a notification on May 11, 2020, directing the opening of all private clinics, nursing homes and labs to deal with all emergencies, including COVID-19.
Mumbai’s municipal corporation has ordered ward officers to register a criminal offence against private hospitals, clinics and nursing homes that have failed to reopen despite repeated orders from the civic body, The Indian Express reported on May 20, 2020. Earlier, the municipal authorities had directed private hospitals and clinics to open their OPDs for non-COVID patients.
“Reviving OPD and elective surgeries in the private sector is going to be a challenge,” said Sakthivel Selvaraj, director, health economics, financing and policy, at the Public Health Foundation of India, pointing to the stigma and fear surrounding the pandemic among both non-COVID patients and the medical fraternity.
(Mallapur is a senior analyst with IndiaSpend.)
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