A future backlog looms for Ontario’s health-care system as the province cuts down on surgeries and treatment for patients requiring care unrelated to the coronavirus pandemic.

The Ontario government announced last month that all non-essential care and elective surgeries must be put on hold to protect health-care providers, patients and the public and to manage what’s expected to be a “tremendous” demand on the system from the spread of COVID-19.

Patients with serious but not emergent medical issues — meaning patients who do not face imminent harm if not treated within the next 14 days — are encountering obstacles as they try to access normal care, like cancer surgeries or essential rehabilitation for stroke, cardiac and vascular patients, who could be facing permanent disability without it.

Experts warn it could lead to a future backlog for a health-care system that is preparing for tougher days ahead.

Ontario’s health-care system is treating patients facing imminent harm normally, according to Dr. Madhu Natarajan, a structural and interventional cardiologist at Hamilton Health Services and the regional physician lead of the Hamilton-Niagara Integrated Heart Investigation Unit.

Urgent patients, meaning people who are hospitalized but are not in immediate danger, are being triaged daily in order to properly prioritize patients and minimize lengths of stay. Postponing elective surgeries for cardiac patients in urgent care should be safe for most people because wait times were short in Ontario before the coronavirus outbreak. Four to six extra weeks of waiting may cause some patients anxiety but should not compromise their well-being.

But there is another tier of patients, those who are currently at home waiting for a procedure or treatment, that Natarajan worries about. Part of the contingency planning involves doing as many regular procedures as possible during the ongoing pandemic to maintain a patient flow. If that gets bogged down because of coronavirus measures, the wait for procedures and treatments could grow.

“This is going to be a big problem for (patients at home). Are they going to face long waiting lists? I think part of it is a little bit unknown ... the extent of the surge is difficult to predict, and how much outpatient care we can continue.”

In some cases, people needing medical care are not going into the hospital at all, which also threatens to put further pressure on the health-care system in the future.

Experts in stroke care are seeing fewer people present to emergency departments with milder, non-disabling stroke symptoms, or transient ischemic attacks (TIA), according to Dr. Leanne Casaubon, a stroke neurologist and director of the TIA and Minor Stroke Unit at Toronto Western Hospital. The number of doctors’ referrals to stroke prevention services is also on the decline — anecdotally, she said, because the data hasn’t totally been analyzed yet.

Life- and limb-saving acute care and stroke prevention services are intact as the country’s health-care system battles COVID-19, but patients with milder symptoms who may not be calling 911 or visiting the emergency department — either for fear of contracting coronavirus or adding unnecessary pressure to the health-care system — could fill hospitals’ beds in future if their symptoms worsen.

“Our concern is that an unintended consequence of this will be a potential increase in stroke into the near future, that we certainly want to help to avoid as best we can,” said Casaubon.

Planning for the inevitable backlog surge in elective surgeries is very much like trying to hit a moving target. While some of the logistical elements will be known — number of cases and their prioritization, for example — other elements, such as the length of the coronavirus crisis, and the resources available at the end of it, are completely up in the air.

Dr. David Urbach is the Surgeon-in-Chief at Women’s College Hospital in Toronto, and a Professor of Surgery and Health Policy at the University of Toronto. Simply put, he defines elective surgeries as those which are scheduled in advance. By that nature, they are not immediately life-threatening, in contrast to emergency surgeries.

The numbers are not trivial: in 2017, there were 183,647 elective surgeries in Ontario; in 2018, the last year for which Ontario was able to provide totals, that figure was 184,125.

Within that elective surgery category are subcategories, which vary according to discipline. For example, Cancer Care Ontario subdivides surgeries into four priorities, ranging from priority one — surgery necessary within 24 hours — to priority four — surgery required within 84 days.

Across the board there are systems that prioritize the urgency of patients’ care, based in part on type of operation, patient status and hospital resources, said Urbach. These form the basis for decisions about which surgeries get postponed.

“The directive is to curtail elective surgery as much as possible,” he said. “We know from modelling that the hospitals in Ontario are likely to be stressed, possibly overwhelmed in the next one to two weeks with very sick patients. And in order to make sure as many people can be saved as possible, they want to make sure that as many hospital resources are free for those people.

“All of this is a tradeoff. Nothing is certain, and people are trying to essentially make decisions that will create as much net benefit as possible and minimize harm and save as many lives as possible.”

Whatever decisions are made, what is certain is that at such time that the coronavirus lifts and eases the immediate pressure on the health-care system, there will be a backlog of elective surgeries to perform, and more difficult decisions will have to be made.

“There’s going to have to be a catch-up period where we’re either going to have to increase our ability to do elective surgery at a later date once this crisis lifts, or there will be just a period of time where there’s a lot longer waits to have surgery,” said Urbach.

Post-coronavirus crisis, some of the solutions for the backlog could be found in unusual allocations of resources, he said. Certain hospitals could be designated as only for use by non-COVID-19 patients. Or hospitals that do treat COVID patients might segregate certain areas for use by non-COVID patients.

Depending on the trajectory of the pandemic in Canada, there might even be a scenario when hospitals, no longer as taxed as they were at its height, might go back to a regular schedule of elective surgeries in several weeks time.

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Dr. Chris Simpson, a cardiologist and Vice-Dean, Clinical at Queen’s University School of Medicine, said the coming backlog will create complicated demands on the health-care system.

Simpson was the former chair of the now-disbanded Wait Time Alliance; a federation of medical specialty societies and the Canadian Medical Association that created benchmarks for wait times for all procedures and reported on provinces’ abilities to match those wait times.

He says the impact of the postponement of these elective surgeries is still an unknown. In the short term, everyone agrees it’s necessary. Hospital resources must be preserved; personal protective equipment must be conserved. But the long-term outlook is still fuzzy.

“If we’re slowing down for three or four months, two things start to happen,” he said. “The first being, clearly we’ve got a very sizable backlog of procedures and care that’s going to have to be provided after this is all over, which is no small task.

“But the second thing is that a lot of things that are quote unquote elective today and can be safely put off — by three or four months from now, they’re no longer elective — they’ve become more urgent because they’ve waited longer than they should have.”

That’s going to create strains on health care. First, he said, we’ll be dealing with a health-care workforce that is tired and burned out from dealing with the coronavirus crisis. Asking them to work overtime to help clear the backlog of elective surgeries is asking a lot.

There are also physical limitations in that there are a fixed number of operating rooms, procedure rooms and clinic rooms in which to perform these surgeries. The capacity of those rooms could be increased by using them after hours and on weekends, but again, that creates a lot of strain on an already tired health-care workforce.

There is also the question of money.

“A lot of funding, of course, is quite appropriately being redirected to scaling up for the COVID crisis,” said Simpson “What’s that going to mean for health-care budgets if they have to spend several months going at hyperspeed doing procedures that cost money? And to what extent will that be a constraint?”

During the SARS epidemic in 2003, Toronto hospitals suspended elective surgeries for a number of weeks, creating a similar shutdown to the current one. Once the crisis passed, it took months — even with hospitals ramping up procedures as much as they could — to get back to a pre-SARS level of elective surgery.

Simpson believes scaling up from the SARS experience that it could be “months to years” before wait times for elective surgeries return to their pre-coronavirus levels.

While provinces and hospitals are creating plans for dealing with the anticipated backlog, those plans are necessarily incomplete — the information needed to flesh them out is just not available. For health-care administrators, said Simpson, the keys will be flexibility and adaptability.

“I think it’s going to require a very thoughtful approach,” he said. There will have to be a very concerted effort to devote resources to the patients who need them most.

“That’s going to require a judgment call. And those judgments won’t be easy. But I think everybody would buy into the notion we’ll probably have to have a hierarchy of priorities and saving lives will be number one.”