By Mary Brindle, MD, MPH
A pediatric surgeon’s job is characterized by urgency — whether operating on a neonate born with a life-threatening condition or a teenager badly injured in a motor vehicle collision. We are familiar with rapid decision-making informed by best evidence. These are qualities that proved essential in confronting the COVID-19 pandemic.
I am a pediatric surgeon at a hospital located in the foothills of the Rocky Mountains and at the western border of the Canadian prairies in one of the largest urban centers in Canada. We serve a catchment area of about 2.5 million people. I am also a health systems researcher, running a research lab and serving as director of the research arm of our provincial surgery strategic network. As COVID-19 began its inexorable march across the continents, I found myself well-positioned as a researcher to help identify best practices and build tools to support them, while at the same time putting those practices into action as a clinician.
In the midst of one of our busiest times of year for surgery in Calgary, we became aware that what appeared to be a local viral outbreak on the other side of the globe might threaten our surgical systems in a way that we had never considered. My colleagues and I urgently began trying to determine how we would approach the pandemic when it inevitably arrived here in Canada.
We heard so many stories, but it seemed there was little certainty on how to prepare. We saw teams of health care workers donning hazmat suits in China, and Italian doctors becoming infected and dying as a result of inadequate personal protective equipment (PPE). And soon, we were confronting COVID-19 in my province. Non-urgent surgeries were immediately postponed, but we still had patients requiring surgery every day. Patients were afraid to come to the hospital and delayed seeking medical attention. My fellow health care workers feared that our PPE supply would be rapidly consumed, or that what we had was insufficient to protect them. Many of my colleagues created wills for the first time. We were sequestered, either at work or at home, and yet we wanted to do more to help in the response to COVID-19.
While medical research across much of North America came to a pause, my health systems research didn’t stop. If anything, it felt more critically important, and my work started to more closely resemble the urgency and pace of my clinical work. The need to develop system-level responses had perhaps never been greater. We knew we needed to pivot from our large-scale, multi-year projects to address the immediate needs of the global community.
My department head asked me to organize the set-up and flow of the operating rooms at the hospitals in Calgary. This request came at the same time as I was preparing to take on the role of Director of Safe Surgery and Safe Systems at Ariadne Labs, a joint center for health systems innovation at the Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health.
As it turned out, what we wanted to know in Calgary was exactly what my colleagues were scrambling to figure out in other parts of the world. Cities like Singapore and Hong Kong had already responded to COVID-19 and had lessons that they retained from earlier epidemics. Some of this early experience was already published.
I approached Ariadne Labs Co-founder and Chairman Atul Gawande, MD, MPH, and he and I put together a set of recommendations based on the best evidence and reports of what was working in places that had already seen the first wave of COVID-19. We published this brief perspective piece in mid-March. It was recommended by the American College of Surgeons and formed the foundation for a blueprint to confront COVID-19 that has been adopted by surgical systems worldwide. It also informed the guidance that I was developing for operating rooms in my city and, ultimately, the rest of our province.
Our piece outlined seven key recommendations for setting up operating rooms to handle COVID-19 when the first cases arrived. These were:
- Prepare for a rapidly evolving situation.
- Postpone elective operations immediately.
- Develop a plan for essential operations during the pandemic.
- Educate all staff on PPE and COVID-19 management.
- Decrease unnecessary exposure of health care staff.
- Develop a dedicated COVID-19 operating space.
- Prepare for repurposing OR spaces for critical care use.
In Alberta, the recommendations about operating space proved to be the most critical. Our publication recommended that there should be a specific COVID-19 operating room, where unnecessary items are removed and traffic is minimized. We also recommended that patients should recover the operating room with dedicated staff and that pathways be kept clear during the transfer of patients with COVID-19. Surgical procedures should consider approaches to minimize risk and care pathways should be adapted for local context.
While much of this work is now common practice, at the time, having this guidance available in one document proved very useful.
To apply these recommendations firsthand, I had joined operational leaders across Alberta in infection prevention and control, surgery and anesthesia to visit operating rooms, take photos, and meet with teams. We thought through care pathways, sketching our ideas on paper, and walked through physical spaces, tracing patient paths and evaluating spaces for possible transformation to intensive care units to handle the growing demand. We wrote, revised, and reported ways to create pathways quickly as centers were eager to adopt best practices.
In Alberta, we have been lucky to have a single, centralized system that allows us to create a unified approach to support a population of millions of people while allowing for local implementation and adaptation in hospitals across the province. And it has been largely successful — despite the fear at the beginning of the pandemic, we have yet to have a single known transmission of COVID-19 during surgery in our province. But we realize that the risk is far from over.
Research work can be exciting and innovative, but it is also slow, by nature and by design. From our various isolated locations, the global research community has worked to identify opportunities to synthesize existing knowledge as quickly as possible and to create new knowledge through interviews, surveys, and collecting quantitative data where we could. Our community keenly felt the balance between providing urgently needed information while ensuring that it is accurate and reliable.
Much of the learning we will achieve from how our systems responded to COVID-19 will be retrospective, and many lessons remain to be learned. We have needed to act without complete information, but there are opportunities to learn from our experiences. At Ariadne Labs, we have been interviewing health care leaders from hospitals in the United States and across the globe who are shedding light on some of the unanticipated challenges in uprooting and reorganizing entire systems while the people in those systems deal with fear and loss.
Understanding how to optimize care during a crisis will remain important during and beyond the pandemic. Understanding how some of the adaptations spurred by the pandemic will establish themselves in the new normal of health care will also remain critical.
Critical challenges can remind us of how dynamic and exciting health systems work can be. They sharpen our focus on why this work is important and highlight the limitations of what we know. They also give us an opportunity to address our responsibility as physicians to improve, whenever we can, the systems that care for our patients and their communities.
Mary Brindle, MD, MPH, is director of the Safe Surgery/Safe Systems program at Ariadne Labs. An internationally recognized pediatric surgeon, Dr. Brindle previously served as Director of the EQuIS (Efficiency Quality Innovation and Safety) Research Platform at Alberta Children’s Hospital in Calgary. She is Scientific Director of the Alberta Surgery Strategic Clinical Network and holds a leadership role within the International ERAS (Enhanced Recovery After Surgery) Society.
Illustration by Julia August / iStock