Surgical smoothing as key to unlocking hidden hospital capacity in COVID-19 epidemic

Bridget Marcinkowski; Erin Kane, MD

Individuals in face masks, scrub caps, and gowns standing in an operating room next to a table of tools.
Photo by Piron Guillaume on Unsplash

With COVID-19 cases once again spiking across the US, hospitals are facing shortages of staff and beds.¹ As many hospitals have already scaled back elective surgeries,² the backlog of surgical cases mounts. Discussions about rationing surgeries if hospitals reach their maximum capacity have become more commonplace.³ The outlook appears grim, but Eugene Litvak, CEO of the Institute of Healthcare Optimization (IHO), says, “It’s important to understand there is a solution that allows hospitals to alleviate overcrowding and significantly improve patient access to care.”

Litvak has spent his career studying and applying queueing theory to help hospitals maximize the use of a fixed capacity. “What some people don’t understand is that it is always a matter of demand and capacity. They keep talking about demand and completely ignore capacity. Current demand exceeds mismanaged capacity,” Litvak says. Litvak advocates that hospitals proactively manage capacity to serve the most patients possible, and his process termed “surgical smoothing” has gained momentum as a likely solution.

Just over a year before the pandemic began, the University Health Network (UHN) in Toronto, Ontario implemented surgical smoothing — a process that upends the standard practice of scheduling the bulk of elective procedures early in the week. Instead, by dispersing these procedures evenly throughout the week, hospitals can better avoid peaks and troughs in occupancy. In conjunction with the IHO, UHN also designed a nine-tier urgency classification system in which each tier correlates to a specific number of resources.⁴ Together, these changes allowed UHN to predict its resource availability down to the specific bed. When Toronto experienced an influx of COVID-19 cases, UHN was able to scale back their elective surgeries based on priority and resource availability. Similarly, UHN was one of the first hospitals in the province to resume their normal rhythm of procedures despite managing the majority of Ontario’s serious COVID-19 cases.

As we now enter the third wave of this pandemic, many hospitals face substantial backlogs of surgeries that have been delayed. Studies predict that the US may face a cumulative backlog of more than one million joint and spine cases and another one million cataract surgeries by 2022.⁵ ⁶ Numbers like these are staggering, but this problem of overcrowding is not new. Many hospitals have grappled with capacity issues like emergency department boarding and ambulance diversion long before the pandemic.

While many hospitals are now turning to surgical smoothing out of necessity, keeping these systems in place after the pandemic will ensure hospitals are better poised to respond to similar crises in the future. Smoothing has historically been a “big lift” because surgeons must be willing to alter surgical schedules and hospital administrators must supply ancillary support to accommodate more elective procedures throughout the week, including running key services on the weekend. The current health crisis may motivate hospitals to address long-standing deficiencies in how they manage capacity. Litvak says, “If there is any silver lining to the COVID epidemic, it’s the willingness to change.”

1. Stone, W. (2020, November 10). COVID-19 Hospitalizations Hit Record Highs. Where Are Hospitals Reaching Capacity? NPR.

2. Wu, K., Smith, C. R., Lembcke, B. T., & Ferreira, T. B. (2020). Elective Surgery during the Covid-19 Pandemic. New England Journal of Medicine, 383(18), 1787–1790.

3. Antkowiak, P. S., Cocchi, M. N., Chiu, D. T., & Sanchez, L. D. (2020). Who should we treat: elective surgical admissions or patients with COVID-19?. Am J Manag Care, 423–424.

4. Butler, C. (2020, July 13). How surgical smoothing could help ease the medical backlog created by COVID-19. CBC.

5. Jain, A., Jain, P., & Aggarwal, S. (2020). SARS-CoV-2 impact on elective orthopaedic surgery: implications for post-pandemic recovery. The Journal of bone and joint surgery. American volume.

6. Aggarwal, S., Jain, P., & Jain, A. (2020). COVID-19 and cataract surgery backlog in Medicare beneficiaries. Journal of Cataract and Refractive Surgery.

Bridget Marcinkowski, MS2 at GW SMHS

Bridget Marcinkowski is a medical student at the George Washington University School of Medicine & Health Sciences. She received bachelor’s degrees in Biology and Nanoscience from Virginia Tech where she also served as an EMT on the Blacksburg Volunteer Rescue Squad. She previously conducted research as a post-baccalaureate fellow at the National Cancer Institute. Her research interests include social emergency medicine, trauma and violence prevention, and health policy.

Urgent Matters

Innovative practice in ED flow and quality, disaster management, technology, and health policy.

Urgent Matters

Urgent Matters serves as a dissemination vehicle for strategies on emergency department (ED) patient flow, quality improvement, disaster management, innovative practice & technology, and social & health policy.

Bridget Marcinkowski

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Bridget is a 2nd-year medical student at George Washington with previous stops as an EMT in Southwest VA and a research fellow at the National Cancer Institute.

Urgent Matters

Urgent Matters serves as a dissemination vehicle for strategies on emergency department (ED) patient flow, quality improvement, disaster management, innovative practice & technology, and social & health policy.