The COVID-19 pandemic caused by the SARS-COV-2 virus has resulted in unprecedented challenges for the health care system. In March 2020, the Canadian Province of Ontario’s Ministry of Health (MoH) enacted a provincewide directive to decrease surgical services to preserve hospital capacity [1]. However, this directive led to significant backlogs for time-sensitive scheduled (elective) surgeries in adult and pediatric centers across Ontario with an impact on patients and families, similar to reports from other jurisdictions [2-5]. In children, surgical delays are a source of significant morbidity because of three key issues: timing of surgery has a critical impact on the growth and development of the child; treatable conditions may deteriorate over time because of the effects of growth; and excessive surgical wait times may result in the need to perform more complex surgeries than were initially planned, leading to an increase in avoidable complications [5-9].

Due to the mandated reduction in surgical activity, the surgical wait list at our institution increased by 29% from 3799 (December 2019) to 4915 patients by the end of December 2020. This increase was despite a successful increase in surgical activity from July 2020. The Paediatric Canadian Access Targets for Surgery (P-CATS) use diagnosis-based categories to define time-based targets (windows) for completing scheduled pediatric surgeries [10]. During the COVID-19 pandemic, between March and December 2020, PCATS-defined out-of-window rates for cases on our surgical wait list increased from an already high rate of 44% to 58%. Using novel machine learning algorithms, we demonstrated that even on resuming our usual level of surgical activity the surgical wait list would not decrease without a substantial increase in resources. In resource-constrained environments, more medically urgent procedures may gain preferential access to the operating room (OR), which leads to a virtual two-tiered wait list system where lower acuity day-case procedures have further increased in wait times. By December 2020, our out-of-window rates for day-case surgical procedures exceeded 60% and increased at a faster rate than those of higher complexity surgeries.

Following the resumption of scheduled care, the MoH provided additional targeted funding for 3 months (January to March 2021) to address the surgical backlog. At our institution, despite additional funding, limited health human resources and OR real estate prevented an increase in scheduled surgical activity hours during our typical Monday to Friday workweek. In addition, we calculated that any attempt to increase the proportion of day-case surgical activity during the weekday schedule would serve to overwhelm the limited postanesthesia care unit (PACU), causing bottlenecks. These bottlenecks would reduce OR access to more medically urgent and complex cases. Thus, we recognized that an innovative program would be required to increase surgical activity above historical norms, specifically target low-acuity day-case procedures, and ultimately reduce the surgical backlog. In response to the MOH funding initiative and respecting our human health resources and physical capacity limitations, we designed and implemented a novel pilot weekend surgical program called Operating Room Ramp-Up After COVID Lockdown Ends—Extra Lists (ORRACLE-Xtra).

This pilot QI project aimed to assess the feasibility of efficiently reducing the number of patients on the surgical wait list by scheduling elective surgeries on the weekends with a high level of satisfaction among participating parents and providers.

We have shown that it is possible to establish a highly efficient weekend surgical day care model in a tertiary care pediatric hospital that can run alongside a regular weekend emergency service without interruption. ORRACLE-Xtra either met or exceeded all operational targets with low cancellation rates or preanesthesia fasting violations [16]. In addition, we found that case throughput per list and operational efficiencies were superior to those seen during the weekdays. As such, we believe that this pilot program lends itself favorably to being a sustainable model for health care delivery in the future.

The short surgical time and subsequent rapid turnover time were quicker than comparable lists during the week. However, this seemingly positive finding led to unintended consequences. The preoperative processes of each surgical list were broadly based on typical timings seen during weekday surgery. However, due to more rapid OR turnovers experienced on the weekend, the OR called subsequent patients on each list sooner than planned yet were not ready due to incomplete preoperative check-ins and fasting status. Using DMAIC, we were able to identify this problem early in the program and address it by using a preoperative flow coordinator to ensure timelier check-in of patients, particularly during the early part of the day when congestion was at its peak. As a result, predicted surgical booking times were adjusted in line with actual times, and more cases were scheduled for each list. Standard preanesthesia fasting times were also extended to account for a faster turnover of surgical cases.

In addition, due to the unexpected rapid OR throughput, the PACU was filled with postoperative patients. On occasion, the PACU could not accept subsequent patients who had completed surgeries resulting in further delays in subsequent surgeries on the list. We addressed this problem by altering the PACU staffing model to ensure more nursing availability earlier in the day to facilitate receiving more children at one time.

As operational efficiencies improved throughout this pilot program, many surgical lists finished well before the planned end-of-day allowing the surgical and nursing team to leave early (in contrast to our typical weekday workflow of reassigning teams to other areas). This had the effect of improving team morale, as reported on our provider satisfaction survey. We considered this an important finding, particularly as all staff joined the program voluntarily, and as such, we believe it helped stimulate further sign-up for future weekend lists. In addition, similar efficiencies could be realized on weekdays following similar staffing and scheduling approaches.

We also found that we could not schedule as many out-of-window cases as planned (only 38% of cases out-of-window). This meant that the overall out-of-window rate on our overall wait list did not appreciably change, given the small pilot and difficulties in bringing such children for surgery. Many families, already having waited a long time for surgery, were now reluctant to attend for surgery during the ongoing pandemic and elected to postpone until the pandemic was over. Alternatively, we found that those children who had participated in a primary assessment during the pandemic and were listed for surgery (in-window) were more willing to accept a surgical date [2]. This could be explained in part to a different risk tolerance for scheduled care during this unprecedented time. Further efforts need to be made to ensure equity of access to provide care for those children who have already experienced excessively long surgical wait times.

Over 95% of parents were satisfied with the care provided over the weekend with consistency across all surgical services. As a tertiary institution, our patient catchment area is spread across the entire province of Ontario and therefore is a sizable geographical area. However, the weekend surgeries did not appear to be a barrier to access for weekend surgery as patients from areas that are 6- to 8-hour drives away presented for a weekend surgery. Indeed, families who travelled from outside of the Greater Toronto Area commented that the hospital was more accessible on the weekend due to reduced transit time and reduced need for caregivers to take time away from work. Over 79% of staff reported being satisfied with working on the weekend. Working in this program on the weekends gave teams a sense of accomplishment and community by helping with the surgical backlog. However, some negative impact on workload and well-being was reported by nursing staff, particularly given that weekend work was in addition to the regular work schedule and thus impacted work-life balance. Administrators will need to carefully consider the overall effect of increased service from a finite pool of health care providers, with a focus on well-being.

An added benefit of using the DMAIC process to run a well-defined pilot scheduled weekend surgical project was that we were able to identify several critical improvements in service delivery. These improvements could be implemented on regular weekdays and lead to more substantial reductions in the surgical backlog:

In conclusion, through the ORRACLE-Xtra pilot program, we have shown that hospitals impacted by COVID-19 can use targeted MoH funding to reduce the surgical backlog associated with the COVID-19 pandemic via the use of innovative models of service delivery. In addition, sustained institutional funding to expand the perioperative workforce is critical to achieving more meaningful reductions in wait times for scheduled surgeries over the longer term. Our institution and other pediatric institutions may find the information herein helpful for regular weekday work and future pandemics.