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Secondary service impacts from COVID-19 restrictions on vulnerable rehab patients

Virtual care is one of the best ways to catch up on years-long backlog

By Andrew Ward
August 2, 2022
The estimated accumulated backlog created by scaling back non-essential surgeries in Ontario from March 15 to June 13, 2020, was 148,364 surgeries and a rolling average increase of 11,413 additional surgeries for every week that the provincial policy direction remained in place.

Takeaway messages

  • Secondary impacts related to COVID-19 restrictions on rehabilitation patient cohorts are compounding the existing backlog for surgical services and will heighten community service demand for years to come.
  • Surgical backlog and community service demands will place a growing strain on limited nursing resources in Ontario.
  • Virtual care provides a viable option to mitigate service backlog and to provide coordination and rehabilitation programming for the chronic disease management of patients.

The COVID-19 pandemic has led to an unprecedented disruption of surgical services across Canada due to the concern for aerosolizing medical procedures, and the strain on nursing resources (Søreide et al., 2022). COVID-19 was recognized as a pandemic on March 11, 2020, by the World Health Organization. Following this announcement, the Ontario government began directing hospitals to start scaling back ambulatory services and non-essential surgeries on March 15, 2020.

For resource allocation guidance, a risk stratification model — which is a formal process of assigning risk to patients and providing them the appropriate level of care to improve health outcomes — was developed for North American hospitals in order to best prioritize surgical and outpatient services (Stahel, 2020). In this model, all elective procedures would be reviewed and considered for minimalization, cancellation, or postponement to a time when COVID-19 was no longer a competing strain on health-care resources. This risk stratification framework has assisted surgical leaders in categorizing joint replacement and total knee arthroscopy (TKA) surgeries as elective or discretionary and thereby postponing them for a minimum period of three months or until respective public health guidance is altered.

The population of Ontario is more than 14.7 million and is sectioned into five separate health regions — North, East, Toronto, Central, and West. Over 640,000 surgical procedures were completed in more than 90 operating rooms across Ontario in 2019–2020. Like most North American hospitals, Ontario categorized their respective surgical procedures into four priority levels based on the clinical condition of the patient in order to manage wait times and risk stratification.

The literature suggests that such a mitigation strategy will lead to an unprecedented impact on the TKA patient population across Ontario and a surgical backlog for multiple years, depending on the length of time that COVID-19 creates secondary service disruption. A modelling study completed by Wang et al. (2020) estimated that the accumulated backlog created by scaling back non-essential surgeries in Ontario from March 15 to June 13, 2020, was 148,364 surgeries and a rolling average increase of 11,413 additional surgeries for every week that the provincial policy direction remained in place.

The best option for Ontario is to take immediate action by addressing the growing backlog of non-essential surgeries.

The longer a patient waits for surgery, the likelihood increases that their condition will worsen. If left unaddressed, a patient’s condition will continue to deteriorate and decondition until their symptoms are exacerbated and the patient’s priority changes to that of an urgent or immediate need for surgical intervention. Without intervention as planned, the patient cohort waiting for surgery could become less and less likely to successfully manage their post-surgical rehabilitation, thereby increasing the demand on health-care services for the medium to long term (Søreide et al., 2020).

The heightened TKA patient care needs and the escalating surgical backlog due to COVID-19 will continue to create strain on the limited nursing staffing resources and negatively affect patients’ quality of life in Ontario for years to come. As of June 3, 2021, the Ontario provincial government issued notice to hospitals that they would be allowed to resume non-essential surgeries if they meet certain criteria and regulations. However, on January 3, 2022, the government paused non-essential surgeries again, in light of the growing impact of the COVID-19 Omicron variant on the health system (Tait, 2022).

The purpose of this paper is to highlight the secondary impact related to COVID-19 restrictions on the TKA patient population and nursing service implications, and to promote a call to action for the Ontario health system.

The professional issue

Stahel (2020) recognizes that the Ontario government’s directive to postpone elective surgeries was issued acknowledging that discretionary procedures would contribute to the spread of COVID-19 within acute care facilities and unnecessarily tie up medical resources that would be needed to address the waves of COVID-19 surge cases. It is generally assumed that as a mitigation strategy, halting elective surgeries and outpatient programming will reduce potential transmission of COVID-19, save lives, and free acute care capacity for essential services (Gomez et al., 2021). However, halting elective surgeries and outpatient programming could lead to increased symptom severity for patients, compounding service backlog and increased demand for acute care services in the future (Søreide et al., 2020).

Stahel (2020) estimates that over 50 per cent of all surgical cases that are deemed elective have a potential to impose considerable harm on patients if delayed or cancelled. Moreover, a postponement or cancellation of surgical intervention may lead to a decline in patient health, permanent morbidity, and potentially create a state of increased vulnerability due to the effects of a COVID-19 infection (Waters et al., 2021). Policy-makers must consider weighing these factors against the need to reduce acute care burden during the COVID-19 pandemic. It is important for them to remember that an elective surgery does not mean an unnecessary surgery.

Considering the options

When considering the issue from multiple angles, two primary options present themselves. The first option is to address the surgical and service backlog once the pandemic is over (Wang et al., 2020). The benefits of addressing the backlog after the pandemic ends would allow for complete attention of the health system to be placed on the pandemic as the current priority.

As COVID-19 disruptions to the health-care system started to wane, Humber River Hospital forecasted that their surgical capacity will be more than 120 per cent in both August and September of 2021 (Lee, 2021). However, it is unknown how long the pandemic will constrain the health-care system, and since there is no certain end date for COVID-19-related disruption, the backlog for surgical services and outpatient programming will continue to grow for as long as any moratorium on non-essential services remains in place.

Another possibility that could be considered by surgical leaders and provincial health-care administration is to start addressing the backlog before the pandemic is over. This option would require the implementation of virtual care models and public awareness campaigns for immediate and increased patient engagement (Moynihan et al., 2021). Such immediate action would slow the rate of the increasing backlog and potentially stave off undue patient hardship and morbidity. Although COVID-19 requires significant attention as a primary priority for our health system, the best option for Ontario is to take immediate action by addressing the growing backlog of non-essential surgeries.

Exploring the best option

Routine patient engagement with health-care practitioners has been hampered because of the uncertain nature and risk of spread of COVID-19 and the fear of infection because of indirect or direct contact with either confirmed or suspected COVID-19 patients. Unfortunately, limited engagement contributes toward vulnerable patients having reduced access to health-care programming (Moynihan et al., 2021). Often, vulnerable rehabilitation patients include individuals with multiple co-morbidities, reduced functional capabilities, limited support systems, and/or difficulty with aspects of the social determinants of health.

Commonly, these patients need chronic disease management and frequent monitoring from experienced health-care providers because of the heightened requirement for follow-up care and routine patient assessment related to the given condition. Case managers or care coordinators are engaged in the coordination of the services that vulnerable patients require as part of chronic disease management practices. In Ontario, there are more than 4,500 care coordinators that are registered nurses who support patient service navigation (Government of Ontario, 2019).

COVID-19 has hampered the normal access to care and regular chronic disease management for patients, which has created the need for proactive outreach from care coordinators. Recognizing that face-to-face engagement with patients is not always a possibility during the pandemic, virtual engagement is the most appropriate option.

Surgical and health-care leaders are confronted with the challenge of how to maintain care provision during the COVID-19 pandemic, especially to the most vulnerable. Gleicher et al. (2021) conducted a pan-Canadian needs assessment that recognized the need for evidence-based, outpatient pathways for the vulnerable TKA patient population, pathways that include outpatient education materials and enhanced virtual rehabilitative care. To limit the use of acute care resources, the provincial health system needs to rapidly implement outpatient care pathways, which include evidence-based non-surgical care, virtual rehabilitation, and collaborative partnerships among care coordination, primary care providers, and surgical inpatient units.

Call to action

With vaccination rates increasing across Canada, restrictions will begin to ease, and non-essential services will resume with public health guidance. However, a significant backlog of surgical and programming demand is anticipated. In order to address this demand, virtual care options and redeployment of care coordinators should be considered to address the new demand for years to come.

Like Humber River, many hospitals will be considering expanding elective surgery capacity depending on their respective opportunity to manage the operational increase. However, many limitations such as nursing resources, bed availability, and access to external resources (e.g., laboratory and imaging) will be key variables in every facility readiness plan. When addressing the immediate opportunity to resume non-essential surgeries, exceptional costs will be anticipated for health-care systems because surgical teams will be working outside of normal business hours (i.e., weekends and after hours), and this will lead to overtime and greater staffing demands.

Provincial nursing resources are already at an all-time high risk for burnout due to the workload demand and psychological strain created by COVID-19 (Wang et al., 2020). Unfortunately, very little reprieve or opportunity to return to a steady state for nursing personnel will be possible if policy-makers and acute care leaders pivot toward an aggressive campaign for resumption of non-essential surgeries. By redeploying nursing care coordinator resources toward virtual rehabilitation and collaborative partnerships with primary care stakeholders and acute care organizations, complex surgical interventions can be staved off with early offerings of home and community care services.

By addressing the backlog immediately, provincial leadership will need to be mindful of the potential for nursing burnout and to prioritize nursing wellness. As a focus, nursing quality of life should be part of the resumption plan for non-essential surgeries. Nursing input throughout the planning, implementation, and evaluation of the surgical resumption of services will be key to ensure success across Ontario and to mitigate the potential strain on existing nursing resources.


Secondary impacts related to COVID-19 restrictions on rehabilitation patient cohorts are compounding existing surgical backlog created because of COVID-19 restrictions. This has also heightened the demand for community rehabilitation services. Moreover, the surgical backlog has placed a growing strain on limited nursing resources that provincial leaders will need to balance when addressing their resumption planning for surgical services. Finally, in order to stave off the compounding service backlog, an immediate pivot toward virtual care coordination and rehabilitation programming is required with expanded public awareness campaigns and chronic disease management for patients.


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Gomez, D., Dossa, F., Sue-Chue-Lam, C., Wilton, A.S., de Mestral, C., Urbach, D., & Baxter, N. (2021). Impact of COVID 19 on the provision of surgical services in Ontario, Canada: Population-based analysis. British Journal of Surgery, 108(1), e15–e17.

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Tait, C. (2022, January 3). Ontario moves schools online, closes indoor dining and gyms, pauses non-urgent surgeries amid COVID-19 surge. The Globe and Mail.

Wang, J., Vahid, S., Eberg, M., Milroy, S., Milkovich, J., Wright, F.C., … & Irish, J. (2020). Clearing the surgical backlog caused by COVID-19 in Ontario: A time series modelling study. CMAJ: Canadian Medical Association Journal, 192(44), E1347–E1347.

Waters, R., Dey, R., Laubscher, M., Dunn, R., Maqungo, S., McCollum, G., … & Held, M. (2021). Drastic reduction of orthopaedic services at an urban tertiary hospital in South Africa during COVID-19: Lessons for the future response to the pandemic. SAMJ South African Medical Journal, 111(3), 240+. Gale Academic OneFile.

Andrew Ward, RN, BScN, MN, is a graduate teaching assistant at the University of Windsor, where he is also pursuing his PhD.