Tens of thousands of B.C. residents waiting for their operations to be rescheduled won’t be required to get a COVID-19 test before their operations unless they have worrisome symptoms or exposure to individuals with the virus.
The decision not to test all patients is contrary to precautionary principles touted by some American hospitals and medical groups like the American Society of Anesthesiologists which contend that testing will help protect hospital staff and other patients. University of California hospitals are asking surgery patients to get tested before their operations and other hospital-based procedures so others are not put at potential risk. This, even though the previous testing on patients without symptoms revealed that 0.3% were positive after testing while the positive rate was only 3.33% in those with symptoms.
Despite the low rates, the anesthesiology society states: “Patients who are scheduled for surgery should always be assumed to be potential carriers of the virus throughout the duration of their hospital stay, even if they pass the pre-assessment triage including normal temperature, no history of exposure or travel, and no respiratory symptoms.”
Even with a test, “clinicians must be mindful that a negative test does not negate the possibility that an individual is infected” the organization noted, referring to the fact that the nasal swab test is imperfect, with substantial false negatives and positives.
In the British Journal of Oral and Maxillofacial Surgery, testing of all patients pre-surgery is urged as “patients who are scheduled for surgery should always be assumed to be potential carriers of the virus throughout the duration of their hospital stay, even if they pass the pre-assessment triage including normal temperature, no history of exposure or travel and no respiratory symptoms.”
The author contends that “not being aggressive with testing while carrying out surgical services could have catastrophic consequences.”
The BC Ministry of Health worked with representatives from the BC Centre for Disease Control, the Provincial Health Officer, WorkSafe BC, the College of Physicians and Surgeons and an expert panel to develop guidelines for the gradual resumption of surgeries and procedures. The experts decided that pre-surgery testing isn’t required for all patients. Instead, they will undergo risk assessment screening prior to surgery. If they have any symptoms or have had exposure to someone with the illness, they’ll be referred to a testing site.
The ministry sent a statement to me which says:
“Now that we have flattened the curve and the overall prevalence of the disease is low in B.C., we anticipate that the vast majority of surgical patients will not be infected with COVID-19. Testing criteria for surgical patients is set out in the updated Infection Prevention and Control Protocol for Surgical Procedures During COVID-19 document (the Surgical Protocol): http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID19_IPCProtocolSurgicalProceduresAdult.pdf
“Testing is one part of a comprehensive suite of controls – including engineering controls (plexiglass barriers), administrative controls (physical distancing), patient screening, and appropriate PPE use – to minimize risks for clinicians and health care workers. Under these guidelines, patients are being asked to take some steps to make sure that they, and their surgical team, and the many other health-care providers who support the patient will be safe.”
Patients will complete their pre-surgical assessment in advance of their surgery and again on the day of their surgery. This assessment includes identification of any risk factors relating to the patient’s travel history, contacts in the community, and contacts at work.
In B.C., there are tens of thousands of patients who’ve been waiting for non-urgent surgery since the health ministry canceled such operations in mid-March because of the COVID-19 pandemic. Screening tests like breast mammograms and colonoscopies were also put on hold. Health Minister Adrian Dix said it will take two years to clear the backlog.
In early March, there were a record 93,000 patients waiting for non-urgent surgery, including over 30,000 that were already scheduled and canceled. (About 17,000 emergency and urgent cases did proceed since the middle of March).
Dix said Thursday that nearly 7,000 patients have already been contacted by health authorities to discuss the rescheduling of their operations.
The test for COVID-19 misses up to 30% of infected patients and Provincial Health Officer Dr. Bonnie Henry said she thinks there is little value to doing random testing of those who are asymptomatic. B.C. is one of only a few jurisdictions in Canada that has done relatively low levels of testing. Health columnist Andre Picard wrote a persuasive column about Canada’s “half-hearted” embrace of testing and the “dawdling” pace of testing this week.
Henry said Thursday in a press conference that it’s not that B.C. doesn’t have the capacity – the province has the resources to do 7,000 tests a day – but only about 2,000 per day are actually done, suggesting there are no stampedes by B.C. residents seeking tests. She made it clear that she’s not a fan of “random” testing because of the test limitations. In another press conference, she said: “We aren’t going to test for no purpose. That is wasteful.”
In B.C. most recently, detecting COVID-19 has been like finding a needle in the haystack since case numbers are drastically down – only 15 new cases today, for example. As the province “re-opens” however, there is a risk, and some would argue a likelihood, that cases will spike. Relying on pre-surgery patient assessments could be a bit of a gamble that could result in hospital outbreaks.
Dix has said that as part of his $250 million plan, he wants to hire many hundreds more nurses, physicians, and other hospital staff. And he hopes health professionals will forego their usual summer holidays and work weekends and evenings. Some may well do that but I doubt he’ll get total buy-in, especially from health care workers who’ve been on the front lines of the COVID-19 pandemic and are flat-out exhausted.
What’s your opinion on B.C’s decision? Leave a comment or email me: email@example.com
Excellent overview of a disturbing reality, Pamela. When Dr. Bonnie Henry makes it clear that she’s not a fan of random testing because of the “test limitations”, it begs the question: why do we continue to rely on testing despite acknowledging such limitations? Would we continue to rely on pregnancy tests that were wrong one-third of the time?
Experts have pondered the possible reasons for test limitations, including but not limited to problems with chemical reagents used to perform the tests, the biology of the individual patient, timing (if symptoms are waning, false negatives may be more prevalent), and – perhaps most worrisome – incorrect swab placement by the person doing the nasopharyngeal testing (one physician joked – sort of! – that he wants to see cerebral spinal fluid on each swab!)
The daily briefing announcements of BC’s current COVID-19 positive cases is a joke, given the number of both sick people, asymptomatic people or dead people who are never tested. When a friend in Vancouver became ill and tested positive on March 19th (a few days after a big family birthday party at her home), none of her party guests could get tested, although several family members did later test positive. Now, with added capacity since then, we’re told that anybody who wants to be tested, can be. The public health policies, including now this policy for surgical patients that reinforces Picard’s “half-hearted” embrace of testing, are unfortunate.
Isn’t it better to know a little than to know everything? I think this is financially and politically driven.