Michael is a 35 year old with a past history of gallstones. He began to feel a stabbing pain in his belly one evening and tried to sleep it off. He was woken up by an excruciating pain, something he’d never felt before, and his wife drove him to the local emergency department.
First, Michael waited in the emergency department to see a doctor, who suspected gallbladder inflammation related to gallstones. The doctor ordered diagnostic tests to confirm this and called for a surgical consultation. The surgeon on-call was busy with a full slate of scheduled cancer surgeries that day, and not wanting to cancel those patients, waited until he had a moment towards the end of the day to see Michael.
By the time the surgeon saw Michael, he realized he needed surgery to remove his gallbladder within the next day. The doctor bumped a patient scheduled for surgery for the next morning and fit Michael in.
Michael is a fictitious patient. However patients like him arrive daily to Canada’s emergency departments. A 2007 Canadian Institute of Health Information report found that about 20% of the one million Canadians admitted to hospital from the emergency department require surgical care, some of it urgent.
An ignored and fragmented patient population
There are many conditions that require urgent surgery, but disorders such as hip fracture, acute cholecystitis (acute gall bladder inflammation) and appendicitis are particularly common.
Time is of the essence in treating patients who require urgent surgery. Delaying an urgent surgery for lengthy periods of time, in some cases, increases complications and may even lead to death. For example, an inflamed appendix, untreated, may rupture, spreading infection throughout the abdominal cavity.
There is a growing body of research suggesting that patients with urgent surgical needs are waiting too long for surgery. From the time that they present to an emergency department to being booked in for surgery, they can experience many periods of prolonged waits.
The diagram below, from a study led by surgeons at Sunnybrook Health Sciences Centre in Toronto, shows the many different steps in the typical journey of an urgent surgical patient. It details the waiting periods from the emergency department waiting room to operating room. (Click on the image for an enlarged view.)
Patients with urgent surgical needs are described by the Canadian Association of General Surgeons as a “sometimes ignored and fragmented patient population”. These patients cross many different clinical areas and hospital spaces, in comparison to patients booked into elective surgery.
Surgical services in larger hospitals are often organized by specialty, with operating rooms dedicated towards specific areas, such as cancer and orthopaedics. These are generally scheduled surgeries, with patients having a pre-surgery consult and care.
Urgent surgeries have traditionally been slotted into the existing surgical schedule, wherever they might fit, which can include after hours or else bumping an existing surgery booking. Typically each surgical division and surgeon will be allotted a certain ‘block’ of operating time for their elective surgery. Surgeons use this time to manage patients requiring surgery who have been referred to them. If their ‘elective time’ is continually utilized by ‘urgent surgery cases’, their elective wait lists will grow, ultimately affecting the timeliness and quality of their services.
As there has been increasing attention focused on improving elective surgery wait-times, hospitals and surgeons tend to fiercely protect ‘elective surgical blocks’. In some cases, this may result in urgent cases being delayed until later in the day, when surgeons have completed their elective list of surgeries for the day.
Urgent surgery wait times are not being measured
Measuring surgical wait times is well established across Canada. In 2004, provinces agreed to a 10-Year Plan to Strengthen Health Care, with a major focus on wait times. This plan identified five priority areas for wait time reductions, elective surgeries in cancer care, cardiac care, diagnostic imaging, hip and knee joint replacement and cataract surgery.
The plan set benchmarks for wait times in these areas, and involved a substantial amount of new funding – $1.7 billion in Ontario – to increase the number of these procedures, and a commitment to publicly measure and report on wait times. In Ontario, publicly reporting on wait times for surgery has expanded beyond the five priority areas to a broad range of elective surgery and diagnostic procedures. However, conspicuously omitted from this list are urgent surgeries, such as the one required by Michael.
There are gaps in our knowledge about how long patients are waiting across Canada for urgent surgery. “We’ve made an assumption that patients with urgent needs are protected from waits, queues and backlogs” says Chris Simpson, cardiologist and incoming Canadian Medical Association President. However, evidence suggests that this assumption may not always hold true.
New approaches in acute care surgery
The past decade has seen a movement across some larger Canadian hospitals to improve access to surgical services for patients with urgent surgical conditions. This has been in part motivated by some evidence and concerns from surgeons and hospital administrators that these patients are waiting too long.
Avery Nathens, Chief of Surgery at Sunnybrook Health Sciences Centre, says these programs are driven by the “need to build emergencies into the routine.”
As of 2009, there were 13 dedicated acute care surgery services across Canada. These dedicated services usually mean that the surgeon on call has no other elective cases booked, and can focus on urgent patients. Often, but not always, hospitals with these services have dedicated operating room blocks for urgent procedures so that patients are not left waiting. “Why act as though an emergency is unexpected?” asks Nathens. “Depending on the surgical specialty, over a third of all surgical cases are urgent – why not plan adequately for emergency surgical care?”
Paula Doering, Vice President of Clinical Programs at The Ottawa Hospital was motivated to develop the hospital’s acute care surgery program in response to elective surgeries being cancelled to accommodate urgent cases. She says it was “not fair to patients and surgeons who were getting cancelled.”
Sudhir Sundaresan, Chief of Surgery at the Ottawa Hospital notes that dedicating operating rooms to urgent cases “seemed counter-intuitive” as they were not being fully utilized. However, the costs of maintaining operating room space were offset by the reduction in cancellations for elective surgeries, and fewer patients waiting for surgery taking up emergency department beds. “There wasn’t a patient in the room every minute of the day, which helped to build in capacity and flexibility to meet the needs of urgent cases”, he said.
Emergency department overcrowding and concerns that patients are waiting too long for surgical consults in the emergency department is another motivator for acute care surgery programs. Sunnybrook developed an Acute Care Emergency Surgery Service (ACCESS) program with a dedicated surgeon and operating room for acute care surgery patients. A review of the data after ACCESS was implemented found that it reduced the time it took for surgeons to consult and book urgent patients for surgery, as well as improved emergency department overcrowding.
Fred Brenneman, a surgeon at Sunnybrook who participated in the development of ACCESS, notes that an acute care surgery program may not applicable for all hospitals, and in particular small hospitals. However, he says “there probably could, and should, be more effort into measuring these waits and patient flow.”
We can’t manage what we can’t measure
Stewart Hamilton, former chair of the surgery department at the University of Alberta hospital in Edmonton explains that the “whole picture” is not being measured for urgent surgery patients. He says that in Alberta wait times are collected for emergency department waits, as well as waits once a patient has been booked into an operating room, but that this information is not put together to be able to measure the full wait for urgent surgery patients.
Doering describes trying to measure waits for urgent surgeries as “a nightmare” with multiple, disconnected data sources from different parts of the hospital.
The public reporting and measurement of wait times for elective surgeries, along with significant government funding to increase the number of surgeries, has helped to reduce waits for some surgical procedures across Ontario. However, Nathens suggests that in this environment where elective surgery wait times are being counted and measured, surgeons feel pressure to meet government-set targets. He says “everyone is so focused on making their targets that there is the potential for urgent surgical patients to be left behind.”