Children's wait for surgery improving

By James Wright, MD, MPH, FRCSC

In the rush to reduce surgical wait times in Canada, the focus has largely been on adults. The National Wait Times Strategy (NWTS), announced as part of the Canadian 2004 federal-provincial health accord, focuses on five key areas: cancer surgery, certain heart procedures, cataract surgery, hip and knee replacements, and MRI and CT scans. While these are certainly important, they are not priority areas for most children.

The perception is that children don’t have to wait for surgery, or that they are less affected if they do wait. Certainly, fewer children than adults need surgery, however, children do wait for surgery, and the wait can affect a child’s growth and development.

Different kinds of waiting

Waiting times are not always easy to measure. For one thing, each patient usually faces several different waits between initially noticing a problem and having surgery:

• WAIT ZERO is the gap between noticing a problem and seeing a family doctor or other primary health care provider. Most wait time strategies do not address this wait, as it is largely under the control of the patient or family. Better access to primary care can help eliminate this problem as well.
• WAIT ONE is the gap between seeing a primary health care provider and seeing a specialist.
• WAIT TWO is the gap between visiting a specialist and having surgery. This gap gets the most attention from wait time strategies.
• WAIT THREE is the gap between surgery and getting any needed rehabilitation or other care after surgery.

What is an acceptable wait time varies greatly depending on the nature of the surgery and the individual patient. For example, some surgeries are urgent and require immediate attention: others are elective, and can be scheduled on that basis. Most significantly, some surgeries involved “planned” or deliberate waits. For example, doctors and surgeons may decide the best strategy is to give a child time to grow or grow stronger before addressing a problem with an operation.

Addressing children’s wait times for surgery

In Ontario, improving wait times took a two-pronged approach:

• Investment in more surgeries, with all the extra staff, rooms and equipment needed for that.
• Increasing efficiency in the existing surgical process as a whole.

Although there were many ideas about how to improve efficiency and which surgeries should get priority for additional funding, there was very little in the way of hard data to guide efforts. So, an expert panel was appointed to make recommendations, the first of which was to gather data. Next, an independent assessment of the whole paediatric surgical process started and specific surgeries were prioritized for additional funding.

More surgeries

In Ontario, the Provincial Wait Time Strategy (PWTS) already has or is providing about $13 million in additional funding to perform over 6,500 additional paediatric surgeries over two years. This money has been allocated to 29 different hospitals. In terms of wait times, dental surgeries requiring anesthesia had the biggest problem and so were allocated a larger chunk of the money to clear the problem. About one third of the new surgeries are dental. Following that, eye surgeries were the next biggest problem and about 1000 more will be performed.

Efficiencies and data

In terms of efficiencies, it's known that paediatric surgery can never be as efficient as adult surgery. Why? Well, for one thing, the patients tend to be less cooperative. Adults usually don't tend to get too upset when an IV is put in. Four-year-olds, who may not understand what is happening to them, are another story. Simple procedures that are a necessary part of the whole surgical process often take longer. In this regard, there is little that can be done to improve efficiency, however, this is not to say that paediatric surgery is perfectly efficient.

One area targeted for improvement was surgical start times. Often, similar surgeries are scheduled for the same day. For example, there might be 10 dental surgeries done all in a row. The idea is that the people, room and equipment are used most efficiently in this way. However, if the first surgery doesn't start on time, a cascade begins: the schedule gets progressively behind until the last few surgeries of the day end up being cancelled and rescheduled for the next time. Result: only nine of ten are completed.

Interestingly, once data collection became mandatory, start times immediately improved without changing any other part of the process. It seems once people know they must gather data about their activities, and therefore must be more accountable for what goes on, things get better.

This phenomenon is likely to have a longer lasting effect: when detailed data gathering began, it was thought this would end once a true picture had emerged. Now, it seems likely that this type of data capture has a purpose in and of itself and will therefore continue.

Better public reporting

Although a reporting system that tracks how long children wait for surgeries is already up and running, part of the PWTS is to capture better information that more accurately reflects surgical wait times. Current posted statistics don't really reveal a true picture of what is going on. For one, they are voluntary and not every hospital is reporting. Second, the information posted does not take into account “deliberate”, “planned”, or “developmentally appropriate” waits. This is changing.

By early 2009, all Wait Time Strategy-funded hospitals will report their wait times and the reporting system will accommodate discrepancies such as deliberate waits. Moreover, in the past, specific types of operations were categorized on a priority basis. Now, surgeons themselves decide the priority on a case-by-case basis. It's an acknowledgement that each case is different and may require more immediate attention, or not. These differences will also be taken into account when reporting wait time data.

Summary

As this much better data is gathered and analyzed, the focus of the strategy may change. The Wait Time Strategy should be seen as a project in development.

Over the course of 2009, complete wait time data for paediatric surgeries in Ontario can be viewed at:

Dr. James G. Wright, MD, MPH, FRCSC, is Surgeon-in-Chief, Robert B. Salter Chair of Pediatric Surgical Research, and Senior Scientist, Population Health Sciences at The Hospital for Sick Children (SickKids). He is also a professor in the Departments of Surgery, Public Health Sciences, and Health Policy, Management, and Evaluation at the University of Toronto.

Surgeon's Corner columns by James G. Wright