David Watters: Defining elective

DEFINING the urgency of elective surgery has been inconsistent across Australia but that should change with recommendations for a nationwide categorisation system.

The Australian Institute of Health and Welfare and the Royal Australasian College of Surgeons worked together during 2012 to compile recommendations on elective surgery urgency categorisation (ESUC). We were assigned the task by the Council of Australian Governments (COAG) on the recommendation of an expert panel established to report on elective and emergency access targets.

The ESUC report has been submitted to the COAG Standing Council on Health.

Currently the way clinical urgency categories for elective surgery are assigned differs between the states and territories. For example, about 70% of joint replacements in NSW were assigned to category 3 (within 1 year), yet in Victoria two-thirds were category 2 (within 90 days) on account of pain and deformity associated with the need for surgery.

Indeed, it was the variability of the descriptions used to guide assignment of category that was responsible for the inconsistency. This meant patients often did not have their surgery within the expected time frame due to inefficient and clogged waiting lists.

The process of reviewing the categorisation involved extensive stakeholder consultation with surgeons, waiting list managers, surgical service directors and jurisdictions. It led to a package of integrated components.

A guiding principle was that the urgency category be assigned by the treating clinician. The category should be appropriate to the patient and their clinical situation, and not influenced by the availability of hospital or surgeon resources. As the treating clinician is responsible for assigning a category, there is no need for jurisdictions to use clinical terms or descriptions to prompt a particular categorisation.

Simplified urgency category definitions, based on the time frame in which the procedure is clinically indicated, were agreed — category 1: within 30 days; category 2: within 90 days, and category 3: within 1 year.

It was acknowledged that patients would not all have the same urgency within these periods, so “treat in turn” was introduced as a principle for elective surgery management. It was envisaged that 60%–80% of cases could be treated in turn, but there would always be some patients whose clinical condition demanded earlier surgery.

To assist clinicians, surgical specialty groups will develop listings of the “usual” urgency categories for higher volume procedures. There was considerable debate about this but it was favoured by clinicians in many states, and it was agreed such a list would be a guide, not a ruling.

There will always be cases where patients need to be placed in a more urgent category than the usual. The word “usual” was agreed after much discussion of alternatives such as “most frequent”, “normal” or “recommended”.

Reports allowing comparisons of urgency categorisation performance will be produced for jurisdictions. The information should enable jurisdictions and surgical services to reflect on their categorisation and become more consistent without jeopardising clinically urgent cases. Treat-in-turn reports will also be generated.

There has been much confusion over how to treat patients who are not ready for surgery either for personal reasons or because of their clinical condition. In some cases, patients may need a staged procedure within a particular time frame and the management of these cases has been inconsistent. It has been agreed that waiting list management should assign these patients to a new category that will ensure only patients ready to have surgery are actually on the waiting list, thus improving efficiency and reporting.

It was also recommended that other procedures currently excluded (such as colonoscopy) should be brought under the national elective surgery waiting times reporting arrangements.

The definition of elective surgery was also discussed. The current definition of elective care is impractical — “care that, in the opinion of the treating clinician, is necessary and admission for which can be delayed for at least 24 hours”.

Today, emergency surgery is often scheduled for later than 24 hours so we redefined elective surgery as “surgery for patients whose clinical condition requires a procedure that can be managed by placement on a waiting list”.

These national definitions are expected to facilitate access to elective surgery for patients, as they will be assigned a category based on their clinical need, maximising the chances of equitable access across Australia.

Greater consistency should lead to better waiting list management with benefits for patients, their families, clinicians and elective surgery waiting list managers.
 

Professor David Watters is the chair of the Professional Development and Standards Board of the Royal Australasian College of Surgeons.