Backlogs and Waiting Times: How can Australia reboot elective surgery and increase capacity in a COVID-19 world?

Elective surgery backlog management is a key priority for all health systems as they enter the recovery phase from COVID-19. While some health systems in Australia have already started this journey, others are still dealing with restrictions on non-urgent surgery and mass cancellations of operations as a 2nd wave of the pandemic begins to emerge.

The issue at hand

In recent weeks we have seen news headlines in Australia which describe how state governments have partnered with the private hospitals and have allocated millions of dollars for public patients to have elective surgery in these facilities to cut the backlog created by the coronavirus pandemic. At the same time, public hospitals continue to seek to increase surgery capacity whilst ensuring sufficient resources remain available to support hospital admissions related to COVID-19. Research in May 2020 by the international CovidSurg project estimated that Australia had 400,000 elective surgeries cancelled due to COVID-19 restrictions (including 25,000 cancer surgeries) – and this was based on a 12 week period of activity. The reality is that as the threat of COVID-19 continues, the backlogs and waitlists keep growing.

The ongoing national trend is clear

Analysis by the Australian Institute of Health and Welfare (AIWH) has shown that surgery waiting times and the quality of care, as determined by health outcomes, varies a lot between states. AIWH’s analysis shows waiting times for elective surgery can also vary depending on a number of factors, including Indigenous status, remoteness of where people live, socioeconomic status, and funding source. However, the ongoing national trend is clear. According to AIWH data, public hospital elective surgery demand is growing. In 2018-19 there was a 2.2 percent increase in patients added to elective surgery waitlists compared to 2017-18. Since 2014-15 the median waiting time for patients to be admitted for elective surgery has increased from 35 days to 41 days in 2018-19.

Providing effective healthcare to all Australians is getting more challenging as the population grows and ages. COVID-19 has added another layer of complexity to an already challenging situation.

It is important to remember elective surgery does not mean optional surgery

The decision of the National Cabinet in late March 2020 to pause non-urgent surgeries across the country allowed health systems to prepare both public and private hospitals, our ICU capacity and increase supplies of PPE (personal protection equipment) for COVID-19. However, there has been no sudden return to normal for healthcare organisations and health systems. The primary goal for any hospital treating patients requiring surgery at this time must be to deliver care safely and to ensure the workforce is protected, and where possible can work in a COVID-19 free environment. Clinical teams continue to have to carefully weigh the risks of exposure to COVID-19 and related complications against the benefits of surgery. It is important to note that elective surgery does not mean optional surgery. It simply means non-urgent surgery, and what is truly non-urgent is not always transparent.

So how do you maintain surgery capability and where do you focus?

Using KPMG’s Healthcare Operational Excellence global network, and the reflections from Australian health executives, managers and frontline staff, we have compiled some areas of focus. They are:

Governance

States should establish regional governance structures encompassing public and private providers to optimise utilisation of their cumulative surgical resources.

Communication and clear messaging

Health systems and organisations should regularly brief their workforce so that they are aware of the options to address the challenges in managing waiting lists and the expectations of government, including the option of purchase of public surgery in private hospitals.

Hospital systems and state health departments need an effective communication strategy and dialogue with the public focusing on easing patient fears about how their surgical procedures will be undertaken while flagging any COVID-19 associated risks.

Demand and capacity management

Planning to scale up and scale down operating theatres is a necessity, there are likely going to be spikes, waves and local outbreaks of COVID-19 over the next 24 months.

Clinical prioritisation should be undertaken by a multidisciplinary team – clinical leads, an independent peer, anaesthetist and a surgery nurse manager as a minimum.

Surgical treatment decisions should always be well-thought-out, reducing risks whenever possible. Careful prioritisation of clinical urgency and coordination of cases will be required, to ensure social distancing and personal protective measures are maintained and the risk of transmission of COVID-19 is minimised.

System-wide collaboration

Long conceived notions of competition between healthcare providers needs to give way to local and regional collaboration between public and private providers. All assets and resources available to the health system should be effectively utilised, and the focus should be on patient needs and increasing capacity to work through the backlog.

Managing risks

Theatre managers should review and assess the availability of consumables and PPE daily to determine if demand can be met. Management and clinical leads should develop policies and procedures for more robust infection control through stringent cleaning routines and hygiene qualifications.

Where feasible, identify specific operating theatres or designated facilities for patients requiring emergency surgery and who may have been exposed to COVID-19. Where a patient is suspected or confirmed COVID-19 positive, anaesthetists in particular need to be able to protect themselves.

Consider designating hospitals in the health system for high complexity emergency cases. If possible, all emergency surgery patients should be tested for COVID-19 so that they can be housed in appropriate wards to minimise cross infection. Consider and plan contingences should emergency surgery need to be reduced.

As a system or network, continue investing in measures to keep the curve flat: COVID-19 testing and contact tracing, social distancing, long-term and agile supply chain management of personal protective equipment.

Thanks to Dion Newell and Roy Elliot for their contributions to this article.

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