Revisiting the concept of urgency in surgical prioritization and addressing backlogs in elective surgery provision.

Abstract

© 2022 CMA Impact Inc. or its licensors CMAJ | August 2, 2022 | Volume 194 | Issue 29 E1037 In Canada’s health care systems, urgency has long been the first consideration in patient prioritization. In the context of allocat­ ing surgical resources, urgent procedures are prioritized over elective (scheduled) ones.1 However, prioritizing urgency, par­ ticularly in times of resource constraints, leads to a problem of 2 wait lists: a growing wait list of urgent cases and a much larger wait list of scheduled cases that frequently become delayed past their appropriate wait times, leading to adverse patient out­ comes. We discuss this problem, which we refer to as the urgency dilemma, as well as some potential solutions. Two types of surgical cases are negatively affected by a nar­ row understanding of urgency. The first type is the scheduled case that will eventually become urgent, where the consequence of a delay in timely surgery is that the patient’s outcome is worse than it would have been had they been treated earlier. As delays worsen, an increasing number of patients with scheduled surger­ ies progress to requiring urgent surgery. A 2022 cohort study sug­ gested that delays in cancer detection will leave higher propor­ tions of cancers “unresectable or incurable at presentation.”2 It is “a matter of time before elective cancer surgery becomes urgent,”3 adding further burden to a resource­constrained sys­ tem.4 The problem becomes deciding where urgency begins such that health care resources can be appropriately allocated. The second type of case is the one that will never escalate to an urgent classification. Here, the consequences of delay will not be loss of life or limb, but rather persistent and seriously compro­ mised quality of life for the patient, in domains that may include development, mobility, fertility or mental health. Delays may increase the complexity of a surgery or lead to higher risks of complications or poor postoperative outcomes.5–7 Moreover, pediatric patients who require time­sensitive surgeries to co incide with critical developmental milestones may have life­ long consequences of delayed surgery. The surgical wait list problem has prompted calls from health care leaders to redesign how we deliver surgical care in Can­ ada.8–10 Given the urgency dilemma we have described, we pro­ pose a multistep plan to improve access for scheduled surgeries while not abandoning urgent cases in the process. The first step is to reframe what “urgency” and “scheduled” mean in surgery. Urgency is relative, and scheduled surgeries are not optional. “Urgent” and “scheduled” designations are not 2 discrete classifications of surgical importance; rather, they are 2 different and movable points on the same dynamic continuum of time­sensitive care. Reconceptualizing this continuum would allow and encourage health care systems to explicitly preserve room for scheduled cases. Urgent cases that can wait until the end of their urgency window should do so to allow scheduled cases more predictable access. To further account for this com­ plexity, we encourage the development and validation of nuanced prioritization tools for scheduled cases that account for factors beyond degree of urgency, such as the risks associated with prolonged delay, impacts on quality of life and consider­ ations of long­term disability. The recognition of additional fac­ tors would provide justification for sharing limited surgical time with a wider range of cases than just those deemed urgent in the traditional sense. Commentary