As trusts consider clearing the waiting list, there is an absence of objective approaches to prioritisation. There are 40 million variations of operative type and the NHS elective waiting list may reach more than 10 million. A coronavirus second wave may cause further delays and expansion of the waiting list.
This blog from hub topic lead Richard Jones describes a proven approach to prioritising the waiting list built around individualised risk-adjustment for each patient and evolved from the core POSSUM methodology that is widely used for individual risk assessment pre-operatively.
A significant backlog of elective surgical cases has built up during the COVID-19 crisis. The freeze on elective surgery has produced a waiting list that may take years to clear.
In the US, the CDC has issued guidelines that "facilities should establish a prioritization policy committee consisting of surgery, anesthesia and nursing leadership to develop a prioritization strategy appropriate to the immediate patient needs".
According to the CDC, this committee should work around 'objective priority scoring'. The MeNTS (Medically-Necessary, Time-Sensitive Procedures) instrument is a clever attempt to deliver this scoring, responding to availability of resources and the situation around COVID-19. However, the key challenge is that that the list needs to be prioritised in a way that reflects patient needs and ensures their safety. This is not something that MeNTS can deliver. It also is built around COVID-19 related limitations on resources and this will vary in significance depending on the hospital location and where it is in the journey out of lockdown.
The risks of mortality and complications for a patient are a complex combination of the severity of the procedure and the physiological variables of the patient. As an example, a 55-year-old undergoing a radical laproscopic prostatectomy has a risk of mortality of 1.6%. However, if the patient has low blood pressure, that risk triples. If the patient also has low sodium then the risk is 10 times higher [C2-Ai insights]. The spectrum of different operations and key physiological variables creates at least 40 million potential combinations and hence risk. This is hard to manage with one patient but trying to prioritse a group of 5, 10, 100, 1,000 or even 10,000 becomes unmanageable.
New patients will be joining the list while others leave following their procedures and so triage of the list will not be a one-off event. The list will need to be populated and triaged intelligently and in a consistent way repeatedly at least until there is a return to ‘normality’.
There is evidence that some trusts are attempting to build their own systems for prioritisation. This may be possible around matching operative type and resource availability but the efficiency of these systems overall should be a concern. Best intentions are fine but, when reviewed later, the ability to correctly prioritise patients to minimise harm and mortality is likely to be limited if not flawed.
C2-Ai’s COMPASS Surgical List Triage system is an example of a system that can support evidence-based triage and individualised risk assessment of patients, while supporting the objectives of the CDC. It supports clinical decision making across all phases from crisis back to steady state. It has been developed by the creator of the POSSUM system and is built around the world’s largest patient data set (140 million records from 46 countries) through the support of NHS Digital. The underlying algorithms are constantly refined against new and existing data sets to ensure relevance and accuracy. The Surgical List Triage tool combines the mortality and complication risks from the different patients to derive the prioritisation.
The system carries out bulk assessments using individualised risk assessments for each patient. These reflect the operative type and their physiology to calculate the risk of mortality and complications, as well as providing a detailed breakdown of potential complications with percentage probability with a simple click. This system also suggests patients that should be reviewed for potential optimisation before any procedure. The physician can click on the link to see the detailed risks for the patient to support their decision making.
The system can be used regularly to maintain the logic and integrity of the elective surgical list. This is superior to the potentially fragmented approach where parts of the list are manually considered in isolation as this cannot support effective optimisation of the whole list and the absence of any supporting evidence means the triage will vary enormously.
COMPASS SLT is an evidence-based approach that supports optimal ordering of the list and clinical decision making that reduces avoidable harm and mortality. This in turn reduces variation, and cost while freeing bed capacity and also allowing the list to be tackled more quickly.
When a patient comes in for the operation, an individual risk-assessment can be done using the COMPASS Pre-Operative Risk Assessment app. This provides a final check on whether the patient’s condition would justify optimising their condition before their procedure. However, it also details the most likely post-procedural complications individualised for the patient and their condition. That allows the treatment pathway to be tailored to that patient as well as recruiting the patient into their own recovery. For example, knowing that chest infection is the highest risk for a patient supports a conversation with them to stress the need for them to get up and about on the day of the operation. As an aside, the risk of mortality and complications can also be used as a strong element in showing informed consent has been obtained from the patient.
In combination, these tools can provide a platform to support effective and ongoing triage of the list while reducing harm and unnecessary costs. The systems are currently in use in 12 trusts in the NHS.
How are you prioritising waiting lists? We'd be interested to hear and share how you and your trust are dealing with the backlog.
About the Author
With over 30 years spent in advanced technologies, Richard has extensive experience as an entrepreneur, in strategy development, business planning/modelling, and creating commercial implementations for companies.
Richard is President and Chief Strategy Officer of C2-Ai, one of 10 Essential Digital Health Ideas for a UK National Covid Response according to Healthcare UK. He was a COGX keynote speaker on the Global Leadership stage and won (with C2-Ai) two awards including the prestigious Overall Tech4Covid award as well as appearing on BBC News to discuss these innovations.