The surgical waiting time initiative: A review of the Nigerian situation.

The concept of surgical waiting time initiative (SWAT) was introduced in developed countries to reduce elective surgery waiting lists and increase efficiency of care. It was supplemented by increasing popularity of day surgery, which shortens elective waiting lists and minimises cancellations. It is established in Western countries, but not in developing countries like Nigeria where it is still evolving. A search was carried out in Pub Med, Google, African journals online (AJOL), Athens and Ovid for relevant publications on elective surgery waiting list in Nigeria, published in English language. Words include waiting/wait time, waiting time initiative, time to surgery, waiting for operations, waiting for intervention, waiting for procedures and time before surgery in Nigeria. A total of 37 articles published from Nigeria in relation to various waiting times were found from the search and fulfilled the inclusion criteria. Among them, 11 publications (29.7%) were related to emergency surgery waiting times, 10 (27%) were related to clinic waiting times, 9 (24.3%) were related to day case surgery, 2 (5.5%) were related to investigation waiting times and only 5 (13.5%) articles were specifically published on elective surgery waiting times. A total of 9 articles (24.5%) were published from obstetrics and gynaecology (OG), 7 (19%) from general surgery, 5 (13.5%) from public health, 3 (8%) from orthopaedics, 3 (8%) from general practice (GP), 3 (8%) from paediatrics/paediatric surgery, 2 (5.5%) from ophthalmology, 1 (2.7%) from ear, nose and throat (ENT), 1 (2.7%) from plastic surgery, 1 (2.7%) from urology and only 1 (2.7%) article was published from dental/maxillofacial surgery. Waiting times mean different things to different health practitioners in Nigeria. There were only 5/37 articles (13.5%) specifically related to elective surgery waiting times in Nigerian hospitals, which show that the concept of the SWAT is still evolving in Nigeria. Of the 37, 11 (24.5%) publications were from obstetrics and gynaecology (O & G) alone, but these were mostly related to emergency antenatal care rather than surgery. Therefore, more research and initiative needs to be undertaken from all the surgical sub-specialties in order to disseminate this concept of SWAT towards early diagnosis and treatment of elective life-threatening conditions, as well as effective patient care. Adopting this concept will help healthcare managers and policy makers to stream line and ring face resources to cater for non-urgent or semi-urgent cases presenting to our hospitals in Nigeria.

INTRODUCTION

Waiting times mean different things to different medical practitioners in Nigeria. However, this is a review of the surgical waiting times, as currently understood and practised in Nigeria by different health professionals. The surgical waiting time initiative (SWAT) was introduced in the UK and other developed countries, in order to reduce waiting lists and increase efficiency of patient care (Frankel, 1989).1 It was later supplemented by increasing popularity of day surgery, which shortens elective waiting lists and minimises cancellations. SWAT is now well established in Western countries like UK (Mills et al., 1991),2 USA and Canada (Casas et al., 2007)3 where it is practised alongside day surgery; but not in developing countries like Nigeria where this concept is still new and evolving. So far, most of the centres in Nigeria do not have a ring-fenced or dedicated elective surgery service and most of these cases are admitted to the same wards with emergency patients, with no dedicated theatre time or space. This leads to frequent cancellations of the elective cases as they are perceived to be less urgent than emergencies, and so the patients end up suffering while their diseases may continue to progress or deteriorate, especially cancers.

In 2000, the UK department of Health (DoH) set up a mandatory target for urgent referral and management of patients with suspected bowel cancer. They recommended that all patients referred from their general practitioners must be reviewed by a specialist within 2 weeks and must be offered treatment within 62 days (Mukherjee et al., 2010).4 This initiative has since been extended and rolled out to include other cancers and public health issues of interest in the UK (Lewis et al., 2005).5 In June 2004, the UK National Health Service (NHS) introduced the 18 week patient pathway, which guaranteed that no patient should wait for more than eighteen weeks before any planned (elective) surgery in the UK (Bruni et al., 2010).6 This has resulted in a significant improvement in the early diagnosis and treatment of patients referred from their general practitioners (GPs), especially in the fields of oncology, orthopaedics, general surgery, rheumatology and cardiology, among others.123456

MATERIALS AND METHODS

A search was carried out in PubMed, Google, AJOL, Athens and Ovid for relevant publications on surgical waiting times in Nigeria. The search included all articles published within and outside Nigeria related to the topic in question, and also restricted to articles published in English language only. The types of articles considered include both prospective and retrospective case series, case reports, review articles, literature reviews, reports, guidelines, published reviews and commentaries. Search words used include waiting/wait time, waiting time initiative, time to surgery, waiting for operations, waiting for intervention, waiting for procedures and time before surgery in Nigeria.

RESULTS

A total of 37 articles published from Nigeria in relation to various waiting times were found from the search and fulfilled the inclusion criteria.78910111213141516171819202122232425262728293031323334353637383940414243 A total of 11 publications (29.7%) were related to emergency surgery waiting times,7891011121314151617 10 (27%) were related to clinic waiting times,32333435363738394041 9 (24.3%) were related to day case surgery,232425262728293031 2 (5.5%) were related to investigation waiting times4243 and only 5 (13.5%) articles were specifically published on elective surgery waiting times.1819202122 A total of 9 articles (24.5%) were published from obstetrics and gynaecology (OG), 7 (19%) from general surgery, 5 (13.5%) from public health, 3 (8%) from orthopaedics, 3 (8%) from general practice (GP), 3 (8%) from paediatrics/paediatric surgery, 2 (5.5%) from ophthalmology, 1 (2.7%) from ENT, 1 (2.7%) from plastic surgery, 1 (2.7%) from urology and only 1 (2.7%) article was published from dental/maxillofacial surgery. These results are illustrated in Tables 1–7.

Table 1

Summary of intervention types in relation to waiting time

Table 7

Summary of articles focusing on investigation waiting time

DISCUSSION

A review of the published articles on waiting times in Nigeria showed that 11/37 (29.7%) of the publications focused on emergency surgery/care [Tables 1 and 3].7891011121314151617 This is not surprising, because there is currently a lot of focus on emergency care and surgery in many health centres in Nigeria. This may be a result of delayed presentation by patients, inadequate funding of the hospitals, lack of dedicated elective surgery services, lack of awareness among patients with non-urgent medical conditions and the general negative attitudes of the healthcare practitioners and managers towards non-urgent (elective) surgery. A total of 10/37 (27%) of the publications were focused on clinic waiting times [Tables 1 and 6],1819202122 which is a reflection of the growing public health interest on measures of patient satisfaction with healthcare services. This is a good development as these outcomes can be used to improve the overall standard of healthcare facilities in Nigeria.

Table 3

Summary of articles focusing on emergency surgery/care

Table 6

Summary of articles focusing on clinic waiting times

Furthermore, 9/37 (24.3%) of the publications were related to day surgery practice in Nigeria;232425262728293031 and most of the authors highlighted the increasing role of day surgery in facilitating and even ring-fencing elective surgeries in order to prevent or reduce frequent cancellations in favour of emergency cases [Tables 1 and 5],232425262728293031 and 2/37 (5.5%) of the published articles were related to investigation waiting times [Tables 1 and 7]. However, none of these articles specifically focused on elective or planned surgical waiting times as well as the need for an organised initiative to improve the waiting times for non-urgent surgical intervention in Nigeria.

Table 5

Summary of articles focusing on day surgery

In contrast, only 5/37 (13.5%) of the relevant published articles were specifically related to elective surgery waiting times [Tables 1 and 4]; and most of these articles are non-randomised retrospective case series in single centres; only one study was a prospective review of laparoscopic procedures in paediatric patients (Misauno et al., 2012). Also, one of the five publications related to elective surgery reviewed the effects of cancellations on the surgical waiting list, and the authors recommended adequate planning and good communication between staff and patients as the key to avoiding frequent cancellations of surgical lists (Kolawole et al., 2002). One of the articles was a review of day surgery practice in Nigeria, and explained the ideal concepts of this idea, as well as its role in carrying out elective surgeries in order to reduce the surgical waiting times (Abdulkareem, 2011).

Table 4

Summary of articles focusing on elective surgery waiting times

With regards to specific sub-specialties, 9/37 (24.5%) of the publications were from OG, but a few of these publications related to emergency antenatal care rather than emergency surgery; 7/37 (19%) were related to waiting times in general surgery, which is the most established surgical sub-specialty in Nigeria, 5/37 (13.5%) of the publications were related to public health, which reflects the increasing effort of physicians in getting patient feedback regarding their satisfaction with healthcare services in Nigeria, whereas orthopaedics, paediatric surgery and family medicine each had 3/37 (8%) of the publications related to various types of waiting times, ophthalmology had 2/37 (5.5%) of the published articles, while anaesthesia, plastic surgery, ENT, dental surgery and urology each had 1/37 (2.7%) of the relevant publications. These results are illustrated in Table 2.

Table 2

Summary of specialties in relation to waiting times

A review of the current literature elsewhere showed that management of elective surgical waiting times has become well established in the healthcare systems of many developed countries such as UK, USA, Australia and Canada. This is especially true in the fields of cancer, joint replacement surgeries (arthroplasties), sight restoration, cardiac problems and diagnostic imaging among others (Bruni et al., 2007).44 Briggs et al., (2011)45 reviewed the effect of active management of surgical waiting lists in a urological service in Australia, which resulted in a significant reduction in the surgical waiting times for semi-urgent and non-urgent patients from 248-180 days in the 10-month period of the review. Other workers (Mills et al., 2005)46 also revealed a significant reduction in the surgical waiting times of their patients as a result of the waiting time initiative in an ENT surgical unit.

Gray et al., (2010)47 also investigated the effects of reducing the pre-operative waiting times in patients undergoing spinal surgery, and revealed that this reduction in waiting times did not compromise the patient's quality of care, but rather had a positive influence on the patients due to the added convenience. In another study of patients suspected to have colorectal cancer, Mukherjee et al.,4 observed that the 2-week referral pathway reduces both diagnostic and treatment waiting times for these patients, and led to an improved rate of early diagnosis of colorectal cancer in their cohort of patients.

In a systematic review of the effect of prolonged surgical waiting times for patients with renal cancers, Jewett et al., (2006)48 revealed that waiting times ranged from 26 to 82 days, with a median of 64 days from referral to surgery in one Canadian study. This was found to have exceeded the National and International guidelines, which recommended 2-4 weeks for all cancer surgeries. However, they observed that there were no studies looking at the association between surgical delays and clinical outcomes in cancer patients. In another Canadian study, however, Fradet et al., (2006)49 did a systematic review of 18 published articles evaluating waiting times for bladder cancer surgery, 10 of which evaluated the effects of prolonged waiting times and overall survival or tumour grade. Three of these studies measured the association between a delay of 3 months and the tumour grade, and found a positive correlation between prolonged delay and tumour grade.

Aiono et al., (2000)50 prospectively reviewed the waiting list of a general surgical unit over a 13-year period. They found that surgeons had no control on the length of the surgical waiting lists in spite of the introduction of the SWAT. They revealed that funding, lack of beds and theatre sessions were the main factors influencing the length of the surgical waiting times, and emphasised that an imbalance between these factors will lead to insufficient beds being available to cater for the theatre sessions created leading to frequent cancellations.

In most Western countries like the UK, for example as a result of this ring-fencing system, which ensures that all elective cases are properly pre-booked and carried out on dedicated theatre lists and at specified times, there is hardly any cancellation of elective surgical cases without a definite clinical reason; and when this happens, the erring departments or hospital trusts are fined by the supervising agencies (personal experience). This system will ensure that, elective surgical cases are adequately catered for and patients do not therefore suffer from the consequences of any delays in intervention. In view of this, healthcare managers and policy makers in Nigeria can adopt a similar system to ring-fence all elective surgical cases, and ensure that these procedures are carried out within a specific time frame to improve the quality of care to patients. However, these measures require adequate planning, funding, staff training and patients’ co-operation.

CONCLUSION

Waiting times mean different things to different health practitioners in Nigeria. There were only 5/37 articles (13.5%) specifically related to elective surgery waiting times in Nigerian hospitals, which show that the concept of the SWAT is still evolving in Nigeria. A total of 11/37 (24.5%) of the publications were from OG alone, but these were mostly related to emergency antenatal care rather than surgery. Therefore, more research and initiative needs to be undertaken from all the surgical sub-specialties in order to disseminate this concept of SWAT towards early diagnosis and treatment of elective life-threatening conditions, as well as effective patient care. Adopting this concept will help healthcare managers and policy makers to stream line and ring face resources to cater for non-urgent or semi-urgent cases presenting to our hospitals in Nigeria.