National Paediatric Surgical Wait Times Strategy: Access Targets

Report 3

The National Child and Youth Health Coalition (NCYHC)

The National Child and Youth health Coalition is a coalition of the following five organizations who work collaboratively to advance the health and healthcare of children and youth across Canada:

• The Canadian Association of Paediatric Health Centres
• The Canadian Child Health Clinician Scientist Program
• The Council of Canadian Child Health Research
• The Paediatric Chairs of Canada
• The Paediatric Surgical Chairs of Canada

Objectives of the NCYHC Paediatric Surgical Wait Times Strategy

The NCYHC Paediatric Wait Times Strategy is the outcome of a National Consensus Workshop held in February 2006. Representatives from all sixteen paediatric academic health centres across Canada came together and unanimously endorsed a framework and methodology to establish national access targets for ten paediatric surgical subspecialties. Drawing from a national pool of experts, the Strategy builds on the collective work of provincial groups across Canada and is fashioned after the model developed by the Ontario Children's Health Network (OCHN).

The Strategy sets out to:

• Establish national access targets for ten paediatric subspecialties
• Determine the current wait time "burden" i.e. the number of children across Canada who are not receiving care within the established access targets
• Develop strategies to optimally manage wait times
• Assess the system's capacity to provide timely care and
• Develop resource allocation recommendations

The following principles guide the Strategy:

• The Children's Strategy must aim to make system - wide changes for the betterment of surgical services for children and their families
• The Children's Strategy must be designed to complement and leverage the adult wait time strategy
• The Paediatric Surgical Wait Times Strategy should serve as a model for evaluating and addressing wait times in non-surgical specialties for Canada's children and youth

The Strategy Framework

Workshop delegates unanimously endorsed the framework and methodology developed by OCHN and described below. They further recommended that the OCHN access targets (refer to Appendix: OCHN Access Targets) serve as the basis for national standards and that a national consultation be undertaken to address any refinements required for national adoption.

The OCHN model establishes access targets for approximately 350 diagnoses within nine subspecialties: Cardiovascular Surgery, General Surgery, Gynaecology, Neurosurgery, Ophthalmology, Orthopedics, Otolaryngology, Plastic Surgery and Urology. Table 1 outlines the major areas where access targets have been developed. The National Workshop delegates recommended adding a tenth subspecialty - Oral Surgery. A process is currently underway to establish consensus access targets for this subspecialty.

Table 1: Major categories having access targets within the nine subspecialties

Paediatric General Surgery

• Neonatal Conditions
• Thoracic Neonatal conditions
• Abdominal Wall
• Colon, Rectum, Anus
• Esophagus
• Stomach, Duodenum, Small Bowel
• Solid Tumors
• Neck Mass
• Trauma Care
• Biliary System and Spleen
• Genitalia

Paediatric Gynaecology

• Adolescent Pregnancies
• Vulva, Cervix, Vagina
• Gynaecological Congenital Anomalies
• Genital Trauma
• Ovaries
• Ante-natal Care for Adolescent Pregnancies
• Solid Tumors
• Miscellaneous Procedure

Paediatric Neurosurgery

• Developmental Malformations: Spine, Brain Structures, Craniofacial, Vascular
• Intracranial Cyst and Abscess
• Brain Tumors
• Cerebro-Spinal Fluid Build-up
• Skull Tumor
• Epilepsy and Spasticity
• Trauma

Paediatric Ophthalmology

• Strabismus
  • Oculoplastics: Lacrimal Surgery, Eyelid, Orbital
• Surgery
• Anterior Segment
• Cornea
• Retinal Surgery
• Glaucoma

Paediatric Orthopedic Surgery

• Disorders of the: Hip, Spine, Upper Extremities, Lower Extremities, Feet
• Minor Variants of Normal
• Bone and Joint Infections
• Fractures
• Skeletal Displasias
• Musculoskeletal Tumors
• Other

Paediatric Otolaryngology

• Disorders of the Airway
• Neck Mass
• Sino-Nasal Disorders
• Salivary Gland Disorders
• Otologic Surgery
• Disorders of the Head and Neck

Paediatric Plastic Surgery

• Clefts
• Burns
• Congenital Hand and Upper Extremity
• Soft Tissue and Skin Conditions
• Craniofacial
• Trauma
• Ear
• Solid Tumors
• Miscellaneous

Paediatric Urology

• Urinary Incontinence
• Renal/Bladder Anomalies
• Genital Anomalies
• Urinary Tract Calculi
• Solid Tumors
• Genitourinary Trauma
• Inguinal Pathology (non-malignant)
• Miscellaneous

Paediatric Cardiovascular Surgery
(50 diagnoses)

Priority rating system and diagnostic themes

Sub-specialty access targets are based on:

• A priority rating system and
• Diagnostic themes within each subspecialty.

A seven grade priority rating system developed to address the specific needs of the paediatric population will be used. This system is flexible as it can be truncated into a four grade scale that is consistent with grading for many adult wait time initiatives.

Priority Classification Level	Access Target Time Frame
Priority I	within 24 hours
Priority IIa	between 24 hours and 1week
Priority IIb	between 1 to 3 weeks
Priority III	within 6 weeks
Priority IV	within 3 months
Priority V	within 6 months
Priority VI	within 12 months
All cases	Within 18 months

The Strategy Methodology

Multiple wait times

The national paediatric surgical wait times strategy focuses on two critical wait times, W1, the time period between referral from primary provider to surgeon and W2, the time period between the decision by surgeon and family to proceed with surgery and the actual surgical procedure.

A comprehensive Paediatric Surgical Wait Times Strategy will require developing standards for two other critical "wait times". These will be addressed at a later date:

1. The wait time for diagnostic procedures at the stage of primary care or specialty consultation and
2. The wait time for after care services

Access targets are then based on diagnostic themes within each subspecialty. There are several advantages of this approach. First, the diagnosis is the basis of referral for consultation and the most appropriate determinant of waits. Second, diagnosis is easily understood and agreed upon by the surgical specialties. Finally, diagnosis is less prone to manipulation in any waiting list management system. Including all sub-specialties and diagnostic themes within the strategy has an additional advantage: It provides a basis for monitoring whether or not any subsequent strategies to address waiting times compromise one aspect of care for the sake of another.

The appended attachment "Ontario Paediatric Surgical Wait Time Access Targets - Ontario Children's Health Network" details the access targets for the approximately 350 diagnoses contained within the nine subspecialties.