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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
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Year : 2021  |  Volume : 26  |  Issue : 6  |  Page : 427-431

An audit of the provisional date of elective surgery allotted to pediatric surgery outpatients of a tertiary care, public-funded teaching hospital of North India

Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi, India

Date of Submission06-Sep-2020
Date of Decision04-Feb-2021
Date of Acceptance08-Mar-2021
Date of Web Publication12-Nov-2021

Correspondence Address:
Prof. Veereshwar Bhatnagar
Room No. 4002, Department of Paediatric Surgery, Teaching Block, All India Institute of Medical Sciences Hospital, Ansari Nagar, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaps.JIAPS_304_20

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Aim: The aim of this study was to review the compliance to the provisional date of elective surgery allotted to pediatric surgery outpatients at our center. Patients and Methods: This retrospective study was conducted in the department of pediatric surgery at our center. The children who were brought to the outpatient department with a previously allotted date of admission for elective surgery (DAES) and the final operation theater (OT) lists of elective surgery between July 2007 and September 2018 under one senior consultant (VB), were reviewed. Results: A total of 2409 cases were allotted a DAES during the study period. Out of these, 12% (288/2409) were defaulters with a male gender preponderance (82%). Most of the defaulters (>49%) belonged to the day-care surgery group, followed by simple reconstructive (32%), major reconstructive (18%), and infectious sequelae groups (<1%). The difference in the proportion of defaulters from both the reconstructive groups was statistically significant (P = 0.0001). On a further system-wise subcategorization of children in the day-care group, the genitourinary subgroup constituted the majority (80%). Children who had to undergo staged procedures showed a significantly better compliance (P < 0.0001) to provisional DAES as compared to those belonging to the single-stage group. Conclusions: Compliance to provisional DAES is poor among the children scheduled for day-care surgeries and those undergoing simple reconstructive surgeries in a single stage.

Keywords: Day-care, elective surgery, waiting list

How to cite this article:
Anand S, Tomar S, Dhua AK, Agarwala S, Bhatnagar V. An audit of the provisional date of elective surgery allotted to pediatric surgery outpatients of a tertiary care, public-funded teaching hospital of North India. J Indian Assoc Pediatr Surg 2021;26:427-31

How to cite this URL:
Anand S, Tomar S, Dhua AK, Agarwala S, Bhatnagar V. An audit of the provisional date of elective surgery allotted to pediatric surgery outpatients of a tertiary care, public-funded teaching hospital of North India. J Indian Assoc Pediatr Surg [serial online] 2021 [cited 2023 Oct 1];26:427-31. Available from: https://www.jiaps.com/text.asp?2021/26/6/427/330379

   Introduction Top

Prolonged waiting time of surgery has always been a cause of concern across the globe, especially in developing countries. Much is talked about the waiting time of surgery in adults; however, data regarding the waiting time of children's surgery are limited.[1],[2] A measure of the duration of the waiting period for surgery is also considered as one of the surrogate markers of the quality of the health-care services in any population. An extrapolation from the concept of the waiting list for surgery would be to analyze the defaulters among those who has been allotted a date of admission for elective surgery (DAES). The authors believe that such an analysis by individual hospitals can give us an insight into the variables coming into play during the waiting period. This attempt may help us in providing evidence and data to stagger future appointment date for admission and not allot dates just empirically, or in first-come-first-serve basis. The aim of this study was to analyze the compliance to the provisional DAES allotted to pediatric surgery outpatients at our center.

   Patients and Methods Top

This single-center retrospective study was conducted under a single pediatric surgery consultant (VB) of the Department of Pediatric Surgery, of a tertiary care, public-funded teaching hospital of North India. Children who were brought to the outpatient department (OPD) between July 2007 and September 2018 and who required only elective surgery were included. As per the department's protocols and after a thorough workup, once any surgical procedure is contemplated, a detailed preanesthetic evaluation was performed before their provisional enlisting for elective surgery [Figure 1].
Figure 1: Schematic representation of the workflow in the outpatient department

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A record of the provisional DAES was maintained manually in a dedicated diary/register. All elective dates were given in chronological manner in the next available day/slot. Not more than three major and three day-care cases used to be dated, however, this number was altered based on the anticipated operative time of any of the previously dated cases. Routine dates were not given beyond 3 years. Those who insisted on earlier dates were also advised to seek early dates in other hospitals with pediatric surgery facilities.

Routine dates were not allotted during the vacation period, i.e., between May 15 and July 15 and also between December 20 and January 10 in view of curtailed elective operation theater (OT) services (faculty of all departments get one month of summer vacation and 10 days of winter vacation in either first half or second half of the total duration of vacation ensuring the availability of 50% of faculty in the departments to ensure continuity of patients care services). The schedule of availability of a faculty in summer and winter vacations (1st half or 2nd half) of the faculty is generally confirmed by May 1 and December 1, respectively. During this period, the patients who had missed previous dates or those who were not able to find early dates were adjusted on a priority basis. Furthermore, if a parent insists on getting a date of surgery during the vacation period because of school vacations of their wards, they are advised to visit in the 1st week of May or 1st week of December (after the availability of consultant is confirmed in the first half or second half) to get DAES during the summer vacation.

On any particular outpatient day, all the patients who had been already dated for a surgery were given OT slots in addition to the canceled cases, urgent and semi-urgent cases in the OT days of the consultant within the next 7 days. The operation lists were prepared and managed under the supervision of VB and one copy was preserved in the department for record. Those who were enlisted in the definitive list were either admitted in the ward for necessary preoperative preparation (inpatient group) or were instructed to come on the day of surgery (day-care group). To also put into context, the hospital caters to the population of Delhi and the National Capital Region (NCR) with a substantial subset of cases from outside the NCR across India. The treatment is essentially free when compared to other hospitals as there are no charges for the procedures, consumables, sutures, and medicines. The investigations are highly subsidized and after admission are charged <Rs. 100/per day of hospital stay.

The register for maintaining DAES to OPD patients, the actual OPD attendance of patients identified for surgical intervention, and the final OT lists formed the basis of our data. We reviewed all the final OT lists and collected the data regarding the compliance to the provisional DAES from the register. Children who did not attend the OPD on the provisional DAES were considered as “defaulters”. The “dated” patients who attended the OPD on the allotted dates but were otherwise found to be unfit were marked out for giving a fresh date after steps were taken to ensure fitness before the new date. But for the purpose of the study, they were not considered as defaulters. Additionally, a subset of patients who were allotted DAES, but the procedure was deemed unnecessary upon re-examination (phimosis, hydrocele, etc.) at the time of admission were not counted as defaulters. Similarly, those cases who turned up on their allotted date but could not be offered an OT slot in the next 7 days because of various reasons (lack of OT time due to spike in semi-emergent cases, holiday declared by administration outside those mentioned in the gazette list of holidays, strike by resident doctors, nursing staff, etc.) were also not considered as defaulters. Such patients were adjusted in the subsequent available OT slots as early as possible.

A year-wise trend of the compliance was also assessed. For further analysis, the defaulters were classified according to the type of surgery planned, i.e., simple reconstructive, major reconstructive, infectious sequelae (perforation peritonitis on stoma, interval appendicectomy, etc.) and day care. The simple reconstructive group included procedures requiring a limited (upto 5 days) hospital stay, e.g., chordee correction, urethroplasty, closure of complex urethrocutaneous fistula, pyeloplasty, etc. On the other hand, the major reconstructive group included children undergoing surgeries and requiring a prolonged (more than 5 days) hospital stay, e.g., ureteric reimplantation, posterior sagittal anorectoplasty, primary repair of bladder exstrophy, bladder neck repair, augmentation cystoplasty, esophageal replacement, Kasai's portoenterostomy, etc. The day-care group had no separate designated OT or specific OT days and consisted of children who were planned for discharge on the same day of admission after the surgery. This group was further subcategorized on the basis of the involved organ system, i.e., genito-urinary (hernia, hydrocele, undescended testis, select posterior-urethral valve cases, and phimosis), head and neck (cysts, sinuses, and lymph nodes), vascular (vascular malformation), umbilical disorders (patent vitellointestinal duct excision with mini-laparotomy, umbilical granuloma, umbilical cyst, and umbilical hernia), and soft-tissue lesions (lipoma, superficial cysts, etc.). We also grouped the defaulters into those who were a part of a staged (requiring more than one surgery) and single-stage (requiring a single definitive surgery) group on the basis of the number of surgeries required for that particular disease.

Data entry was done using Microsoft Excel (Version 15.24) and analysis was done using Stata/Se 12.0 (StataCorp. Stata Statistical Software: Release 12. College Station, Tx: StataCorp LP). Data were expressed as number and proportion. The qualitative variables were analyzed using Fisher's exact test. P < 0.05 was considered to be statistically significant.

   Results Top

During the study period, OT lists of 425 theater days were available. A total of 2409 patients were allotted a DAES, and 4243 patients were in the definitive OT lists. Thus, 1834 patients were in the final OT lists as lateral entries due to semi-urgent/time-bound interventions or those who could get an undated slot due to the defaulters. Of the patients provisionally planned for surgery, 12% (288/2409) were defaulters. A male predominance (235/288; 82%) was noticed among the defaulters. [Figure 2] depicts the year-wise distribution of the defaulters.
Figure 2: The trend of defaulters in the study period

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Based on the type of surgery planned [Table 1], children who belonged to the day-care group constituted the majority (142/288; 49%) of the defaulters. Approximately 32% (91/288) and 18% (53/288) of the defaulters were from simple and major reconstructive groups respectively. A statistically significant difference (P = 0.0001) was observed on comparing the proportion of defaulters from both the reconstructive groups. Further, only two children belonged to the infectious sequelae group.
Table 1: Distribution of the defaulters according to the type of surgery planned and the system-wise subcategorization of children in the day-care group

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On a system-wise subcategorization of children in the day-care group [Table 1], majority of children (80%; 114/142) belonged to the genitourinary group. The remaining 8% (11/142), 2% (3/142), 4% (6/142), and 6% (8/142) belonged to head and neck, vascular, umbilical, and soft-tissue groups, respectively.

On further analyses of the other “groupings” of the defaulters, 18% (52/288) and 82% (236/288) of the children were found to belong to planned staged procedures and single-stage procedures, respectively. When both the proportions were compared, a statistically significant (P < 0.0001) difference was observed.

   Discussion Top

Despite the availability of advanced computerized electronic medical records and patient appointment systems, the practice of allotting dates for elective pediatric surgery even today is done manually and empirically in most centers. Although these dates for surgery and OT lists are a necessity to have an organized system of patient management, there is a dearth of research on the compliance of the provisional DAES. In an attempt to review the compliance to provisional DAES in this study, we found that around 12% of patients were defaulters. A clear male preponderance among the defaulters highlights the significant proportion (114/288; 40%) of them belonging to the genitourinary subgroup and having diseases such as inguinal hernia, undescended testicle, and phimosis. On year-wise comparison [Figure 2], a reduction in the numbers was noticed between 2012 and 2014. This is possible because our electronic medical record system was developed in 2012. However, since then, there has been a progressive increase in the number of defaulters as per the current data. Apart from the continuously increasing patient-load leading to longer duration of waiting periods, few other factors might also have contributed to these spiraling figures. Being a renowned referral center of Northern India, a sizeable number of patients just come for a second opinion. They would have taken a provisional date at our center but could have undergone the surgery elsewhere. Another reason that can be speculated is the slow but steady improvement in the pediatric surgery facilities in both government and private sectors throughout the country.[3] Children belonging to day-care group might have been operated at these centers without having to wait on a “waiting list” at a center which may not even be close to their home. However, the exact cause of this progressive increase in the proportion of defaulters over the past years still eludes us; further studies need to be conducted before definite conclusions are drawn.

A significant difference in the proportion of defaulters among the simple and major reconstructive groups clearly depicts the level of expertise and multidisciplinary care needed in the management of these complex congenital malformations. Some of the anomalies such as exstrophy bladder, posterior urethral valves, and anorectal malformations require a life-long follow-up too. It seems reasonable therefore to speculate that such cases requiring complex reconstructive surgery were generally referred from other centers to ours and majority of the patients did respect the allotted date for surgery/admission due to the nonavailability of other options. A similar explanation is expected for the significant difference noticed in staged versus single-stage groups. A financial angle may also play a role, since some of these cases required a prolonged hospital stay or repeated interventions that were being done at a minimal or no cost at our center. Thus, a detailed disease-wise analysis in larger numbers will provide an exact testing of these hypotheses. It is also noteworthy that a subset of children belonging to a simple reconstructive group (for e.g., those requiring pyeloplasty, etc.) required preferential early DAES. In fact, these were given priority due to the risk of organ damage; even when compared with some children belonging to major reconstructive procedures. Therefore, classification into simple or major reconstructive groups in this study is arbitrarily based on the duration of hospital stay and must not be confused with urgency for surgery.

The current study provides a glimpse on the patterns of compliance to provisional date of elective surgery in one surgical department of the public-funded hospital. To the best of our knowledge, we did not come across any study from India or elsewhere dealing with this particular aspect of patient management. The authors also understand that there are some limitations of this study. The duration of waiting time, which may be considered to be an important factor affecting the compliance, could not been studied. A detailed analysis on the impact of waiting time on compliance and its disease-wise correlation would have provided additional information. Second, no provisional listing was done during the vacation periods. The vacation period also corresponds to the vacation in schools. The effect of school holidays affecting the compliance could not be commented upon. Finally, this study is based on the data from a single institute only. Lack of an organized referral system and being a public-funded hospital where services are almost free to the patients, might have skewed the data. Hence, it must not be assumed that the same pattern would be the norm throughout the country.

Despite these limitations, we believe that these data can be the basis of allotting dates with differential waiting time based on the diagnosis and type of planned procedure to better utilize limited resources by avoiding dropouts. Compliance to the DAES may be another indicator that could be explored to improve our health-care system. It could also be a stepping stone to initiate robust prospective multicentric data collection to understand various factors affecting the compliance as well to develop, manage, and improve our pediatric surgical health delivery system.

   Conclusions Top

Among the patients attending the outpatient department of a tertiary care public-funded teaching hospital being planned for elective pediatric surgery, the compliance to the provisional date of elective surgery allotted is poor among the children scheduled for day-care surgeries and those undergoing simple reconstructive surgeries in a single-stage.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Organization for Economic Cooperation and Development (OECD). Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019.  Back to cited text no. 1
Wright JG, Menaker RJ; Canadian Paediatric Surgical Wait Times Study Group. Waiting for children's surgery in Canada: The Canadian Paediatric Surgical Wait Times project. CMAJ 2011;183:E559-64.  Back to cited text no. 2
Gupta DK. Pediatric surgery in India: Time now for review. J Indian Assoc Pediatr Surg 2015;20:57-9.  Back to cited text no. 3
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