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Australian Health Review Australian Health Review Society
Journal of the Australian Healthcare & Hospitals Association
RESEARCH ARTICLE (Open Access)

Using an under-utilised rural hospital to reduce surgical waiting lists

Tracey Edwards A # , Andrea Boerkamp A B # , Kimberley J. Davis https://orcid.org/0000-0002-7835-7259 A C and Steven Craig https://orcid.org/0000-0001-6403-7863 A B *
+ Author Affiliations
- Author Affiliations

A Graduate School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Keiraville, NSW 2522, Australia.

B Department of Surgery, Shoalhaven District Memorial Hospital, Illawarra Shoalhaven Local Health District, Scenic Drive, Nowra, NSW 2541, Australia.

C Research Operations, Illawarra Shoalhaven Local Health District, NSW, Australia.

* Correspondence to: steven@drstevencraig.com.au
# These authors contributed equally to this paper

Australian Health Review 48(3) 248-253 https://doi.org/10.1071/AH23191
Submitted: 28 September 2023  Accepted: 8 March 2024  Published: 25 March 2024

© 2024 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)

Abstract

Objectives

This study aimed to evaluate patient outcomes from a 12-month pilot program establishing specialist surgical services in a small rural (Modified Monash Model, MM4) hospital on the south coast of NSW.

Methods

Suitable patients for ambulatory surgery were selected based on strict anaesthetic, surgical and social criteria. Skills shortfalls among nursing staff, usually with emergency or inpatient experience, were addressed by appropriate re-training and in-service training in scrub, scout and anaesthetic duties. An anonymous post-operative patient survey was administered during the pilot program, which assessed patient experiences and outcomes. Of 162 patients undergoing surgery during the pilot, 50 consecutive participants completed the survey.

Results

Of the 161 procedures during the pilot program, 100 were performed under sedation and locoregional anaesthesia and 62 under general anaesthesia. Half (n = 86, 53.4%) were complex excisions of malignant skin lesions, and of these 63% also required either a skin graft or local flap repair. Survey respondents reported adequate information and pain relief upon discharge (n = 45, 96%) and 100% were satisfied with the care received. No respondents needed to see a doctor following discharge. There were no mortality events or major issues of morbidity during the study period or subsequently, no further overnight admissions or return to theatre and no re-presentations within 48 h of operating. Two superficial surgical site infections were reported.

Conclusions

There is merit in drawing on underutilised resources in small rural hospitals in support of initiatives to reduce surgical waitlists. Appropriate outpatient surgeries can be safely performed with high levels of patient satisfaction.

Keywords: elective surgery, health services administration, patient satisfaction, rural health, rural health services, rural hospitals, rural surgery, waiting lists.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic exacerbated existing surgical backlogs in public hospitals throughout Australia. The Australian Medical Association estimates that by the end of 2023, approximately 507,764 patients will be awaiting surgery.1 This backlog will be more pronounced in regional and rural areas, where the centralisation of surgical services has led to a gradual decline of surgical departments and a reduced capacity to increase services to address waitlist problems.2,3 Rural patients – both in Australia and worldwide – are already disadvantaged by lack of ready access to some healthcare services due to workforce issues and the need to travel long distances for specialist care.48 This can result in patients not accessing care if the burden is too great, and the many risks of loss of local health service capacity have long been known.9,10

There is often a lack of appropriate specialist services in rural areas, meaning that by the time a patient can access appropriate care their condition may be more serious than a comparable metropolitan patient.6 Previous work has also explored the personal and medical costs – both literally and figuratively – involved for rural patients undergoing a journey to a metropolitan centre for their specialist care, finding a correlation between increased remoteness of a patient and levels of problems experienced.10 Clearly then, a great need exists to provide and deliver appropriate health services in rural areas, particularly in light of the COVID-19-induced burden on the health system.

One strategy to alleviate the strain on surgical services in NSW arising from the temporary suspensions of non-urgent elective surgery during the COVID-19 pandemic has been to maximise the safe use of same-day surgery. Even during the height of the pandemic, there were multiple rural hospitals across NSW that were identified as under- or un-utilised, and could be used to assist with the surgical backlog.11,12 This study aimed to pilot a program introducing specialist, day-surgery services at a rural (Modified Monash Model, MM4) hospital which had a single, unutilised operating theatre. Outcomes evaluated covered both clinical efficacy and safety, in addition to patient satisfaction with the care received.

Methods

Setting

The Illawarra Shoalhaven Local Health District (ISLHD), sought to utilise existing human resources and infrastructure (including same-day surgery) to increase surgical capacity. As a result, it implemented a pilot program that introduced specialist, day-surgery services at its most rural site, a small rural (MM4) hospital with a single, unutilised operating theatre. It was a level two hospital with an 11-space emergency department seeing approximately 15,000 presentations per year, and a 25-bed inpatient ward. The inpatient ward worked on a general medicine model, and had four monitored beds plus capacity for two over-census beds to monitor post-operative patients if required. There was also an outpatient renal dialysis unit, an outpatient oncology infusion unit and outpatient allied health services.

The pilot program was intended to create additional operating capacity, and thereby reduce surgical waiting lists, improve timely access to surgical services and reduce the need for travel by patients and their overnight admission. A multi-disciplinary committee comprising nurses, anaesthetists, surgeons and administrators designed the pilot program. Suitable patients for ambulatory surgery were selected based on strict anaesthetic, surgical and social criteria.

Patient selection

Patients were selected from the waiting list for the closest larger referral hospital, with preference given to those residing locally or for whom travel to this larger hospital would be burdensome. Prospective patients were excluded if they presented with any of the following anaesthetic criteria: body mass index >35 kg/m2; high risk of severe obstructive sleep apnoea (OSA) score at ≥5 on STOPBANG screening (Snoring, Tired, Observed, Pressure, Body Mass Index, Age, Neck size, Gender); known OSA with poor compliance, tolerance of, or access to continuous positive airway pressure (CPAP); known OSA with CPAP requiring long acting opioids for pain management post-operatively; American Society of Anesthesiologists (ASA) physical status classification system score >3 requiring sedation or general anaesthetic; past history of post-operative delirium, significant dementia, cognitive impairment or other risk factors for post-operative delirium; and a potentially difficult airway.

Surgery inclusion criteria were: duration <2 h; anticipated blood loss <200 mL and low risk for bleeding; no deep space surgery (e.g. intra-abdominal procedures, deep cervical spaces); likely discharge on oral analgesia or less and with normal enteral diet; very low risk of intra-operative or immediate complications; and surgery not likely to significantly impede daily living (e.g. bilateral arm immobilisation).

Social criteria for selection included: patient having a competent carer staying in their home overnight post-operatively; not a principal carer for another person; lived within a 1-h drive of the study site; and would be contactable by phone for 48 h following surgery.

All patients who received surgery during the study required their surgery to be performed in a local hospital setting rather than as office-based surgery, with the latter being offered by consultant surgeons in a clinic adjacent to the hospital. Specific requirements for hospital surgery were for a variety of reasons such as access to particular medical equipment, the need for sedation, tolerance of local anaesthesia, or the extent and complexity of surgery. If a patient were eligible for an office-based procedure they were not booked on the public waiting list and were thus excluded from the pilot study.

Staff training

The nursing staff engaged had usually been assigned to emergency departments or inpatient wards, and most had minimal theatre experience. Skills shortfalls were addressed by appropriate re-training and in-service training in scrub, scout and anaesthetic duties, however, most upskilling training was provided to staff during theatres by the existing theatre nurse clinical nurse educator or clinical nurse specialist.

A general practitioner (GP) visiting medical officer (VMO) provided anaesthetic services and was supported by a supra-numerary specialist anaesthetist who also provided teaching and supervision to medical and nursing staff. The specialist anaesthetist was also present every fortnight in a supervisory capacity and to provide further teaching and upskilling both of nursing and medical staff.

Pilot program logistics and evaluation

Surgery was conducted by one general and one plastic surgeon. The general surgeon resided in the local area (MM4), while the plastic surgeon routinely visited the area on a monthly basis. No surgical trainees were involved, however there were medical students and GP registrars. Peri-operative logistics (e.g. request for admissions (RFA) screening, management of blood thinners and patient scheduling) were managed by a larger regional (MM3) hospital located within the district. This enabled the study site operating theatre to function as a ‘satellite theatre.’ Most procedural supplies were maintained at the study site, though some sterilisation services and instruments were also provided by the larger regional hospital.

Patients selected for surgery based on suitable procedure type and anaesthetic assessment were operated on at the study site between May 2021 and May 2022. All selected patients were offered their procedure at this rural study site in lieu of either a larger regional (MM3) hospital (61 km or approximately 1 h drive away) or the nearest metropolitan (MM1) hospital (138 km or 2 h drive away). The day-surgery patient information outlined communication options if patients had concerns, which was to the surgeon’s office if during business hours or to the study site’s emergency department (ED) if after hours or the surgeon was not contactable. The study site had a 24 h staffed ED with on-call support to the nearest referral centre with a 24 h surgical registrar available. Existing patient information sheets and day surgery website information that had been developed at a Local Health District (LHD) level were used during this pilot program.

In the event of an unexpected adverse event, escalation of care was at the direction of the surgeon or anaesthetist, and would depend on the nature and seriousness of the event. Options included: admission to the study site for simple observation; road transfer to the nearest regional hospital for admission to ward/intensive care unit and/or return to theatre; or if a case required cardiac, neurology or other subspeciality care, either air or road transfer to the nearest metropolitan referral hospital was available.

Between 2 and 7 days following their procedure, a total of 50 patients completed an anonymous, five-question patient satisfaction survey. The pilot program was reviewed monthly in an open forum in terms of case numbers, complications, morbidity and mortality events.

Ethical considerations

This project was reviewed by the LHD’s Low and Negligible Risk Research Review Committee and was deemed exempt from further ethical review according to the NSW Office for Health and Medical Research Guideline GL2007_020: Quality Improvement & Ethical Review: A Practice Guide for NSW.

Results

Clinical outcomes

Of the 161 operations, 100 were performed under sedation and locoregional anaesthesia and 61 under general anaesthesia. Eighty-six (53.4%) were excisions of malignant skin lesions, including melanoma, squamous cell carcinomas and basal cell carcinomas (Table 1). Of these 61 (37.9% of the total procedures) also required either a skin graft or local flap repair.

Table 1.Procedures undertaken during the pilot program.

Proceduren%
Excision of malignant skin lesion + skin graft3219.9
Excision of malignant skin lesion + local flap2918.0
Excision of malignant skin lesion2515.5
Release of carpal tunnel2113.0
Vasectomy85.0
Repair of inguinal hernia74.3
Excision of subcutaneous tumour74.3
Repair of umbilical hernia63.7
Repair of ventral hernia63.7
Drainage and debridement of wound/haematoma/abscess42.5
Excision of benign breast lesion31.9
Excision of benign skin lesion31.9
Excision of ganglion31.9
Release of dupuytrens contracture21.2
Excisional biopsy of tongue10.6
Excision of pilonidal sinus10.6
In-grown toenail10.6
Perianal fistula10.6
Removal of portacath10.6
Total procedures161

There were no mortality events or major morbidity events either during the study period or subsequently to the time of writing. No patients required overnight admission or return to theatre, nor were there any re-presentations to the study hospital within 48 h of operating. Two superficial surgical site infections were reported (one skin excision and one carpal tunnel), and both were managed conservatively with oral antibiotics.

Patient experience

Of the 50 survey questionnaires completed, all respondents expressed satisfaction with their care at the study site (Table 2). None indicated that they needed to see a doctor following discharge. Almost all respondents (n = 48, 96%) reported adequate pain relief post-discharge and satisfactory control of nausea.

Table 2.Patient satisfaction questionnaire and associated response frequencies.

QuestionResponse n = 50
Yes n (%)No n (%)
Did you have adequate pain relief post-discharge?48 (96)2 (4)
Did you have any nausea and/or vomiting after you were sent home?2 (4)48 (96)
Did you need to see a doctor after you were sent home?0 (0)50 (100)
Were you given enough information/instructions when you went home?48 (96)2 (4)
Were you happy with the care you received yesterday?50 (100)0 (0)

Discussion

This study shows that a wide variety of day surgical procedures can be safely undertaken in a rural setting without significant morbidity events or mortality. At the time the pilot program commenced, there were 450 overdue patients on the public waiting list who had breached the recommended waiting time. For a large part this had been exacerbated by COVID-19 restrictions, whereby non-urgent elective surgeries in NSW had been cancelled for a period of time and in particular during various lockdowns.13,14 As a result of the pilot, 161 of these were addressed within the first year, representing a 36% reduction in the patients awaiting surgery.

Access to timely surgical care, however, is not the sole indicator of a successful day surgery program; patient satisfaction and the perceived outcomes of patients as consumers of health care are also important.15,16 All patients surveyed were satisfied with their care, and did not require non-routine medical attention following discharge. The vast majority of patients (n = 48, 96%) had no post-operative nausea or vomiting, and their pain was well controlled on discharge. Reasons for the high observed levels of patient satisfaction include the opportunities provided for continuity of care, the ability to stay close to family, receiving support in the post-operative period and reduced travel times and expenses. These factors have been previously associated with the ability of rural patients to receive their care (where appropriate) in a smaller, local facility instead of travelling to a larger referral centre.4,10

Many small, rural hospitals have seen a decline in service provision in recent decades, both in Australia and overseas.1719 However, most still retain the physical infra-structure of an operating theatre (albeit in various states of functionality) and would have the capacity to provide additional services if staffing, logistics and funding were available. The pilot program reported here demonstrates that previously idle operating rooms in rural hospitals can be brought online to deliver specialist operating services effectively. The COVID-19 pandemic prompted severe constraints on elective operating wait lists due to the forced interruptions of elective surgery, reductions in bed availability and staffing shortages. Health administrators should acknowledge that rural hospitals can play a vital role in delivering ambulatory procedures to reduce pressure on regional and metropolitan hospitals, and permit these hospitals to focus on more complex cases.

In addition to the physical resourcing required (i.e. provision of a theatre), another barrier in rural areas is human resourcing. Previous work in North America has shown that local GPs (or ‘family physicians’ in this context) can be safely used to undertake basic procedures such as colonoscopies,20,21 or even surgical procedures such as appendicectomies.22 There is also significant Australian precedent for the use of GPs for anaesthetic or obstetric support in rural areas.23,24 This evidence, in addition to the success of procedures reported in this paper, supports the ongoing use of local GP VMOs acting as anaesthetists, thus reducing the burden upon a hospital in trying to secure, often at great financial cost, the services of a locum specialist anaesthetist.

There are many flow-on effects and benefits to a rural community of having a local surgical service, including potential decreases in morbidity. This arises from reductions in the risk of acute deterioration of surgical condition, decreases in the fragmentation of care and reductions in the burden of travel – something that is critical for many elderly and infirm patients.4,7 Socioeconomically, the benefits include decreasing the number of GP visits, reducing the need for community transport services and helping to upskill local healthcare staff. Although many would raise arguments of economies of scale against small local services such as this,19 the fact remains that financial considerations must be linked with broader healthcare costs including at a primary healthcare level. Furthermore, failing to upskill local staff and rather rely on expensive locums unnecessarily drives up the apparent cost of the rural service and must be considered when undertaking a full financial analysis.19

This study is limited by its single-site design, as there was only one rural hospital (i.e. the study site) with an unutilised theatre within the LHD. The generalisability, however, of the pilot program reported here has already been demonstrated, as one additional rural and regional LHD has already successfully implemented a very similar program based on the evidence provided by this pilot. Furthermore, only 50 patients out of 161 who received a surgical procedure completed a survey, however, achieving a larger response rate was limited by the availability of workforce to administer the survey.

Conclusion

Overwhelmingly positive benefits arise from providing an ambulatory, rural surgical service. We urge other rural hospitals to explore the benefits of re-activating, or increasing the utilisation of, their operating theatres. Doing so will help provide long sought-after benefits to the broader community by reducing operating wait lists, lessening rural health disparities and providing timely access to surgical services.

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Declaration of funding

The research did not receive any specific funding.

Author contributions

TE: Formal analysis, Writing – original draft. AB: Formal analysis, Writing – original draft, Writing – review and editing. KJD: Methodology, Project administration, Visualisation, Writing – review and editing. SC: Conceptualisation, Methodology, Supervision, Writing – review and editing.

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