About the Project
Outpatients awaiting emergency surgery typically wait on the ‘add-board’ for a surgical time to become available. With the short turnaround time of emergency surgery, it can be challenging to connect with clients without a phone, without transportation, or who have particular circumstances (e.g. being unhoused, having substance use issues, having mental health conditions.) This can mean they miss their OR time, are not able to follow critical pre-operative instructions about fasting or bringing a chaperone, or fail to connect post-operatively for crucial follow-up care.
These missed surgical appointments not only mean less optimal care for the patients; they trigger a myriad of effects across multiple departments and services, including: re-presentation at the Emergency Room seeking care for a more complex injury due to the delay, at a cost of approximately $300 per visit1; or seeking treatment from community providers or services that are overburdened. In the past, these patients were often admitted prior to surgery but given the complex needs of these patients, pervasive bed shortages, and an approximate cost of $5,600 per standard Island Health admission, this is not an optimal solution.
Dr. Morgan Evans, Plastic Surgeon, wanted to bring together key stakeholders in hospital and community to identify a reliable mechanism to close the loop between the OR and disadvantaged outpatient populations, and avert the need for a unnecessary preemptive hospital admissions. He connected with collaborators in various Mental Health and Substance Use services, including Rob Schuckel from Central Access and Rapid Engagement Services (CARES/IMCRT) and Morgan Boc from the Intensive Case Management Team (ICMT), who helped to identify further community outreach services to include in this initiative. These included:
- Echo Kulpas from the Assertive Community Treatment (ACT) team
- Elysia Hartley from the Encampment Outreach Team (EOT) team
- Ami Brosseau and Dr. Chris Fraser from the Cool Aid Clinic
- Ash Heaslip from Addictions Medicine
- Lee-Ann Bertrand from Surgical Services RJH
- Caroline Ferris from Rapid Access Addictions Clinic (RAAC)
- Kristin Atwood from the Victoria Division of Family Practice
- Devin Lynn from Mental Health and Substance Use at Island Health
- Georgia Vermette, UBC Medical Student
One might think that assembling all these key players would be challenging, but as Dr. Evans observed, everyone was motivated to develop a better way to help these people. “Those in the community, they see this problem coming up again and again, and have had to find solutions. They have gone through this before.” One collaborator remarked, “It’s awesome that folks have given thought to how to make services more accessible to the clients we serve. I love these kinds of efforts!”
Rather than try to develop a new grass roots referral service, the group determined to leverage existing established resources. A critical moment was recognizing that many of the individuals requiring surgery may have an existing relationship with one or more of these community services. Using already established centralized intake lines for community services such as the CARES clinic, these services would aim to quickly identify the closest known community contact for the individual, make the connection, and support that person to get urgent surgery within a matter of hours or days.
Given the costs, time, and adverse patient experience associated with missed appointments, the extra work up front to identify, connect, and support these individuals was a strong inducement for all. One of the community service representatives described the value of this team effort:
“In our experiences of supporting clients to get urgent day surgeries in the past 2 weeks, there have been a cascade of efforts all around to make it successful. Both of these clients are healing well. All the good-will choices by all the players are what made it work.”
Through the course of doing this work, the team gained familiarity about each others’ perspectives. Dr. Evans learned about the array of community teams supporting people, which from the outside can be “a real alphabet soup of acronyms”. And those in the community gained a perspective on how inpatient surgery works, and the constraints facing the surgical team prior to, during, and after surgery.
Having established this pathway, the group is in the process of addressing the next challenge: What if an individual isn’t yet known to any of the community services? This may prove to be an opportunity to get an individual attached to some kind of community provider.
This initiative may be of interest to other communities where plastic surgeons are on hand to provide trauma surgery and stronger linkages could be made with community services.
We thank this amazing team of community service providers and clinicians for undertaking this initiative!
1 According to the Canadian Institute for Health Information. October 2020. “Hospital Spending: Focus on the Emergency Department”. https://www.cihi.ca/sites/default/files/document/hospital-spending-highlights-2020-en.pdf