In-depth: The human cost of surgical delays

In-depth: The human cost of surgical delaysTygerberg Hospital. Photo:Nasief Manie/Spotlight
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It is the fifth week of her husband waiting on a surgical procedure for a stent at Tygerberg Hospital when Spotlight catches up with *Mrs Brooks. In February this year, they saw a GP where they live who diagnosed him with jaundice. Tests showed that there was a mass growing on the pancreas that is closing the gallbladder pipe (bile duct) and obstructing bile. By then, Mrs Brooks says, her husband had already lost 12 kg.

The GP referred them to their nearest district hospital, where in April – six weeks later – more blood and other tests were done that confirmed the diagnosis. The family was then referred to Tygerberg Hospital for the surgical procedure because the procedure cannot be done at district level.

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“By this time, my husband couldn’t sleep at night. The pain was constant and he slept on a chair at the dining room table with his head on a pillow. He had severe pain and could not eat,” Mrs Brooks tells Spotlight.

Her husband had an appointment at Tygerberg Hospital later in April.

“We waited in a queue for hours before we could see the doctor. He said they will have to treat the jaundice before they can treat the tumour. He also said my husband had cancer and that patients with this type of cancer do not have a long life expectancy so we must prepare ourselves. In the meantime, they will book a stent so that the jaundice can be treated and he can gain some weight before they start chemo treatment.”

She says the first date given to perform the procedure was 17 May.

“We went home, totally traumatised. You know how doctors talk in tongues using phrases and language that is so difficult to understand that it sounds like you’re about to drop dead. We were gutted.”

The following week, Mrs Brooks says they received a call from a doctor at Tygerberg. “He said that my husband must come to be admitted. They had a meeting with the oncologist who said they must do a stent immediately so they will push him in between surgeries to get it done. We were so happy and relieved.”

Tygerberg Hospital. PHOTO: Nasief Manie/Spotlight
Tygerberg Hospital. PHOTO: Nasief Manie/Spotlight

That Monday, she says,  they made the over 50-kilometre drive to the hospital and her husband was admitted. “By the Thursday, nothing had happened,” she says. “He was just lying there – waiting. They then promised the procedure will be done the following week because they have to order the stent and my husband can go home and come back to be admitted the day before. Now how on God’s earth do you book something but there is no stock?”

According to Tygerberg Hospital’s spokesperson Laticia Pienaar, stents placed for intestinal blockages such as tumours in the oesophagus or rectum, are generally done as a semi-urgent case and would be done within a week. “We are aware that stents that are done by the GI (Gastroenterology/ Gastro Intestinal) clinic that is not under the jurisdiction of surgery, may wait several weeks,” she says.

“Many non-urgent cases wait months to years for their surgery, even before COVID, due to insufficient theatre time. Some of them may experience a complication and then get admitted for urgent surgery,” she says.

His eyes were becoming brownish – almost like beer and he lost so much weight that he was just skin and bone.

Rinse and repeat

The day before the scheduled procedure the following week, the family again made the trip to Tygerberg to get her husband admitted. On the day of the procedure, Mrs Brooks again made the trip back to the hospital because she wanted to be there when the procedure was done.

“I waited in the waiting room. At about 13h00 the procedure was still not done.” She says the doctor told them someone mixed up the dates and the procedure was booked for the previous day and they will have to reschedule again.

“Again they gave my husband a weekend pass and we went home.”

The procedure was then rescheduled for 11 May. The following week, however, doctors found the tumour has grown – complicating the procedure and they had to reschedule again.

“By that time, it was 11 weeks and this tumour has been growing untreated. The jaundice has most likely damaged his liver, causing more problems and we are still waiting on a procedure. By then,” she says, “his eyes were becoming brownish – almost like beer and he lost so much weight that he was just skin and bone.”

Mrs Brooks says by then, the family was at the end of their rope.

“You cannot imagine how traumatic this is – how emotionally taxing it has been on my husband and on us. Your life becomes a number and the consequences for a patient and their family – they just don’t care about that. My husband is the breadwinner. He is going to lose his job and we have a seven-year-old daughter. These couple of months I have spent our grocery money just on petrol,” she says. “I understand that they have backlogs but why don’t they get more people to help? All these patients waiting – they’re human beings with families and lives and to these families their life is important. To them, their sick loved one is important. I’m so tired, I’m done – gedaan. I don’t want to make trouble because I really need my husband to get this procedure and get better.”

I understand that they have backlogs but why don’t they get more people to help? All these patients waiting – they’re human beings with families and lives and to these families their life is important. To them, their sick loved one is important.

The numbers

Mrs Brooks is not alone in her frustration.

Health Minister Dr Joe Phaahla recently in a response to a written parliamentary question said the COVID-19 pandemic caused a surgery backlog across the country of at least 107 818 surgeries. This number is for all provinces except KwaZulu-Natal and the Northern Cape which did not provide statistics at the time of publishing the response – so the real number for the country will be higher. He did not give a breakdown of the type of surgeries.

Among the provinces that provided statistics, Western Cape tops the list with a backlog of 77 139 surgeries, according to Phaahla. Gauteng said its backlog was at 13 433 with the smallest backlog in the Free State with 1 923 surgeries (Spotlight recently reported on surgical backlogs in the Free State.).

Health Minister Dr Joe Phaahla. PHOTO: Elmond Jiyane/GCIS

Provinces are now implementing strategies to catch up on the surgery backlogs. Among the interventions at tertiary hospitals such as Chris Hani Baragwanath Hospital in Gauteng, is the use of an electronic theatre booking system. The hospital also appointed a dedicated clinical manager to oversee all 46 theatres and to help ensure theatre time is used efficiently. At Charlotte Maxeke Hospital there are district outreach surgical teams who provide services once a week per quarter and spent time in a district conducting various surgeries utilising all hospitals as part of the Rural Health Matters campaign. At George Mukhari Hospital, Phaahla said in his response that efforts are impacted by 14 in-active theatre posts. In the Free State at tertiary hospitals such as Universitas and Pelonomi, there is monthly monitoring of waiting time and surgery marathons are arranged if the department notices a backlog. They also sometimes use theatres at private hospitals for procedures.

In the Western Cape, University of Cape Town Global Surgery Oncology Lead at Groote Schuur Hospital, Associate Professor Lydia Cairncross tells Spotlight they documented their backlog and calculated the total number of patients waiting for an operation at the hospital across all disciplines including neurosurgery, orthopaedics, and general surgery, among others.  It added up to just over 6 000 surgeries that were postponed or waiting. She says physical theatre space was not as much of a problem as staffing surgical teams for these theatres. ICU/ theatre nurse shortages are a particular challenge, Cairncross says and the hospital started a fundraising campaign to finance a year contract for surgical medical officers, anaesthetic registrars and a nursing team.

Associate Professor Lydia Cairncross
Associate Professor Lydia Cairncross PHOTO: Nasief Manie/Spotlight

As part of the hospital’s recovery plan, theatres are running surgery lists Monday to Thursday. They aim to do 1 500 operations in a year. Cairncross says this means they need to do between 30 to 40 surgeries a week. “It’s a range of operations from cataract surgery to hernia operations to prostate surgery and gynaecological surgery. We are close to hitting our weekly and monthly targets,” she says.

Back at Tygerberg Hospital, Pienaar says they have enough theatres to deal with their additional surgery lists. There are 30 theatres operational and six emergency theatres running 24 hours a day. According to her, all posts in the ICUs are filled and “ICUs are running efficiently and effectively”. She also says medical equipment and consumables needed to perform surgeries “are not a problem at all”. “We have sufficient equipment to perform the additional operations and we have a well-functioning CSSD (central sterile services department) that will be sterilising equipment to be used again for operations,” she says.

Groote Schuur Hospital in Cape Town. PHOTO: Nasief Manie/Spotlight
Groote Schuur Hospital in Cape Town. PHOTO: Nasief Manie/Spotlight

The waiting game

Asked about waiting times in light of cases such as Mrs Brooks, Pienaar says, “At the moment we are doing normal surgical lists, but of course, there is a backlog. From 1 July, we will be running four to five extra lists per week. There is a set programme for how various disciplines will be accommodated to do additional surgery in a particular week.” Pienaar says it is difficult to quantify the number of operations that will be performed on these additional extra lists per week as some operations may only take 20 minutes and others may take more than four hours. “But, she says, “the additional lists will certainly eat away from the waiting lists. We will keep track of every additional operation and at the end of the project will be able to quantify the actual number of additional lists that we’ve done.”

Spotlight also spoke to some nurses at Tygerberg Hospital who asked to remain anonymous.

One nurse said it is an unfortunate situation because there are times when doctors know early on that they won’t get to a patient on the day’s list but then the message only reaches the patient and family by 16h00 in the afternoon.

“Communication and informing patients as things develop is an issue, yes. We can do better. But in this environment time is against us and everyone has to use theatre time and other resources as efficiently as possible – even us as nurses.”

But, says another nurse, there are many factors influencing how a day goes.

“With COVID we lost many colleagues and many got sick, so we couldn’t get to everyone. And we had to prioritise with the limited resources we have – even now. For example, back surgeries that are not a medical emergency often wait long and even when they are scheduled for a particular day, there may be a more serious aneurism case that needs to be pushed in and people are sent home and rescheduled. This causes a lot of unhappiness.”

Both nurses, however, say there are generally – across wards – not enough nursing staff which often has a ripple effect.

According to Tygerberg’s official statistics, the average waiting time for something like spinal surgery can be between 18 months and two years, due to the duration and complexity of these procedures. With orthopaedics’ trauma and emergency workload, there are on average about 60 to 80 patients awaiting emergency surgery on any given day.

closed door at ward in Tygerberg hospital
Tygerberg Hospital. PHOTO: Joyrene Kramer/Spotlight

Stark realities

As with other hospitals, the pandemic exacerbated the waiting times for elective surgical procedures. At Tygerberg there are about 15 000 surgical cases awaiting planned (elective) surgery, Pienaar says. “Up to today, we have not had any catch-up lists to enable us to shorten the waiting lists. Our current theatre lists are used to deal with urgent new admissions such as trauma cases, cancer cases, and other surgical emergencies involving serious infections and life-threatening complications.”

She says cases are booked according to urgency. “For example, cancer cases are prioritised above hernia repairs but we always try to add elective cases to every list. Unfortunately, if the list cannot be completed, or if a more urgent case is admitted, (which happens often), the non-urgent cases may be postponed. Some are unfortunately postponed up to three times. After that, they are considered as emergencies.”

Pienaar stresses that there have been surgery backlogs even before the pandemic. “This is the reality in the public hospitals – the need is much higher than what we can provide for at any time.”

According to her, patients that arrive for pre-booked elective surgeries that are then subsequently cancelled are indeed an area of great concern and frustration. “We fully understand the frustration and the financial hardships that patients may experience.” She says beds for elective surgeries are pre-booked but this all depends on the number of emergency uptakes the preceding night. “If a patient is cancelled, we make a point of reprioritising the patient and to make sure the patient is accommodated on the next visit as far as possible.”

Cairncross also has no illusions about the impact of cancelled surgeries on patients. In an opinion piece co-authored with Professor Bruce Biccard from Groote Schuur’s Department of Anaesthesia and Peri-operative Medicine, they wrote, “For a surgical patient, the cancellation of an operation is devastating. Many patients have waited weeks, months, and sometimes years for their operations… For society, cancelling elective surgery has massive public health implications.”

*Not her real name.

This article is part 1 of a two-part feature on surgical waiting lists. Part 2 will be published tomorrow.