Development of a multi stakeholder partnership to improve access to and delivery of neurosurgical services in Ontario

Highlights

• Government and physicians worked together to identify system wide access issues.

• Partnership worked together to implement novel solutions to address access issues.

• Novel technological solution was development of province wide e-pacs system.

• Novel policy solutions include restructuring provincial system to address inefficiency.

• By restructuring process, system was able to provide improved access to patients with reduced cost.

Abstract

Neurosurgical emergencies require expedient access to definitive care at neurosurgical centers. Neurosurgical resources in province of Ontario are highly centralized, and subsequently, most patients with neurosurgical emergencies will present to non-neurosurgical centers. From 2000–2010, metrics demonstrated the organization of neurosurgical resources might not be optimal. In response to this a program entitled Provincial Neurosurgery Ontario (PNO)- was formed to address these issues in cooperation with neurosurgeons, hospitals and the provincial government.

PNO worked with multiple stakeholders to implement interventions to not only prevent out of country transfer, but to also improve the flow of neurosurgical patients in the province and potentially improve outcome. The main interventions undertaken by PNO were: 1) implementation and development of a province-wide tele-radiology system; 2) development of neurosurgery as a provincially-funded program; 3) significant outreach to non-neurosurgical centers; and 4) specialized funding packages for highly specialized level care.

This report provides background on the challenges faced by neurosurgery in the province of Ontario and the process developed to address these challenges. Finally, we describe the impact provincial strategies have had on improving access to emergency neurosurgical care in the Ontario.

Introduction

Neurosurgical diseases are a major cause of morbidity and mortality and can affect patients across the demographic spectrum. Underlying etiologies of neurosurgical diseases include trauma, vascular disorders, brain tumors, spinal disorders and hydrocephalus. Outcome in these diseases often relies on rapid diagnosis and treatment as functional outcome can be influenced by timing of and access to definitive care which usually involves surgery [1], [2].

To provide context, the concept of centralizing specialized services to large hospitals has been termed regionalization. Like neurosurgery, many other specialities have undergone regionalization not only in Canada but also globally [3], [4]. Key programs that have been regionalized with some consistency across the globe are trauma, perinatal care, cancer care, stroke and acute myocardial infarction [4], [5], [6], [7]. Regionalization of these programs have often demonstrated improvements in outcome however most jurisdictions face challenges with implementation and access. No clear implementation strategy has been identified to help mitigate challenges with regionalization.

Currently, fewer than 10% of the over 125 acute care hospitals in Ontario provide neurosurgical services and the necessary infrastructure to manage patients with cranial and spinal surgical disorders. The small number of hospitals providing neurosurgical services necessitates that these hospitals are responsible to provide neurosurgical coverage to large regions of the province. NC’s (neurosurgical centers) in Ontario are only located in urban centers across the province—hence a majority of neurosurgical patients present initially to Non-Neurosurgical Centers (NNCs) before potentially requiring transfer to a NC. In cases where these NC’s are over capacity and can no longer provide coverage to their region, patients are occasionally transported to the United States.

Over the last decade, issues with access to NCs had reached crisis proportions with the transfer of hundreds of acutely ill neurosurgical patients to the United States due to a lack of resources in Ontario [8]. To address these access issues, the Ministry of Health and Long Term Care (MOHLTC) organized a core group of stakeholders, which ultimately became known as Provincial Neurosurgery Ontario (PNO) to improve access to definitive neurosurgical care in the province.

In this paper we describe a collaborative framework between Ministry of Health and Longterm Care (government), neurosurgeons, critical care specialists and services, nurses, and hospital administrators among other stakeholders to improve access to neurosurgical care for critically ill patients.