Development of a multi stakeholder partnership to improve access to and delivery of neurosurgical services in 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.
Section snippets
Geography
Ontario is Canada’s largest province (1.1 m km2) with a population of 13 million people. Ninety three percent of the population lives in the southern part of the province (comprising 13% of the land mass), in close proximity to the US–Canada border. Ontario borders the US states of Michigan and New York, with the largest border cities being Buffalo and Detroit.
Neurosurgical resources
Existing neurosurgical resources in Ontario in the year 2007 included 65 neurosurgeons distributed across 10 adult neurosurgical centers
Scope of the problem
In 2007, the lack of appropriate resources within NC’s in Ontario, and subsequent transfer of patients to the United States for treatment, led to the commission of a special panel by the Ministry of Health and Long Term Care (MOHLTC) to evaluate how to increase access to neurosurgical services and enhance NC capacity to care for acutely ill neurosurgical patients. This multi-disciplinary panel was named the “Neurosurgery Expert Panel” (NEP). Previous expert panels in other disciplines had been
Provincial neurosurgery Ontario
Despite the increasing demand on NCs throughout the province, neurosurgical services continued to be funded by hospital budgets. The mismatch between the increasing number of neurosurgical cases and relatively static hospital-based budgets for neurosurgical services posed significant challenges for neurosurgeons and allied health care workers in the provision of expedited care to neurosurgical patients.
From 2007–2011, through a concerted effort between the MOHLTC, neurosurgeons, critical care
Solutions implemented by PNO
Through partnerships established at PNO, a variety of novel solutions to intrinsic neurosurgical access problems were identified. The immediate priority was to reduce or eliminate out-of-country transfers. Other solutions included implementing web based provincial imaging for cranial and spinal cases reviewed through CritiCall (although CT scan images are critical to making a decision regarding transfer, no mechanism existed by which consulting neurosurgeons could view CT scan images of
Discussion
This study provides the framework of a multi-stakeholder partnership to improve access to specialized neurosurgical care in the setting of resource scarcity. The limited distribution of neurosurgical services in Ontario, and the subsequent requirement for interfacility transfer posed significant challenges in providing timely access to care. After characterizing these challenges PNO helped provide solutions and implementation to improve access to neurosurgical care.
PNO represents a unique
Conclusion
PNO has demonstrated that significant improvements in system access can be made through collaboration of multiple stakeholders. This model is unique in its broad involvement of government, hospitals and physicians. Although there are still many challenges to tackle, this framework has been welcomed by neurosurgeons, non neurosurgeons and administrators. Many clinical challenges have been identified and addressed by this framework to the satisfaction of clinicians. While significant progress has
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