ROYAL AUSTRALASIAN
COLLEGE OF SURGEONS
Develop agreed national elective surgery urgency
category definitions (including for patients not ready
for care) that will enable consistent application
across all states and territories.
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Equitable access according to clinical need.
Balancing consistency of practice and clinical
decision-making.
Comparable national reporting of waiting times.
Enhancing overall waiting list management.
Question: are the objectives and
approaches appropriate?
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Public submissions (30 March-27 April 2012):
Received 20 submissions from various
stakeholders, providing a wide range of views.
Stakeholder workshops (July-August 2012): A
series of stakeholder workshops being
conducted in major capital cities.
RACS consultations with surgical speciality
societies and associations (July–August 2012).
Consultations through a jurisdictional reference
group established under Health Ministers.
Admissions from Waiting Lists by Urgency Category (%)
NSW
Vic
Qld
WA
SA
Tas
ACT
NT
Total
Category 1
26
28
37
26
33
41
29
43
30
Category 2
31
48
47
35
34
43
49
38
40
Category 3
43
24
16
39
32
17
22
19
31
100
100
100
100
100
100
100
100
100
Total
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Cataract extraction
Coronary artery bypass graft
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Cholecystectomy
Cystoscopy
State or
Territory
Total hip replacement:
% in category 2
Total knee replacement:
% in category 2
NSW
25
12
Vic
74
70
Qld
59
58
WA
58
51
SA
25
17
Tas
71
52
ACT
85
86
NT
-
-
Total
49
39
Data not shown for NT due to small numbers.
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Categories assigned at the discretion of the
treating clinician.
Categories assigned on clinical grounds not on
basis of hospital or surgeon resources.
Question: Are these overarching principles correct?
Are they worth stating explicitly as part of the
definitions?
Urgency Category
Meaning
Category 1
Admission within 30 days desirable for a condition
that has the potential to deteriorate quickly, to the
point that it may become an emergency.
Category 2
Admission within 90 days desirable for a condition
causing pain, dysfunction or disability, but which is
not likely to deteriorate quickly or become an
emergency.
Category 3
Admission at some time in the future acceptable for
a condition causing minimal or no pain, dysfunction
or disability, which is unlikely to deteriorate quickly
and which does not have the potential to become an
emergency.
Note: Differences in definitions are observed among
states and territories – in blue on the next slide.
New South Wales
Urgency Category
Meaning
Category 1
Admission within 30 days desirable for a condition that has the potential to
deteriorate quickly to the point that it may become an emergency.
Category 2
Admission within 90 days desirable for a condition which is not likely to deteriorate
quickly or become an emergency.
Category 3
Admission within 365 days acceptable for a condition which is unlikely to
deteriorate quickly and which has little potential to become an emergency.
Category 4
Patients who are either clinically not yet ready for admission (staged) and those
who have deferred admission for personal reasons (deferred).
Ready for
Care
Not Ready for
Care
South Australia
Urgency Category
Meaning
Category 1 (Urgent)
Very early admission for a condition that has the potential to deteriorate quickly to
the point that it may become an emergency or is life threatening (Admission within
30 days desirable).
Category 2 (Semi-
Admission within 90 days for a condition causing some pain, dysfunction or
disability which is not likely to deteriorate quickly or become an emergency
(Admission within 90 days desirable).
Category 3 (Not-
Admission at some time in the future for a condition causing minimal or no pain,
dysfunction or disability, that is unlikely to deteriorate quickly and that does not have
the potential to become an emergency (Admission within one year desirable).
Category 4
Staged/Medical Deferred/Patient Deferred: Admission deferred to a time that is
medically appropriate, which includes staging surgery whilst the patient waits for
periodic treatment or investigation, or deferred to a time move convenient to the
patient.
urgent)
urgent)
Ready for
Care
Not Ready
for Care
Urgency Category
Meaning
Category 1
Procedures that are clinically indicated within 30 days.
Category 2
Procedures that are clinically indicated within 90 days.
Category 3
Procedures that are clinically indicated within 365 days.
Question: Are the proposed categories, definitions and
timeframes appropriate?
Suggestion: split category 2?
Urgency Category
Meaning
Category 2A
Procedures that are clinically indicated within 60 days.
Category 2B
Procedures that are clinically indicated within 120 days.
Questions: Would splitting category 2 assist in
standardising clinical urgency assignment?
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The new definitions would be used with feedback
of information about comparative urgency
categorisation.
With the aim of reducing variations in distribution.
Question: Would feedback (and publication) of urgency
distribution information be useful to help reduce
variation in urgency categorisation?
Proportion of patients admitted from waiting lists for elective surgery, by
urgency category, Peer Group A hospitals, 2010-11
120
100
Per cent
80
Category 3
60
Category 2
Category 1
40
20
0
Hospital A
Hospital B
Hospital C
Hospital D
Hospital E
Peer Group A
Australia
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Could be used in addition to the new definitions and
feedback arrangements.
NSW and Western Australia have recommended
urgency categories for high volume procedures e.g.
◦ Total arthroplasty of knee, unilateral
◦ Total arthroplasty of hip, unilateral
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Both are recommended to be category 3 in NSW, and
as category 2 or 3 in Western Australia
Question: Would a national list of ‘recommended’
urgency categories for high volume procedures be
useful in reducing variation in urgency categorisation?
Recommended urgency categories could be:
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Derived from the NSW and WA lists?
Based on the most commonly reported urgency
category?
Described as distributions of urgency categories (e.g.
category 1 20%, category 2 70%, category 3 10%).
The next slide shows the distributions for some NSW
and WA examples.
Question: Could the NSW and WA lists form the basis
of a national list of ‘recommended’ urgency
categories for high volume procedures?
100%
100%
80%
80%
60%
60%
40%
40%
20%
20%
0%
0%
NSW
WA
NSW
WA
Prostatectomy
Tonsillectomy
Recommended: 2
Recommended: 3
100%
100%
80%
80%
60%
60%
40%
40%
20%
20%
0%
0%
NSW
WA
Cholecystectomy
Recommended: 1 or 2
NSW
WA
Coronary artery bypass graft
Recommended: 1
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Could also be developed to assist in urgency
categorisation for common surgical
procedures.
◦ Surgical procedure specific, speciality specific,
diagnosis driven (e.g. special rules for cancer),
comorbidity driven or driven by factors such as age of
the patient (e.g. special rules for children).
Question: Would procedure-specific or similar
guidelines or scoring systems be useful in reducing
variation in urgency categorisation?
1.
Staged patients
2.
Deferred for (other) clinical reasons
3.
Deferred for personal reasons
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Should be added to the waiting list at the beginning of the
‘window’ of time during which their procedure is indicated.
The urgency category should match the size of the ‘window’,
e.g. category 1 for a window of 4 weeks.
Patient listing
status
Meaning
Not ready for
care – staged
patients
Patients who have undergone an elective procedure
or other treatment and are waiting for a follow-up
elective procedure, where the patient is not in a
position to be admitted to hospital or to begin the
process leading directly to admission or to
provision of care on a non-admitted basis, because
the patient’s clinical condition means that the
procedure is not indicated until some future,
planned period of time.

Should only be added to waiting lists when they are clinically
ready for the procedure.
Patient listing
status
Not ready for care
– deferred for
(other) clinical
reasons
Meaning
Patients who are not in a position to be
admitted to hospital or to begin the process
leading directly to admission or provision of
care on a non-admitted basis, and are not
staged patients (as defined above) because
the procedure is not indicated until the
patient’s clinical condition changes so that
the patient is suitable for the procedure.
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Should not be added to a waiting list until their personal
circumstances mean that they are ready for care.
Patient listing
status
Not ready for care
– deferred for
personal reasons
Meaning
Patients who for personal reasons are not
yet prepared to be admitted to hospital; for
example, patients with work or other
commitments which preclude their being
admitted to hospital for a time.
Question: Are the definitions of the three ‘not ready
for care’ categories appropriate?
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Cardiac interventional procedures
Peripheral vascular interventional procedures
Bronchoscopy
Gastroscopy
Endoscopic retrograde cholangiopancreatography
Colonoscopy
Living donor organ transplant procedures
The scope could then be referred to as ‘elective
procedures’?
Question: Should this be considered?
Is this an appropriate list?
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Providing surgery for patients in the order in which
they were added to the waiting list, within each
urgency category
Gives more certainty to timing of surgery, so could
assist in reducing urgency category variation?
Reduces mean waiting time and long waits
Needs to allow for patient variation
Aiming for 60-80%?
Question: It is useful to include the principle of ‘treat
in turn’ and would it contribute to improved
standardisation?
Overarching
principles?
Treat in turn?
New
definitions
for staged
and deferred
patients?
Time based
urgency
category
definitions
Recommended
urgency
categories for
higher volume
procedures?
Feedback
about
urgency
categories?
Guidelines
or scoring
systems?
Are the overarching principles
correct?
1.
2.
Categories assigned at the discretion of the
treating clinician.
Categories assigned on clinical grounds not on
basis of hospital or surgeon resources.
Are they worth stating explicitly as
part of the definitions?
Are the proposed urgency
categories, definitions and
timeframes appropriate?
Urgency Category
Meaning
Category 1
Procedures that are clinically indicated within 30 days.
Category 2
Procedures that are clinically indicated within 90 days.
Category 3
Procedures that are clinically indicated within 365 days.
Would it be helpful to split
urgency category 2 into category
2A and category 2B?
Urgency Category
Meaning
Category 2A
Procedures that are clinically indicated within 60 days.
Category 2B
Procedures that are clinically indicated within 120 days.
Would feedback (and publication)
of urgency distribution information
help to reduce variation?
Would a national list of
‘recommended’ urgency categories
for high volume procedures be
useful?
Could they be derived from the NSW and WA
lists?
Could they aim at standardised distributions
of urgency categories?
Could procedure-specific or similar
guidelines or scoring systems be
useful tools?
Are the definitions of the three ‘not
ready for care’ categories
appropriate?
1.
2.
3.
Staged patients
Deferred for (other) clinical reasons
Deferred for personal reasons
Is it useful to include the principle
of ‘treat in turn’?
Should the scope of ‘elective
procedures’ be considered as part of
this project?
Should elective procedures include:
 Cardiac interventional procedures
 Peripheral vascular interventional procedures
 Bronchoscopy
 Gastroscopy
 Endoscopic retrograde cholangiopancreatography
 Colonoscopy
 Living donor organ transplant procedures
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Further consultation:
o Clinicians
o State and territory health departments
o Surgical speciality societies
o General public and consumers
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Preparation of draft report in September 2012.
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Further consultation.
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Final Report to Health Ministers in December 2012.
Visit the AIHW website for more information:
http://www.aihw.gov.au