The blow inflicted by the coronavirus has been so hard, the dimensions of the epidemic so great, that every small step towards normality is costing the health system a world. The last example is offered by the high rejection figures that hospitals encounter when they call patients on the surgical waiting list for surgery. If their condition is not serious, if it is not something very urgent, up to 60% of them prefer to allow a little time to pass before entering the operating room.
“When we timidly started to open the operating rooms, almost a month ago, 75% of the patients told us no, they preferred to wait. That percentage has been decreasing and we are now at 40% or 50% ”, explains the director of care at Hospital del Mar (Barcelona), Julio Pascual.
It is the same hairpin offered by Rocío Cebrián, assistant director of the Vall d’Hebron hospital, also in the Catalan capital. “That is an average. The specific data depends on the type of intervention. They are lower in the more serious ones and much higher in major outpatient surgery ”, he says.
The Ramón y Cajal hospital (Madrid) figures the refusal at 60%, the same proportion as that of Talavera de la Reina (Toledo). Meanwhile, in La Rioja, “22% of patients pending surgery on the waiting list are refusing to do so and requesting a postponement,” explains the regional government. In the Puerta de Hierro (Madrid) the dismissal is 10%, while other large centers such as the Clínic (Barcelona) and the Gregorio Marañón (Madrid) describe these cases as “anecdotal”.
“In reality, the differences are due to the type of patient to whom the centers offer to operate. The hospitals that have the greatest rejection is that they are already intervening patients from the normal waiting list, while those with less are those that still have the accumulated bag of serious and oncological patients “, clarifies Sagrario Martínez Cortijo, general secretary of the Association Spanish Surgeons.
This specialist distinguishes three types of patients: “Those who suffer from a malignant pathology, such as cancer; those who have a benign non-delay, with risk of worsening; and the benign one, which is the great workhorse of Spanish health. It is the pure and simple waiting list, that of the normal hernia, that of the sinus or the fistula. It depends on where they live, they may have been waiting 200 days and now they say they are not going to go to the hospital with what has happened, “he adds.
Martínez Cortijo, who maintains direct communication with colleagues from all over Spain, maintains that “patients with a malignant pathology barely refuse to undergo surgery, less than 5%, because they know that life is going on for them. 40% “. A percentage that “depends on the area of Spain and the impact that the virus has had on it.”
For Salvador Navarro, head of the surgical area of the Parc Taulí hospital (Sabadell, Barcelona), this situation requires the adoption of management measures to mitigate the effects of the refusal of patients to operate. “We call twice to ensure that the patient will come and, if we don’t get it, we call another,” he explains.
Navarro and Pascual highlight the importance of being transparent “and explaining the measures adopted to the patient.” “Nobody is going to be operated on without undergoing a PCR. They insist on the hours so that people are punctual and there are no crowds in the waiting rooms ”, they detail.
Other measures adopted seek to define very well “which patient each healthcare professional cares for.” “They have to know at all times if they have coronavirus or not. And if it does, it must be in a different place, the spaces must be well defined ”, he explains.
The experts consulted consider key “to regain the confidence of the patient”. Beatriz González López-Valcárcel, Professor of Economics, an expert in health at the University of Las Palmas, believes that “trust is gained when the patient goes to the hospital and sees the security measures in place, which are many”.
For Julio Pascual, “the patient will also lose his fear of the de-escalation rhythm”. “If people are told that they cannot leave home because the virus is out there, it is difficult for them to trust. But if he can already go out to eat a paella, it is easier for him to also think that he can go for surgery ”, explains the care director of the Hospital del Mar, located next to the popular restaurants on the beaches of Barcelona.
All the experts consulted agree that a hard second semester awaits Spanish health. “In three months, a lot of activity has stopped and the professionals have not rested,” explains Navarro, who highlights that those “who have been most in the front line against the coronavirus are closely linked to surgical activity, such as staff surgical nursing staff, anesthetists… ”. “Now these professionals have to rest to be prepared in case there is a regrowth in the next winter,” adds the head of surgery at Parc Taulí.
For Julio Pascual, we have to assume that “it will not be possible to do this year what has been left out in these three months.” “This summer we are challenged to increase activity while giving staff a break. We will have to hire, but the waiting lists will increase and it will take at least a year to return to the original situation ”.
Experts also agree that rejection —or to a much lesser extent, absenteeism— by patients is related to the severity of the clinical picture, but also to its intensity: going to an outpatient clinic is not the same as having surgery. “This morning, for example, we have resumed outpatient consultations for COPD patients. They are patients with severe ailment, at the hospital level. Out of 12, only one has failed ”, emphasizes José Miguel Rodríguez, head of the Pneumology service at the Príncipe de Asturias Hospital in Alcalá.
A more punctual and remote healthcare
All the experts consulted emphasize that many of the changes adopted out of sheer necessity during the epidemic are here to stay. “More than half of the visits will be through the screen,” sums up Julio Pascual. “At Hospital del Mar we are developing a plan that estimates that the physical presence of the patient is essential in between 30% and 50% of the consultations. But the rest may be telematic. As much as we doctors like to have patients there and see them in person, we are going to have to adapt ”, he adds.
The health of the future will also be more punctual. Visits will be spaced so that patients do not spend hours in the same waiting room, which can be a savings. “As far as I know, there is no study on this, but if the machinery is adjusted and the people are punctual, it is more efficient. What made no sense were those systematic one-hour waits to see the specialist. It was more comfortable for the doctor, but there is also an opportunity cost borne by the patient. It is a good step for the system to become more punctual ”, he says.
Salvador Navarro agrees that “the times must be adjusted so that the patient arrives and leaves on time without coinciding with other patients.” Other changes that will remain, at least until there is a vaccine, is the protection of professionals, according to Navarro. “We will be protected from any patient and they from us, with well-differentiated spaces for patients with the virus,” he adds. For the head of surgery at Parc Taulí de Sabadell this is key.
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