Heart surgery used to mean waiting. Here’s how we fixed it
A cardiac surgeon changed a hospital’s approach to help more patients — not by making noise but by being an example
Wait times have been a constant pain point in Canada’s medical system.
But when veteran cardiac surgeon Dr. Arvind Koshal encountered them, he discovered that sometimes it takes the simplest of steps to resolve the thorniest problems.
That’s just one of the lessons in Koshal’s recent memoir, “Transplant: A Cardiac Surgeon’s Story of Immigration and Innovation.” His pivotal role at the forefront of transforming cardiac care in Canada — first in Ottawa and then in Edmonton — is even more notable considering his personal journey from India at a time when open-heart surgery was in its infancy.
“When we speak of innovation in medicine, our minds tend to gravitate toward technological advancements and novel techniques,” Koshal writes in his book. “Innovation is not confined to technological marvels. It encompasses the constant pursuit of improving and transforming care through people and processes.”
The most important issue to address — and change — in Edmonton was the insufferably long wait time patients faced to get heart surgery. Some had waited for over a year and a half. Clearly, an unacceptable state of things. Too many people had developed complications while waiting; some had even died: tragic outcomes that must not be allowed to continue. Some patients were being sent to Calgary or elsewhere to get treated earlier. That couldn’t, or shouldn’t, have been happening. I would have to find a way to do something.
The obvious solution was to do more surgery — keep things moving apace. Some of it was just a matter of space. The operating rooms, because they were part of the Department of Surgery, were divided between specialties and access was limited. Not only that, but the hospital had a high rate of occupancy with a limited number of
beds, especially in intensive care. Almost every patient undergoing open-heart surgery needs an ICU bed. Most can be moved out of intensive care in 24 to 48 hours, but if there was a lung transplant patient or a complex case with significant post-operative complications, other patients would have reduced access. How would we work around that?
One of the big problems was that the surgeons on staff did only two operations a day. Back in Ottawa, we did two or three. We needed to work swiftly and efficiently. That was also a benefit for the patients. If you moved too slowly, a patient would spend more time on the heart-lung machine. Two hours, as opposed to 45 minutes, meant longer patient recovery time in ICU.
Within two weeks on the job, I started doing surgery myself. Two or three procedures a day on the days I worked, as I did in Ottawa. The administrative demands of the job would not go away, but I wanted to tackle this problem head-on. Not by telling but by showing. I didn’t want to be the kind of boss who arrogantly proclaims, “Do it like me.” I wanted to offer a model of how things might be speeded up. And anyway, surgeons are a savvy, competitive group. The best of them want to improve. You don’t throw down the gauntlet without them picking it up.
The bigger issue turned out to be financial, an administrative snafu. Cardiac surgeons were on a fee-forservice arrangement, and fiercely envied by other doctors for their earning power. Any request for more OR time was seen as a demand for more money, as though the cardiac surgeons were trying to game the system. How could I explain that performing more surgery was essential to reduce the mortality rates and the long wait time? It wasn’t about the doctors; it was about the patients. Patients had to come first.
Certainly, I could extend my own hours in the operating room, but I recognized that this alone would not bring about significant change. There were moments when I even considered going to the press, publicizing Edmonton’s distressing wait time. There’d be a story to tell. A scandal to make tongues wag. But that short-term thinking would surely backfire on me.
I needed to alert the administration and the powers that be — without any publicity — to get things to change. I talked to the CEO and president, presenting my case, then made a formal presentation to the University of Alberta Hospital board. Tears came to my eyes as I spoke, showing them the dismal statistics.
“There’s so much we can do,” I said, “to change this.” Patients with open-heart surgery didn’t need to stay in the hospital for 10 days; four or five days would do. What we came up with was an early-discharge program with at-home followup by nurses and social workers. “It will help them and help us,” I said. We could double the number of surgeries while reducing the need for more beds — a win-win proposition.
To my great relief, the board understood our needs and agreed to our approach. Within months we had significantly reduced the wait time. I came to Edmonton in 1991. It took year after year of focusing on that goal, making progress a little at a time, but in the last few years before I retired in 2013, we got the waiting list down to a week and a half. Only 10 days of waiting for elective heart surgery. This was remarkable. We were able to treat more patients faster and more efficiently, saving countless lives.
I didn’t have to make some big self-congratulatory speech. The statistics spoke for themselves.
“Surgeons are a savvy, competitive group. The best of them want to improve. You don’t throw down the gauntlet without them picking it up.
DR. ARVIND KOSHAL