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Reducing referral-to-consultation delays in pediatric obstructive sleep apnea through standardized triage: A regional
Evana Francis1, Hussein Smaily2
1Department of Otolaryngology, Head and Neck Surgery, Laval University, Pavillon Ferdinand-Landry, 1050 avenue de la médecine, Quebec City, QC, Canada; Department of Otolaryngology, Head and Neck Surgery, Centre Hospitalier Regional du Grand Portage, CISSS du Bas Saint Laurent, 75 Rue Saint-Henri, Riviere du Loup, QC, Canada; Division of Pediatric Otolaryngology, Head and Neck Surgery, CHU Sainte-Justine, 3175 Chem. de la Côte-Sainte-Catherine, Montreal, Quebec, Canada.
Insights
Timely management of pediatric obstructive sleep apnea (OSA) is crucial. Delays in referral-to-consultation for pediatric OSA in non-urban areas exceed benchmarks, highlighting the need for standardized triage to improve access to care.
Area of Science:
- Pediatric Otolaryngology
- Sleep Medicine
- Healthcare Quality Improvement
Background:
- Pediatric obstructive sleep apnea (OSA) requires timely intervention to prevent long-term health issues.
- Access to care, particularly adenotonsillectomy, is often delayed in publicly funded systems, especially in non-urban regions.
- Prolonged wait times for pediatric adenotonsillectomy were identified at a regional hospital, with referral-to-consultation delay (Wait-1) being the primary bottleneck.
Purpose of the Study:
- To investigate and quantify delays in the pediatric adenotonsillectomy pathway for sleep-disordered breathing.
- To identify factors contributing to delays in care for pediatric obstructive sleep apnea.
- To develop a quality improvement initiative to address access bottlenecks in pediatric OSA management.
Main Methods:
- A retrospective analysis of 82 pediatric patients undergoing adenotonsillectomy over 22 months was conducted.
- Referral-to-consultation (Wait-1), consultation-to-surgery (Wait-2), and total referral-to-surgery delays were quantified.
- Root cause analysis identified non-standardized referral triage as a key issue, leading to the development of a standardized referral template and triage algorithm.
Main Results:
- Mean delays were: Wait-1 (9.0 months), Wait-2 (6.2 months), and total delay (15.2 months).
- Higher tonsil grade and oxygen desaturation index predicted shorter Wait-2, while oxygen desaturation index predicted shorter Wait-1 and total delay.
- Wait-1 significantly exceeded Pediatric Canadian Access Targets for Surgery, while Wait-2 met targets for mild OSA.
Conclusions:
- Access delays for pediatric obstructive sleep apnea in non-urban settings are primarily due to pre-specialty consultation wait times.
- Implementing standardized referral triage with objective severity markers can improve prioritization.
- Standardized triage has the potential to align care delivery with national access benchmarks.
Background:
Timely management of pediatric obstructive sleep apnea (OSA) is essential to prevent sequelae. In publicly funded health systems, delays remain common, particularly in non-urban regions with limited specialty capacity. At a regional hospital serving Québec's Bas-Saint-Laurent region, prolonged wait times for adenotonsillectomy were observed. Preliminary review identified referral-to-consultation delay (Wait-1) as the principal access bottleneck, exceeding Pediatric Canadian Access Targets for Surgery.
Methods:
Using SQUIRE 2.0 guidelines, we conducted a quality improvement initiative. A retrospective analysis of consecutive pediatric patients undergoing adenotonsillectomy for sleep-disordered breathing over 22 months (n = 82) quantified referral-to-consultation (Wait-1), consultation-to-surgery (Wait-2), and total referral-to-surgery delays. Age, tonsil grade, oxygen desaturation index, and McGill Oximetry Score were assessed as predictors of delay. Multivariable regression identified clinical predictors of management timing. Process mapping and root cause analysis identified non-standardized referral triage as the primary modifiable factor. A standardized referral template and severity-based triage algorithm incorporating tonsil grade, Pediatric Sleep Questionnaire, and oximetry findings were developed. Implementation through Plan-Do-Study-Act cycles is planned but not reported here.
Results:
Mean Wait-1 was 9.0 ± 7.0 months, Wait-2 was 6.2 ± 3.6 months, and total referral-to-surgery delay was 15.2 ± 8.6 months. Higher tonsil grade (p = 0.015) and oxygen desaturation index (p = 0.032) predicted shorter Wait-2. Oxygen desaturation index independently predicted shorter Wait-1 (p = 0.023) and total delay (p = 0.008). While Wait-2 met Pediatric Canadian Access Targets for Surgery for mild OSA, Wait-1 substantially exceeded benchmarks.
Conclusions:
In this non-urban setting, access delays occur primarily before specialty consultation. Standardized referral triage using objective severity markers may improve prioritization and alignment with national benchmarks.
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