The future of pediatric cardiac surgery in Manitoba

Finding

The evidence suggests that the Province of Manitoba lacks a sufficient population base to assure the establishment of a high-quality, full-service Pediatric Cardiac Surgery Program.

Finding

The evidence suggests that there are real benefits to patients to having a high-quality, limited service pediatric cardiac surgery program in Manitoba that is integrated into a regional Pediatric Cardiac Surgery Program.

The available information suggests that the limited number of cases that can be undertaken in a province like Manitoba with a population of just over one million increases the risk of morbidity and mortality, particularly in the case of high-risk surgery. Even if the catchment area were expanded to include other areas such as Nunavut or Northwestern Ontario, the base population would still be quite small and the number of complex procedures would still not be large enough to support a full-service program.

However there are difficult issues associated with sending children to other provinces for pediatric cardiac surgery. Some children cannot tolerate travelling such distances very well. Some cannot travel at all. A program that relies exclusively on extra-provincial transportation could contribute to their greater risk and might even doom some of them to death.

There are also the emotional, psychological and physical tolls that are exacted on families who have to travel long distances under very stressful circumstances to face a difficult ordeal, without the strength and support of nearby family members. It seems both unnecessary and unfair to require parents and families of small children and infants to have to travel to other parts of the country in order to have relatively simple procedures performed. Additionally, the cost of delivering all pediatric cardiac surgery services to the citizens of Manitoba by sending them out of province is tremendously expensive.

Collins, who originated the idea of having a full-service program in this province, felt strongly that medical treatment is better when the diagnostic and medical treatment facility and the surgical facility are one and the same, and the surgical team knows the patient and family.

There is merit, as Collins testified, to having a facility where the surgical team can be involved in the initial diagnosis and treatment of a patient and will be involved in the post-surgical treatment and where parents, as well as the patients, are fully prepared for surgery. Where possible, treating a child in such a centre is psychologically preferable to transporting a child to a centre where the surgical team (figuratively speaking) meets the patient the day before surgery and sends the child 'back home' a few days later.

In addition, every province needs to have at least one facility where a full range of services can be provided to the patients who are brought into care. In concert with that, developments in related fields might require the existence of a pediatric cardiac facility. The developing field of invasive pediatric cardiology-which can reduce the number of pediatric cardiac surgical procedures-requires that a pediatric cardiac surgeon be available in the event of complications. If there is no pediatric cardiac surgeon, it would be difficult, if not impossible, to attract such leading-edge pediatric cardiologists to Winnipeg.

Dr. Brian Postl testified that regionalization of pediatric cardiac care in Western Canada has been under consideration since the closure of the Winnipeg program. Such a model might involve the establishment of a regional pediatric cardiac centre in a central location (such as Edmonton). Under this system, a local surgical team would perform lower-risk procedures in Winnipeg. Complex cases would be transferred to the regional centre. If necessary, a surgeon capable of performing complex procedures could travel to Winnipeg and other locations to perform scheduled procedures. Such a program must, of course, pay close attention to the issues of team-building, training, communication and decision-making that have been identified throughout this report. If a surgeon is flown into Winnipeg to perform an operation, the surgeon must also become a well-integrated member of the team. He or she must develop a degree of familiarity and comfort with local team members. Team performance on a regional basis would have to be considered.

Recommendations

It is recommended that: The HSC, the Winnipeg Regional Health Authority and the Manitoba Department of Health pursue discussions with provinces in Western Canada for the development of a Western or Prairie regional Pediatric Cardiac Surgery Program.

It is recommended that: A provincial Pediatric Cardiac Surgery Program be developed at the HSC that is limited to undertaking lower and medium-risk procedures, but can undertake more complex procedures in conjunction with a regional pediatric cardiac surgery centre.

It is recommended that: The Province of Manitoba develop a financial assistance package for families required to travel out of province for surgical treatment of family members. The package should ensure that family members are in no worse a financial position than if the treatment had been provided in Manitoba.

Combining the ICUs

Legitimate questions were raised throughout 1994 about the decision to have both the neonatal intensive care unit and the pediatric intensive care unit provide service to the Pediatric Cardiac Surgery Program. The evidence suggests that pediatric cardiac surgery patients should be treated in one ICU.

It is recommended that: As a part of any planned restart of the Pediatric Cardiac Surgery Program, the post-operative care of pediatric cardiac patients be centralized in a single intensive care unit.