Humanity, since antiquity, has tried to divide the surrounding universe into formal categories. That leaves, perhaps, room for a discussion of the meaning of ‘category’. A deep dive into this discussion would take us back to Aristotle and a survey of the philosophical study of ontology or the ‘nature of being’ but the takeaway point is this: There is a common misconception that categories of things can always be defined by certain necessary and sufficient conditions. If a certain thing or situation has features or qualities X and Y, and does not have P and Q, then it falls into category Z. This is rarely the case in biology, or concepts and categories used in human endeavor.1

Nowhere are the limitations of categorisation more apparent than in our outdated and overly simplistic surgical elective surgery categories (Box 1). How we have persisted in reducing the incredible complexities of surgical pathology, procedures, patient cultural, psychological and demographic make-up into three simplistic categories defies belief in the modern era.

Box 1.Australian Health Ministers’ Advisory Council National Elective Surgery Urgency Categorisation Guideline
The simplified time-based clinical urgency categories are as follows:

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

The danger of such an outdated and simplistic system for scoring clinical urgency has been brought into stark focus with the recent pandemic and the shutdown of elective surgery across Australia and the world. There was understandable outcry when groups such as IVF patients went to the media and pointed out the time critical nature of their surgical procedures. These groups were successful in overturning the ban in some instances2 but are they any more deserving than other groups buried in the broad brush of category?3 Such as the infant awaiting cleft lip repair who might miss developmental milestones or the tradesman awaiting hand reconstruction who can’t work until it is done or the staged breast cancer reconstruction patient who is psychologically devastated by the disease and deformity. All can be argued to be just as deserving and those examples are just from our specialty.

The current simplistic system is also open to manipulation by both hospitals trying to reach benchmarks3 and surgeons trying to ‘boost’ deserving patients.4 In all circumstances it is the ‘responsibility of the treating surgeon to assign the urgency category’.5

This, however, can be manipulated and patients often ‘hidden’ before they even make it on to a waiting list. Data on the ‘wait-to-wait’ list is not included in national benchmarks. A report by the Government of Western Australia’s Department of Health puts the median ‘wait-to-wait’ at public tertiary hospitals at just under nine months.6

Dr Danielle McMullen, President of the Australian Medical Association (AMA) in NSW recently criticised government: ‘Elective surgery shouldn’t be a tap that Government turns “on” and “off” to cover for serious cracks in our healthcare system.’7 While we completely agree with the statement, and acknowledge that shutdowns can have profound implications for patients, one must have some sympathy for governments dealing with a crisis given no alternative but to use the three-tiered simple categories that we, as a profession, have given them. The current system is not sufficiently nuanced for the way that it was initially intended, nor a detailed enough tool in a time of crisis. One can argue all day about adequate resourcing of hospitals and health care, but the global pandemic has shown us that extreme events can and will happen. The medical profession must drive reform in this area to avoid the problems we have seen with shutdowns.

So, what is the answer? The answer is, as in everything, to design and test a much more holistic categorisation system for scoring clinical urgency, one that reflects not only surgical pathology and procedures but also acknowledges a patient’s complexity. This should/could include: demographics, social productivity, culture, psychological distress, level of support, comorbidities and risk of blocking beds, risk to developmental milestones in children, staged/combined surgery, even immunisation status. All of these can be used to create a more holistic and realistic scoring system that is more reflective of urgency and less prone to manipulation or ‘turning off’ in times of pressure. We have a complex alpha numeric TNM classification system in cancer staging that directly applies to prognosis and treatment; it is not beyond us to do the same for waiting list categories.

Much of the score could be allocated automatically, independent of the surgeon. Points can be given or subtracted according to the likelihood of the patient getting back to productive work or of blocking beds. Demographic data is not open to subjective manipulation; body mass index (BMI) has a well-established association with surgical risk.8,9 This, in combination with other categories, can help prioritise those patients less likely to block beds in a time of crisis.

There are well-established categories such as the American Society of Anesthesiologists (ASA) Physical Status Classification System that is already validated10 that could be used to provide a negative score in times of high bed pressure or crisis. The higher the ASA score the more likely a patient is to have complications and thus an extended hospital stay (Table 1).

Table 1.Current definitions and ASA approved examples
ASA PS classification Definition Adult examples, including, but not limited to: Pediatric examples, including but not limited to: Obstetric examples, including but not limited to:
ASA I A normal healthy patient Healthy, non-smoking, no or minimal alcohol use Healthy (no acute or chronic disease), normal BMI percentile for age
ASA II A patient with mild systemic disease Mild diseases only without substantive functional limitations. Current smoker, social alcohol drinker, pregnancy, obesity (30<BMI<40), well-controlled DM/HTN, mild lung disease Asymptomatic congenital cardiac disease, well controlled dysrhythmias, asthma without exacerbation, well controlled epilepsy, non-insulin dependent diabetes mellitus, abnormal BMI percentile for age, mild/ moderate OSA, oncologic state in remission, autism with mild limitations Normal pregnancy*, well controlled gestational HTN, controlled preeclampsia without severe features, diet- controlled gestational DM.
ASA III A patient with severe systemic disease Substantive functional limitations; One or more moderate to severe diseases. Poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, history (>3 months) of MI, CVA, TIA, or CAD/stents. Uncorrected stable congenital cardiac abnormality, asthma with exacerbation, poorly controlled epilepsy, insulin dependent diabetes mellitus, morbid obesity, malnutrition, severe OSA, oncologic state, renal failure, muscular dystrophy, cystic fibrosis, history of organ transplantation, brain/ spinal cord malformation,
symptomatic hydrocephalus, premature infant PCA <60 weeks, autism with severe limitations, metabolic disease, difficult airway, long term parenteral nutrition. Full term infants <6 weeks of age.		 Preeclampsia with severe features, gestational DM with complications or high insulin requirements, a thrombophilic disease requiring anticoagulation.
ASA IV A patient with severe systemic disease that is a constant threat to life Recent (<3 months) MI, CVA, TIA or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, shock, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis Symptomatic congenital cardiac abnormality, congestive heart failure, active sequelae of prematurity, acute hypoxic-ischemic encephalopathy, shock, sepsis, disseminated intravascular coagulation, automatic implantable cardioverter-defibrillator, ventilator dependence, endocrinopathy, severe trauma, severe respiratory distress, advanced oncologic state. Preeclampsia with severe features complicated by HELLP or other adverse event, peripartum cardiomyopathy with EF <40, uncorrected/ decompensated heart disease, acquired or congenital.
ASA V A moribund patient who is not expected to survive without the operation Ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/ system dysfunction Massive trauma, intracranial hemorrhage with mass effect, patient requiring ECMO, respiratory failure or arrest, malignant hypertension, decompensated congestive heart failure, hepatic encephalopathy, ischemic bowel or multiple organ/ system dysfunction. Uterine rupture.
ASA VI A declared brain-dead patient whose organs are being removed for donor purposes

https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system

There is already a validated tool for Productivity Adjusted Life Years (PALY) 11 which could be used to prioritise surgery for a young, fit productive worker who supports a family and employs people over a retiree, for example. The PALY is calculated by multiplying a ‘productivity index’ (ranging from 0 [completely unproductive] to 1 [completely productive]) by years lived. It offers a novel, but now well-tested, approach to quantifying the population-level impact of disease on productivity (arising from unemployment, days off work, reduced efficiency at work and premature death) and the broader economy.11

Similar tools almost certainly can be developed for paediatric surgical timing to avoid such things as loss of developmental milestones, psychological distress, for the cultural impact of long waiting times on compliance among the Indigenous population, and even immunisation status, on beds.

The point is, we can do so much better than the basic three-tier elective surgical categorisation we have currently. Rather than chastising governments for shutting down all category III cases, we should give them a much more adaptive and nuanced system capable of relieving pressure when needed by removing only those patients that significantly block the system and drain resources. Adequately resourcing health is a debate for another day.