If You Cancel Surgery Can You Schedule It Again
J Anaesthesiol Clin Pharmacol. 2012 Jan-Mar; 28(1): 66–69.
Reasons for cancellation of operation on the day of intended surgery in a multidisciplinary 500 bedded hospital
Rajender Kumar
Department of Amazement, Dr. Baba Sahib Ambedkar Hospital, Sector-5, Rohini, New Delhi, India
Ritika Gandhi
Section of Amazement, Dr. Baba Sahib Ambedkar Hospital, Sector-5, Rohini, New Delhi, India
Abstract
Groundwork:
Counterfoil of operations in hospitals is a significant trouble with far reaching consequences. This study was planned to evaluate reasons for cancellation of elective surgical performance on the twenty-four hour period of surgery in a 500 bedded Regime hospital.
Materials and Methods:
The medical records of all the patients, from Dec 2009 to November 2010, who had their operations cancelled on the day of surgery in all surgical units of the hospital, were audited prospectively. The number of performance cancelled and reasons for cancellation were documented.
Results:
7272 patients were scheduled for elective surgical procedures during report period; 1286 (17.6 %) of these were cancelled on the day of surgery. The highest number of cancellation occurred in the subject field of general surgery (7.ane%) and the least (0.35%) occurred in Ear-Nose-Throat surgery. The most common cause of cancellation was the lack of availability of theater time 809 (63%) and patients not turning upward 244 (19%) patients. 149 cancellations (11.6%) were considering of medical reasons; sixteen (1.2%) were cancelled by the surgeon due to a modify in the surgical program; 28 (2.i%) were cancelled equally patients were not ready for surgery; and 40 (iii.1%) were cancelled due to equipment failure.].
Conclusion:
Most causes of cancellations of operations are preventable.
Keywords: Inspect, dosing schedules, morphine
Introduction
Performance theater (OT) is the heart of a hospital requiring considerable human resources and expenditure from hospital upkeep. Nonetheless, OTs are underutilized and lie idle at times. Many patients who are chosen for operation from waiting listing are not operated upon.[1,ii] A significant amount of work needs to be undertaken to prepare the patient for a surgical procedure. This includes the patient notes being written on the solar day of admission, the consultant taking the time to review the notes, OT staff ensuring the right surgical instruments are available, ward staff preparing the ward for the patient, secretarial staff preparing theatre lists, the patient preparing self for admission to infirmary, and preparations for postoperative intendance. Terminal minute cancellations result in inefficient use of resource, non in the interests of the patient or the hospital, and result in lost chapters.[3]
Cancellation of elective operations is a parameter to assess quality of patient care and quality of direction system. The reported incidence of cancellation in dissimilar hospitals ranges from ten% to 40%. At that place are many reasons of counterfoil of elective surgical cases; and they differ from hospital to hospital.[iv] Unexpected operating room (OR) cancellations are traditionally divided into avoidable cancellations (due east.k., scheduling errors, equipment shortages, and counterfoil due to inadequate preoperative evaluation) and unavoidable cancellations (due east.grand., emergency case superseding the elective schedule, unexpected changes in the patient's medical status, or patient nonappearance). The near common factor which has led to cancellation is lack of OR fourth dimension.[four]
The aim of this prospective study was to analyze the causes of cancellation of elective procedures in a multidisciplinary 500 bedded government hospital and to suggest measures for optimal utilization of OR time.
Materials and Methods
All patients scheduled to undergo elective surgical procedures, between December 2009 to November 2010, at our 500 bedded hospital were prospectively enrolled in the written report. Every bit this study was considered every bit inspect under quality balls projection, information technology did non require blessing of the infirmary ethics commission.
Data on operations scheduled for weekdays, excluding public holidays, were obtained from the OT list for that twenty-four hours. This list is generated at xiv:00 h the previous day. Copies of the supplementary course used to make additions to this list were obtained. The OT list provided patient and surgeon details, intended procedure, OT used, and estimated duration of each functioning. After an operation, details are entered into an OT database and passed on to the hospital patient information system. From this, patient demographic characteristics, morbidity, category (ward, day-of-surgery, day-only, or emergency access), and date and actual time of start and stop of surgery were taken. For this study, emergency admissions were defined equally admissions which were unplanned.
A cancellation on the twenty-four hours of intended surgery was divers as any operation that was either scheduled on the final OT list for that twenty-four hour period (generated at 14:00 on the previous twenty-four hours) or was later added to the list and that was not performed on that day. During the mean solar day of surgery, OT staff compiled a list of cancellations. The form for this included a column for "classification and comment," where theatre staff recorded a reason for the counterfoil. We obtained copies of these lists each day. In addition, the reason for each cancellation was investigated on the following working day, by checking in person or by telephone with:
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Staff of the booking function;
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For mean solar day-only and 24-hour interval-of-surgery admissions, the day-only ward records ("pasty characterization book") and senior clerical and nursing staff; and
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For ward patients, the clinical case coordinators or senior resident of the respective wards.
For cancellations where no reason was recorded on the cancellation list or the recorded reason was inconsistent with that reported by staff, the patients' clinical records were audited. If the reason was nonetheless not clear (i.e., there were gaps in the reasoning or the reason given was not consistent with events in the clinical record), the registrar or surgeon was asked.
Cancellations were classified as:
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Potentially avoidable (no OT time, no postoperative bed, list error, administrative cause, equipment or ship problem, communication failure, patient not ready, and no surgeon available); or
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Nonavoidable (cancelled by patient, patient clinical change, emergency priority, patient not ready, and no surgeon bachelor).
Equally this classification was based on the detailed reason given for the cancellation, some of the half-dozen major categories appear in both the avoidable and unavoidable groups. For example, "patient non ready" could be due to failure to adequately set up the patient (avoidable) or to a factor exterior the control of infirmary staff, such as that the patient did not fast (unavoidable).
Results
A total of 7272 patients were scheduled for elective surgical procedures during 12-month study period. The total number of surgical operations performed was 5986.The OT was functional for 231 days during the report period, resulting in 25.9 cases per 24-hour interval. The total number of patients cancelled on the day of surgery was 1286 (17.6 %), resulting an average of 5.v cancellations per 24-hour interval. 809 patients out of 1286 (63%) was cancelled due to lack of availability of OT time; patients not turning up resulted in 244 (nineteen%) cancellations. 149 procedures (11.six%) were cancelled because of medical reasons. In 16 patients (i.ii%) surgery was cancelled past surgeon due to a change in the surgical programme. Patient not being prepare resulted in cancellation of surgery in 28 (2.1%) patients. In 40 patients (iii.1%) surgery was cancelled due to equipment failure [Table i].
Table i
Reasons for cancellation of surgery
Table ii shows the specialty-wise distribution of cases. Full general surgery had highest number of cases scheduled for operation, 2196 (30.1%) followed by orthopedic 1812 (25%), urology 1548 (21.three%), and ear-nose-throat (ENT) 972 (13.iv%). Gynecology had least number of patients scheduled for functioning 744 (10.2%).
Table ii
Specialty-wise distribution of cases (scheduled and cancelled)
Out of the procedures were cancelled, general surgery had the highest number of patients 516 (7%) followed by orthopedic surgery 504 (6.9%) and urology 156 (2.one%). ENT had to the lowest degree contribution to full counterfoil with 26 (0.35%) patients followed by gynecology 84 (1.xv%). When the number of cases cancelled in each specialty was compared with the number of cases booked in the specialty, orthopedics had highest cancellation rate of 27.8% followed past general surgery 23.4% and gynecology xi.2%, while ENT had least cancellation rate of two.6% followed past urology x% [Table 3].
Tabular array three
Cases cancelled as a percentage of scheduled cases
Discussion
An efficient surgical service should have a depression rate of cancellation of operations. If operations are cancelled, OTs are underused; efficiency is jeopardized, waiting list increases, and toll rises.[ane] It is a well-known fact that if resources are not properly utilized, the general population suffers especially the lower income groups, who depend more than on public or regime services for nearly of their healthcare needs. The cost of facility and equipment which is underutilized adds to the cost of its services, which is ultimately passed on to patients. Avoiding cancellation is an essential footstep to reduce these. The National Audit Role in Britain examined v commune health regime in detail and concluded that OTs were beingness used one-half their capacity in spite of huge waiting lists.[1,5]
Cancellations create untold fiscal, logistic, and psychological hardships for the patients and their relatives who plan their working and family lives around postponed date of operation. About operations are cancelled at 24-h discover. The patients and the relatives experience disappointed, frustrated, and anxious. In Great britain, viii% of scheduled constituent operations are cancelled nationally inside 24 h of surgery.[1] In our report, 17.vi% operations were cancelled.
Shortage of operating time (63%) was the near important factor of cancellation of elective functioning in this written report. A lot of OT fourth dimension is wasted due to late starts, time between cases, preparation and cleaning OTs, and delayed transportation of patients to OT.[six,seven] Avoidance of late starts tin be achieved by cooperation from anesthesiologists' and surgeons. A team approach, in presence of efficient theater In-charge, can improve OT management. A diversity of staff piece of work in operation theatre and conflicts among them can lead to inefficiency. A skilful administrator can amend scheduling; reduce time spent preparing/cleaning and handle resources ameliorate.[ane] Garg et al. found that 59.7% of cases were cancelled due to lack of availability of OT fourth dimension.[viii]
Unplanned admissions and lengthy OT lists prepared by junior surgeons, who were not familiar with the procedure, were also a reason for counterfoil of operations. Many patients did not need surgery or required further work up before surgery. Cancellations, due to lack of OT time, were not just acquired by scheduling error only mainly caused past surgeons underestimating the time needed for the operation. Surgeons generally add more patients to the OT listing to reduce the waiting list and in apprehension of any unexpected cancellations.[ane,eight] An assay in U.s.a. examining 56,000 cases retrospectively constitute that 31% of lists were predictably overbooked.[9]
The time interval between two surgical interventions can be longer when the patient takes long time to recover from anesthesia. Overlapping induction, i.eastward., induction of anesthesia with an additional squad while the previous patient was still in the OT has been analyzed and reported to increase the OT productivity past decreasing the nonoperative time by 45.6%.[ten] This requires additional staff and equipments thus increasing the overall cost. However, we can relieve OT fourth dimension by inserting epidural catheters and peripheral and fundamental intravenous access in the side room prior to shifting the patient to the OT while the previous patient was however in the OT.[8]
Pandit et al. also found that over running OT lists were the commonest cause of cancellation of cases on the solar day of surgery (50% lists were overbooked and fifty% over ran their scheduled time).[11] However, unforeseen coldhearted or surgical problems may also delay the planned listing. The time taken for a item surgery too depends on the skill of operating surgeon. Less experienced surgeons and trainees often have more than the expected fourth dimension. For some surgeries, the total duration exceeded the usual surgical time due to an unexpected surgical complication, juniors being taught and allowed to practise the surgery especially for laparoscopic procedures, unavailability of sterilized instruments, and technical problems in instruments.[1,8] Vinukondaiah et al. documented that lack of operating time was the unmarried well-nigh of import gene for cancellation of cases. This was mainly considering surgeons took longer than the estimated elapsing of surgery.[12]
Inadequate preoperative medical optimization, which is most 11.vi% in our study, was some other important reason for cancellation of cases. The major reasons were hypertension, recent onset respiratory tract infections, uncontrolled diabetes, and an acute onset cardiovascular abnormality. All the patients are evaluated mean solar day before surgery past the anesthesiologist in our hospital and patients who required preoperative medical optimization are referred to physician. But, most of the time, surgeons scheduled their patients for surgery immediately after physician reference without optimizing condition of patient. Studies have shown that preoperative anesthesia assessment in preanesthesia clinics significantly reduces operative room delays and cancellations.[13] Hussain et al. reported that 8% of cancellation of cases, on the mean solar day of surgery, was anesthesia related.[14]
Absence of separate facilities for day-case surgery was another cistron in cancellation of operations because aforementioned OT was used for in- and out-patient surgery. Shortage of beds as a issue of mass casualties and emergency surgeries during elective list resulted in cancellation of a number of operations.[i] Although emergency OT in our hospital works 24 h a day, permitting uninterrupted elective operations, sometimes, the senior surgeon is chosen to emergency OT for help thereby delaying or wasting routine OT time and leading to the postponement of an constituent example.
Last-infinitesimal counterfoil by a patient or failure to be present is particularly difficult to resolve. It is about 19% in our study. It may be due to the patient'south final minute doubts and fears. Paschoal reported that 54.3% cases of the total cancelled cases were due to absenteeism of the patient because of unawareness of the date of surgery, clinical problems similar respiratory tract infections and social/economical reasons.[fifteen] Efforts should exist made to better patient communication and facilitate their compliance with scheduled procedures.
Determination
This audit highlight that nigh causes of counterfoil of operations are avoidable, efforts should be made to foreclose cancellation of surgery past conscientious planning, bearing in mind the local constraints in human and fabric resources. The OT list should be fabricated judiciously to avert under or over utilization of OT facilities. The requirement of the instruments/drugs/other equipment necessary for scheduled surgical listing should be discussed amid surgeon, staff nurse, and the anesthesiologist a day prior to planned OT list.
The medical bug tin can exist identified in fourth dimension and the number of cancellations on medical grounds can be avoided past establishing a formal liaison with the physicians and past improving advice betwixt patient, doctors, and nurses. Twenty-four hours-care patients should be counseled adequately to report on time. All patients meeting postanesthesia care unit of measurement belch criteria must be discharged promptly to prevent delay in shifting out of the operated patient. Such audits should exist carried out at regular intervals to find out the effective functioning of the OT.
Footnotes
Source of Support: Nothing
Conflict of Interest: None declared.
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Articles from Journal of Anaesthesiology, Clinical Pharmacology are provided here courtesy of Wolters Kluwer -- Medknow Publications
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275976/
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