An exploratory study of the responses of the patient to the cancellation of his surgery

Surgery cancellation: A scoping review of patients' experiences

AIMS AND OBJECTIVES

To review the literature on patients' experiences of surgery cancellation to gain knowledge of nursing care needs and identify gaps in evidence.

BACKGROUND

Surgery cancellations are an ongoing challenge in healthcare systems with negative impacts on healthcare costs, hospital staff and patients. Most research addresses the reasons for cancellation and implementation of preventive interventions, but limited knowledge exists about patients' experiences of cancellation.

DESIGN

The scoping review was undertaken using the methodology recommended by the Joanna Briggs Institute for Scoping Reviews and the Reporting Cheklist for Scoping Reviews (PRISMA-ScR).

METHODS

A systematic search was conducted by two independent researchers in Cochrane Library, CINAHL, PubMed and PsycINFO. A forward and backward citation search was performed in Scopus, and references in relevant studies were explored. The tool Covidence was applied to select, compare and discuss relevant articles. The Mixed Methods Appraisal Tool was used for critical appraisal.

RESULTS

Surgery cancellation is emotionally harmful with negative effects on patients. Four themes were identified: 'Initial reactions to cancellation', 'Reactions during a new waiting period at home and during readmission to hospital', 'Information about cancellation' and 'The experience of new practical arrangements'. Patients whose surgery was cancelled experienced initial feelings such as anger, rejection and anxiety and physical/psychosomatic symptoms in the extended waiting period. Patients prefered early sufficient information about cancellation from the surgeon. The practical arrangements were stressfull for the patients.

CONCLUSION

Nursing care and identification of vulnerable patients are essential to prevent negative effects in the extended waiting period. Provision of timely, sufficient and professional information about cancellation from the surgeon is important. Further research assessing consequences of cancellation is needed.

RELEVANCE TO CLINICAL PRACTICE

Patients would benefit if hospitals find systems to minimise cancellation, and healthcare professionals could systematically develop professional supportive interventions tailored to patients' individual needs.

Cancelled Surgeries and Payment by Results in the English National Health Service

Objectives

To model the frequency of ‘last minute’ cancellations of planned elective procedures in the English NHS with respect to the patient and provider factors that led to these cancellations.

Methods

A dataset of 5,288,604 elective patients spell in the English NHS from January 1st, 2007 to December 31st, 2007 was extracted from the Hospital Episode Statistics. A binary dependent variable indicating whether or not a patient had a Health Resource Group coded as S22 - ‘Planned elective procedure not carried out’ - was modeled using a probit regession estimated via maximum likelihood including patient, case and hospital level covariates.

Results

Longer waiting times and being admitted on a Monday were associated with a greater rate of cancelled procedures. Male patients, patients from lower socioeconomic groups and older patients had higher rates of cancelled procedures. There was significant variation in cancellation rates between hospitals; Foundation Trusts and private facilities had the lowest cancellation rates.

Conclusions

Further research is needed on why Foundation Trusts exhibit lower cancellation rates. Hospitals with relatively high cancellation rates should be encouraged to tackle this problem. Further evidence is needed on whether hospitals are more likely to cancel operations where the procedure tariff is lower than the S22 tariff as this creates a perverse incentive to cancel. Understanding the underlying causes of why male, older and patients from lower socioeconomic groups are more likely to have their operations cancelled is important to inform the appropriate policy response. This research suggests that interventions designed to reduce cancellation rates should be targeted to high-cancellation groups.

Cancellations of elective surgery may cause an inferior postoperative course: the ‘invisible hand’ of health-care prioritization?

Elective surgery can be cancelled when resources are overwhelmed by emergency cases. We hypothesized that such cancellations, on psychological grounds, are followed also by inferior clinical results and we conducted a retrospective survey of patients following joint replacement surgery. Sixty patients having suffered from administrative cancellation prior to their operation during an 18-month period and with six months follow-up were identified and compared with another 60 matched patients after having the same type of surgery but without prior cancellation. All patients received questionnaires on complications and on visual analogue scale (VAS) assessment on subjective wellbeing and quality of life (QoL) at follow-up. The study group reported 50 complications versus 33 for controls ( P < 0.03). A borderline significant difference was found for myocardial infarction, 4 versus 0 ( P < 0.05). There was no difference in VAS registration and QoL measurements did not quite reach statistical significance ( P = 0.06). Cancellations (postponements) of elective surgery for administrative reasons may be followed by inferior clinical results, and this merits further prospective study.

The impact of pre-operative assessment clinics on elective surgical case cancellations

Pre-operative assessment clinics prepare patients for elective procedures. Little is known about their impact on elective case cancellations. We investigated whether a pre-operative assessment clinic would reduce surgical case cancellations. A retrospective review of all surgical cases over a one year period prior to and subsequent to establishment of the clinic was performed. Case cancellations during both periods were compared. Statistical analysis was performed using the chi-square test. There was a 12.7% increase in the number of elective adult procedures performed following establishment of the POAC (815 vs. 723), although this was not significant (p > 0.05). Pre-assessment resulted in a significant reduction in case cancellations (114 vs. 256, p < 0.001). When we analysed the data in terms of the reason for cancellation, we found that cancellations for medical, but not patient reasons were significantly reduced following pre-assessment (p = 0.013 and p = 0.180, respectively). The data suggest that establishment ofa pre-operative assessment clinic reduces elective case cancellations. In particular we found a significant reduction in cancellations for medical reasons.

Causes of Cancellations on the Day of Surgery at Two Major University Hospitals

Cancellations of elective cases on the day of surgery waste valuable operating-room time. The authors studied cancellations at an American hospital and a Norwegian university hospital to test ( a) whether the quality of hospital administrative data on cancellations is sufficient for meaningful comparative analysis and ( b) whether causes of cancellations at these 2 major academic hospitals are comparable. Large retrospective cause-of-cancellation data sets were obtained from each hospital. The authors then prospectively established root causes of cancellations by on-site investigation and interviews of the hospital personnel involved. The surgical department at the Norwegian hospital cancelled 14.58% of cases in 2003 and 16.07% in 2004. The American hospital cancelled 16.52% of all cases between May 1, 2003, and April 30, 2004. Administrative data may give a rough picture of causes of cancellations. However, most findings at either of the hospitals do not translate easily to the other.

Postponed or cancelled heart operations from the patient's perspective

OBJECTIVES

The aim was to describe postponements or complete cancellations of planned cardiac operations at a Swedish hospital during 1999 and the reception the patients received from the staff in connection with this, from the inpatient's perspective.

DESIGN

A qualitative descriptive design inspired by content analysis was used. Data were collected through questionnaires distributed to all 74 patients who had their heart operation cancelled.

RESULTS

During analysis of the questionnaires, five categories of answers emerged describing the patients' perception of: organization, medical aspects, information, waiting time and staff reception. Overall, the patients reacted negatively to the postponement/cancellation in the form of anxiety and disappointment and fear of being affected by cardiovascular problems, but were generally satisfied with reception received from hospital staff. A number of concerns were revealed, however, with possible practical implications for the health-care system.

CONCLUSION

An understanding of the disappointment and anxiety felt by patients because of the postponement/cancellation of heart surgery can help medical staff to improve the situation. An intervention program is suggested that includes a pre-admission clinic, a change in the planning and waiting list system and support via follow-up telephone calls or internet-based support system.

Patient reactions to cancelled or postponed heart operations

OBJECTIVES

The aim was to survey the rate and cause of cancellations of planned cardiac operations at a Swedish clinic during 1999, and to study how the patients were affected.

DESIGN

Questionnaires were distributed to 74 patients who had their operations cancelled. Their mood after discharge was measured with The Hospital Anxiety and Depression scale. Ninety-three patients, who were operated on without postponement, served as controls.

RESULTS

Sixty-one percent of the patients in the cancellation group reacted negatively, especially if the reason for cancellation was organizational (P = 0.03). The women in the cancellation group had a significantly higher degree of depression than men (P = 0.01) and both women (P = 0.02) and men (P = 0.003) in the control group. Most of the patients, however, were satisfied with the nursing staff's reception and information.

CONCLUSIONS

The patients reacted negatively to the cancellation, especially if it had organizational reasons. Women subjected to cancellation had a significantly higher degree of depression than other patients. To be avoided, organizational and medical problems must be identified in time. One way to do this is to introduce a preadmission nurse clinic.

Cancellation of pediatric outpatient surgery: economic and emotional implications for patients and their families

STUDY OBJECTIVE

To determine the cause and timing of case cancellation in a pediatric outpatient surgical population, and to examine the economic and emotional impact of such cancellations on patients and their families.

DESIGN

Questionnaire survey.

SETTING

Outpatient surgery unit of a large university children's hospital.

PARTICIPANTS

127 parents of children whose elective outpatient surgery had been cancelled.

INTERVENTIONS

A total of 200 questionnaires were mailed to the parents of children who had their outpatient surgery cancelled.

MEASUREMENTS AND MAIN RESULTS

Of those children whose surgery had been cancelled, 34.6% were due to upper respiratory infections (URIs), 30.7% for other medical reasons, and the balance for scheduling errors, because the child had not fasted, or for difficulties with transportation. The majority of surgeries (58.3%) were cancelled prior to their scheduled surgery date. However, 18.9% were cancelled on the day of surgery prior to leaving for the hospital and 22.8% were cancelled on arrival at the outpatient surgery clinic. Of those patients whose surgeries were not cancelled until they arrived at the hospital, 38.5% of mothers and 50.0% of fathers missed a day of work and, of these, 53.3% and 42.1%, respectively, went unpaid for the work day missed. The mean number of miles driven (round trip) to the hospital for a cancelled operation was 158.8 miles (range 8 to 1,350 miles). Additional testing and new appointments were ordered in 25.2% of the cancelled cases. 45% of parents and 16% of children were disappointed by the cancellation; 16% of parents were frustrated by the cancellation and 3.3% were angry.

CONCLUSIONS

This study suggests that last-minute cancellation of surgery has an important impact on patients and their families and suggests a need to review present protocols for screening patients prior to surgery.