Elective surgery cancelation on day of surgery: An endless dilemma

Assessment of Knowledge and Attitude of Anaesthetists in Utilizing Telehealth-Based Pre-anaesthesia Evaluation

BACKGROUND

This study aims to assess anaesthesiologists' understanding and attitudes toward utilizing telehealth for pre-anaesthesia evaluations (PAEs) in instances where a scheduled surgery is deferred to the procedure day due to hospital or patient-related reasons.

METHODOLOGY

This observational cross-sectional study involved anaesthesiologists with over six months of hospital experience, opting to participate voluntarily. Non-probability sampling was employed for participant selection. The study's objectives were communicated, and consent was obtained. Data were recorded in Microsoft Excel and analyzed using STATA 12.0.

RESULTS

Of the 237 participating anaesthetists, 155 were aged 21 to 40. Notably, 88.6% (n=210) expressed interest in advanced telemedicine learning, and 77.6% (n=184) were keen on its implementation. Common sources of information included tele-diagnosis (n=194), tele-education, counselling (n=147), and tele-surveillance, with additional input from telesurgery, tele-triage, tele-monitoring, and teleradiology.

CONCLUSION

The study highlights anaesthetists' strong enthusiasm for adopting advanced telemedicine and teleconferencing. Predominant information sources included tele-diagnosis, tele-education, tele-counselling, and tele-surveillance. The majority endorsed the potential of telemedicine to aid patients, expressing comfort in using it for pre-anaesthesia examinations.

An In-Depth Analysis of Providers and Services of Cancellation in Anesthesia Reveals a Complex Picture after Systemic Analysis

The variances in operating room (OR) cancellation rates between different service lines and operators within these service lines were assessed by reviewing the electronic medical record (EMR) covering 34,561 cases performed by 199 OR operators in 2018. We assumed that cancellations would differ between different service lines, but the between-operators variance was minimal within the service line. We hypothesized that most variability would be secondary to patient-specific (weekdays, time of year, and national holidays), seasonal and administrative issues. Of 4165 case cancellations, the majority (73.1%) occurred before the patient arrived at the hospital. A total of 60% of all cancellations were within gastroenterology, interventional cardiology, and orthopedics. Cancellation rate variability between surgeons operating within the same service line greatly varied between services from very homogenous to very diverse across providers. The top reasons for cancellation were: date change, canceled by a patient, or "no show". The highest cancellation rates occurred on Mondays and Tuesdays, in January and September, and during weeks associated with national holidays. In summary, cancellation variability must be analyzed at the level of individual specialties, operators, and time variability.

Outcomes and Disposition of Patients After Case Cancellation on Day of Surgery for Reasons Attributed to Medical or Anesthetic Care: A Retrospective Cohort Analysis

BACKGROUND

Many day-of-surgery cancellations are avoidable, and different strategies are used to prevent these costly adverse events. Despite these past analyses and evaluations of positive interventions, studies have not examined the final disposition of patients whose cases were canceled in this late manner. This study sought to determine whether surgical procedures canceled for medical or anesthetic reasons were ultimately rescheduled, and the time elapsed between cancellation and completion. In addition, the resolution of the underlying issue leading to cancellation was examined.

METHODS

Two years of surgical case data were reviewed in the electronic health record to isolate all procedures canceled on the intended operative date. These cases were then filtered by the documented reason for cancellation into 2 categories: 1 for cases related to medical or anesthetic care and 1 for unrelated cases. Medical- or anesthetic-related cases were further categorized to better elucidate the underlying reason for cancellation. Cases were then traced to determine if and when the procedure was ultimately completed. If a case was rescheduled, the record was reviewed to determine whether the underlying reason for cancellation was resolved.

RESULTS

A total of 4472 cases were canceled in the study period with only 20% associated with medical or anesthetic causes. Of these, 72% were rescheduled and 83% of all rescheduled cases resolved the underlying issue before the rescheduled procedure. Nearly half of all cases (47.8%) canceled on the day of surgery for reasons linked to medical and/or anesthetic care were due to acute conditions.

CONCLUSIONS

Nearly a fifth of cases that are canceled on the date of surgery are never rescheduled and, if they are rescheduled, the delay can be substantial. Although the majority of patients whose procedure are canceled for reasons related to medical or anesthetic care have resolved the underlying issue that led to initial postponement, a significant portion of patients have no change in their status before the ultimate completion of their surgical procedure.

Reducing surgical cancellations: a successful application of Lean Six Sigma in healthcare

OBJECTIVE

The COVID-19 pandemic emphasises the need to use healthcare resources efficient and effective to guarantee access to high-quality healthcare in an affordable manner. Surgical cancellations have a negative impact on these. We used the Lean Six Sigma (LSS) methodology to reduce cardiac surgical cancellations in a University Medical Center in the Netherlands, where approximately 20% of cardiac surgeries were being cancelled.

METHOD

A multifunctional project team used the data-driven LSS process improvement methodology and followed the 'DMAIC' improvement cycle (Define, Measure, Analyse, Improve, Control). Through all DMAIC phases, real-world data from the hospital information system supported the team during biweekly problem-solving sessions. This quality improvement study used an 'interrupted time series' study design. Data were collected between January 2014 and December 2016, covering 20 months prior and 16 months after implementation. Outcomes were number of last-minute coronary artery bypass graft cancellations, number of repeated diagnostics, referral to treatment time and patient satisfaction. Statistical process control charts visualised the change and impact over time. Students two-sample t-test was used to test statistical significance. A p<0.05 was considered as statistically significant.

RESULTS

Last-minute cancellations were reduced by 50% (p=0.010), repeated preoperative diagnostics (X-ray) declined by 67% (p=0.021), referral to treatment time reduced by 35% (p=0.000) and patient Net Promoter Score increased by 14% (p=0.005).

CONCLUSION

This study shows that LSS is an effective quality improvement approach to help healthcare organisations to deliver more safe, timely, effective, efficient, equitable and patient-centred care. Crucial success factors were the use of a structured data-driven problem-solving approach, focus on patient value and process flow, leadership support and engagement of involved healthcare professionals through the entire care pathway. Ongoing monitoring of key performance indicators is helpful in engaging the organisation to maintain continuous process improvement and sustaining long-term impact.

Non-medical risk factors associated with postponing elective surgery: a prospective observational study

Background

Operation room (OR) planning is a complex process, especially in large hospitals with high rates of unplanned emergency procedures. Postponing elective surgery in order to provide capacity for emergency operations is inevitable at times. Elderly patients, residents of nursing homes, women, patients with low socioeconomic status and ethnic minorities are at risk for undertreatment in other contexts, as suggested by reports in the medical literature. We hypothesized that specific patient groups could be at higher risk for having their elective surgery rescheduled for non-medical reasons.

Methods

In this single center, prospective observational trial, we analysed 2519 patients undergoing elective surgery from October 2018 to May 2019. A 14-item questionnaire was handed out to illicit patient details. Additional characteristics were collected using electronic patient records. Information on the timely performance of the scheduled surgery was obtained using the OR’s patient data management system. 6.45% of all planned procedures analysed were postponed. Association of specific variables with postponement rates were analysed using the Mann–Whitney U test and Fisher's exact test/χ²-test.

Results

Significantly higher rates of postponing elective surgery were found in elderly patients. No significant differences in postponing rates were found for the variables gender, nationality (Germany, EU, non-EU), native language, professional medical background and level of education. Significantly lower rescheduling rates were found in patients with ties to hospital staff and in patients with a private health insurer.

Conclusions

Elderly patients, retirees and nursing home residents seem to be at higher risk for having their elective surgery rescheduled. However, owing to the study design, causality could not be proven. Our findings raise concern about possible undertreatment of these patient groups and provide data on short-term postponement of elective surgery.

Trial registration DRKS00015836. Retrospectively registered.

Factors Contributing to Late Cancellation and No-Show for Otolaryngologic Surgery: A Prospective Study

PURPOSE

Late cancellations and no-shows for surgery place a burden on patients, healthcare providers, and the health system. We aim to identify risk factors contributing to this phenomenon.

METHODS

Patients who did not arrive for, or canceled within 24 hours of, their surgical appointment between January 2019 and 2020 were identified. Controls were matched by date, procedure, and gender. Demographic information was obtained by phone interview and chart review. Chi-square and Student t-test analyses were used to predict risk factors for cancellation.

RESULTS

Thirty-one patients were identified, of whom 21 completed phone interviews. Age, gender, race, language, marital status, and smoking status were not significantly different. Study patients reported more transportation challenges (33.3% vs. 4.8%, p = .01) yet lived closer to the hospital (4.53 miles vs. 14.05 miles, p = .01). Study patients lived in lower income zip codes ($48,145 vs. $63,406, p = .02) and more commonly had Medicaid as their primary insurance (70.9% vs. 38.7%, p = .04). Most commonly, no reason was given for cancellation (22.6%) followed by personal reasons (16.1%) and surgery reconsideration (16.1%).

CONCLUSIONS

Transportation trouble and lower income are significant risk factors for surgery late cancellation. Prior no-show must also be considered. A targeted pilot program may help prevent late cancellations.

Preoperative psychogenic fever: to operate or not to operate

Postponing elective surgery because of fever on the morning of the operation is frustrating for patients as well as doctors. It is also not cost effective and the unused operation capacity could have been used on other patients. On the other hand, surgery and general anaesthesia will put unwanted physiological strain on a patient fighting an on-going infection. Preoperative fever therefore poses a dilemma; to proceed with-, or to postpone the scheduled operation.

We report a case where a 58-year-old woman, scheduled for prophylactic bilateral mastectomy and primary implant-based reconstruction, was postponed because of a temperature of 37.9°C. The morning of her new operation date, she developed a fever of 39.2°C which fell to 38.2°C shortly after administration of 0.25 mg triazolam. She was diagnosed with psychogenic fever, and we went through with the operation, even though the patient was febrile. The operation was successful, and she had no post-operative complications.

Impacts of elective surgical cancellations and postponements in Canada

Purpose

Worldwide, patients experience difficulties accessing elective surgical care. This study examined the perceived health, social, and functional impacts of elective surgical cancellations and postponements in Canada.

Methods

We analyzed a subset of aggregate data from the Canadian Community Health Survey (CCHS) annual components from 2005 to 2014. Multivariable logistic regressions examined associations between past-year non-emergency surgical cancellations/postponements and perceived impacts of waiting for surgery (e.g., worry/stress/anxiety, pain, loss of work, loss of income, deterioration of health, relationships suffered).

Results

Among those who experienced a cancellation or postponement of a past-year non-emergency surgery (weighted n = 256,836; 11.8%), 23.5% (weighted n = 60,345) indicated their life was affected by waiting for surgery. After adjusting for type of surgery, year, and sociodemographics, those who experienced a surgical cancellation or postponement had increased odds of reporting their life was affected by waiting for surgery (adjusted odds ratio [aOR], 2.67; 99% confidence interval [CI], 1.41 to 5.1); in particular, they reported greater deterioration of their health (aOR, 3.47; 99% CI, 1.05 to 11.4) and increased dependence on relatives/friends (aOR, 2.53; 99% CI, 1.01 to 6.3) than those who did not have a cancellation or postponement.

Conclusion

Results highlight the multifaceted perceived impacts of surgical cancellations/postponements. These findings suggest there is a need for improvements in reducing elective surgical cancellations and postponements. Results may also inform the development of targeted interventions to improve patients’ health and quality of life while waiting for surgery.

Applying Lean Six Sigma to Reduce the Incidence of Unplanned Surgery Cancellation at a Large Comprehensive Tertiary Hospital in China

Unplanned surgery cancellation (USC) was an important quality management issue in the course of medical care for surgical patients, which caused inappropriate use of hospital resources and had negative impacts on quality and safety. This study used Lean Six Sigma to reduce the incidence of USC. Following the Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) process, the main factors influencing the USC were identified, such as the time of informing patient admission, the time of submitting operation notice, and the management of test report follow-up. A series of measures were implemented including improving the health education content of virtual bed patients, standardizing the way of communication between the Admission Management Center and the patients, improving the timing of anesthesia evaluation, optimizing the process of operation notice with an information system, and implementing the regulations of virtual bed management. The incidence of USC reduced from 10.21% in Jan. 2016 to 3.8% in Dec. 2016, and the Z-score increased from 1.25 to 1.68, which improved patient safety and demonstrated that Lean Six Sigma was an effective method to solve cross-department issues in hospital.

Resilience in the Surgical Scheduling to Support Adaptive Scheduling System

Operating Room (OR) managers frequently encounter uncertainties related to real-time scheduling, especially on the day of surgery. It is necessary to enable earlier identification of uncertainties occurring in the perioperative environment. This study aims to propose a framework for resilient surgical scheduling by identifying uncertainty factors affecting the real-time surgical scheduling through a mixed-methods study. We collected the pre- and post-surgical scheduling data for twenty days and a one-day observation data in a top-tier general university hospital in South Korea. Data were compared and analyzed for any changes related to the dimensions of uncertainty. The observations in situ of surgical scheduling were performed to confirm our findings from the quantitative data. Analysis was divided into two phases of fundamental uncertainties categorization (conceptual, technical and personal) and uncertainties leveling for effective decision-making strategies. Pre- and post-surgical scheduling data analysis showed that unconfirmed patient medical conditions and emergency cases are the main causes of frequent same-day surgery schedule changes, with derived factors that affect the scheduling pattern (time of surgery, overtime surgery, surgical procedure changes and surgery duration). The observation revealed how the OR manager controlled the unexpected events to prevent overtime surgeries. In conclusion, integrating resilience approach to identifying uncertainties and managing event changes can minimize potential risks that may compromise the surgical personnel and patients' safety, thereby promoting higher resilience in the current system. Furthermore, this strategy may improve coordination among personnel and increase surgical scheduling efficiency.

Evaluation of the Reasons for the Cancellation of Elective Procedures at Level 3 University Hospital on the Day of Surgery

PURPOSE

Unexpected cancellations of planned elective procedures are a global problem for hospitals, causing a waste of hospital resources and manpower, and reduces the efficiency of hospitals. In this study, we tried to identify the causes of cancellations of elective procedures, and to examine the relationship between the causes.

DESIGN

A retrospective, descriptive single-center study.

METHODS

Nine thousand five hundred sixty-six elective procedures scheduled between January 2015 and December 2015 were retrospectively examined. Reasons for cancellation, the associated surgical clinic, and the day and season of the canceled procedures were recorded.

FINDINGS

Of the total 9,566 procedures, 496 (5.2%) were canceled. Of the cancellations, 31.3% were due to patient-related reasons, 29.2% because of inadequate anesthesia preparation, and 19% because of nonavailability of operating rooms.

CONCLUSIONS

Cancellation of elective surgeries causes a waste of time and resources. Determining the reasons for cancellations to reduce cancellation rates is important for each hospital.

Prevalence and Predictors of Cancellation of Elective Surgical Procedures at a Tertiary Hospital in Uganda: A Cross-Sectional Study

Introduction. The cancellation of elective procedures has been shown to waste resources and to have the potential to increase morbidity and mortality among patients. This study aimed to determine the prevalence of the cancellation of elective surgical procedures and to identify the factors associated with these cancellations at Mulago Hospital, a large public hospital in Kampala, Uganda.

Global prevalence and reasons for case cancellation on the intended day of surgery: A systematic review and meta-analysis

BACKGROUND

Cancellation of operation on the intended day of surgery affects the efficiency of Operation Room which incurs a significant financial loss for the patient, hospital, and health care cost of a country at large. This systematic and Meta-Analysis was intended to provide evidence on the global prevalence and determinants of case cancellation on the intended day of surgery.

METHODS

A comprehensive search was conducted in PubMed/Medline; Science direct and LILACS from January 2010 to May 2020 without language restriction. The Heterogeneity among the included studies was checked with forest plot, χ2 test, I2 test, and the p-values. All observational studies reporting prevalence and determinants were included.

RESULTS

A total of 1207 articles were identified from different databases with an initial search. Fort-eight articles were selected for evaluation after the successive screening. Thirty-three Articles with 306,635 participants were included. The Meta-Analysis revealed that the global prevalence of case cancellation on the intended day of surgery was 18% (95% CI: 16 to 20). The Meta-Analysis also showed that lack of operation theatre facility accounted for the major reason for cancellation followed by no attendant and change in medical condition.

CONCLUSION

The meta-analysis revealed that the prevalence of case cancellation was very high in low and middle-income countries and the majorities were avoidable which entails rigorous activities on operation theatre facilities, preoperative evaluation and preparation, patient and health care provider communications.

REGISTRATION

This Systematic Review and Meta-Analysis was registered in a research registry (researchregistry5746) available at https://www.researchregistry.com/browse-the-registry#home/.

Association of Continued Preoperative Aspirin Use and Bleeding Complications in Patients Undergoing Thyroid Surgery

Importance

No evidence exists to direct the management of preoperative aspirin (acetylsalicylic acid) use in patients undergoing thyroid surgery. Nevertheless, a considerable number of patients interrupt receiving aspirin therapy during the preoperative period to minimize bleeding complications despite the increased risk of experiencing major adverse cardiac events.

Objective

To determine whether aspirin therapy continued preoperatively increases bleeding complications in patients undergoing thyroid surgery.

Design, Setting, and Participants

Retrospective analysis of a consecutive sample of 570 patients, aged 18 to 100 years, who underwent thyroid surgery for benign and malignant disease from January 1, 2010, to December 31, 2015, by a single surgeon at a tertiary referral hospital center in New Orleans, Louisiana.

Exposures

Patients receiving aspirin therapy and patients not receiving aspirin therapy (aspirin naive) preoperatively.

Main Outcomes and Measures

Comparison of estimated blood loss, substantial blood loss, operative hematoma, nonoperative hematoma, and recurrent laryngeal nerve injury.

Results

Of 570 patients who underwent thyroid surgery, 106 (18.6%) were performed in patients receiving aspirin; of these, 23 (21.7%) were men and 105 (99.1%) were older than 45 years. Those receiving aspirin therapy displayed a 14.4-year difference in age (95% CI, 11.6-17.1). The aspirin group displayed a 20.3% absolute increase (95% CI, 9.3-30.7) in African American patients. Aspirin therapy was not associated with a statistically significant or clinically meaningful increase in intraoperative blood loss (2.5 mL; 95% CI, -0.4 to 5.3). Aspirin therapy was associated with a statistically significant increase in total hematoma formation (3.3%; 95% CI, 0.4-9.0), but the results were inconclusive. Aspirin therapy was not associated with a statistically significant increase in recurrent laryngeal nerve injury (2.6%; 95% CI, -1.1 to 8.6), but the results were inconclusive.

Conclusions and Relevance

These results suggest that aspirin therapy can be maintained prior to thyroid surgery without increased intraoperative bleeding. Further research with a larger sample size and more outcome events are required to make definitive conclusions regarding the association between aspirin use and complications, including hematoma and recurrent laryngeal nerve injury.

No-shows in ambulatory clinics and non-utilized appointments for elective operations in selected surgical departments at a tertiary hospital in Israel

Background

The phenomenon of a patient missing a medical appointment without notification is called a “no-show”. In contrast, “non-utilized appointments” are a broader phenomenon including all appointments that didn’t occur as registered – whether due to actions taken by providers or patients. Both no-shows and non-utilized appointments can lead to reduced quality of care, loss in productivity, financial losses and impaired patient outcomes.

Methods

The study was carried out between August 2016 and January 2017 in the ENT, Orthopedics and General Surgery Departments of the Jerusalem-based Shaare Zedek Medical Center. The study team sought to examine the reasons for non-utilized appointments in elective operations. The study team also interviewed no-show ambulatory care patients regarding the causes of the no-show and reviewed medical records of no-show patients to determine the nature of the missed appointments.

Results

The rate of non-utilization of appointments for elective operations was 6%. The leading reasons for non-utilization of these appointments were: patient health issues, patient surgery postponement and surgery schedule overload (together accounting for 52% of cases and 72% of known reasons). The no-show rate for ambulatory clinic appointments was approximately 15%. The leading reasons for ambulatory clinic no-shows were: administrative issues, illness and forgetfulness (together accounting for 58% of all reasons). The leading types of appointments missed were:post-operation follow-ups and chronic illness follow-up (together accounting for 46% of cases and 63% of known reasons).

Conclusions

In this study, the non-utilized appointment rate for elective operations was found to be lower than those noted in the medical literature, while the no-show rate for ambulatory visits was found to be similar to that found in the literature. There is room to question the necessity of certain types of postoperative follow-up appointments since they are at “high risk” for no-show. One promising way to reduce the no-show rate would involve improving the hospital’s information and computing systems in order to identify patients who are susceptible to a no-show incident.

Use of a Smartphone Application for Spine Surgery Improves Patient Adherence with Preoperative Instructions and Decreases Last-minute Surgery Cancellations

Background: Smartphone applications (apps) are being increasingly utilized in the health care arena to improve patient care and outcomes.

Objective: To further demonstrate the ability of a smartphone app to improve patient compliance with preoperative instructions and to decrease the number of last-minute surgery cancellations.

Methods: Patients undergoing spine surgery were prospectively accrued. Smartphone app users were compared to non-app users. Patient adherence with preoperative instructions as well as last-minute surgery cancellations were analyzed.

Results: All 85 app users adhered to preoperative instructions according to the acknowledgements sent to the web portal, and there were no cancelled surgeries. Among the 89 non-app users, there were five cancelled surgeries (5.6%).

Conclusions: We demonstrate the ability of a smartphone application to improve patient adherence with preoperative instructions and decrease last-minute surgery cancellations.

Elective Case Cancellation on the Day of Surgery at a General Hospital in Sarajevo: Causes and Possible Solutions

Introduction:

Cancelling elective procedures on the day of surgery presents a constant problem in all higher-level medical facilities, and the research of causes, consequences and possible solutions is the duty of every facility in order to enhance the quality of healthcare services.

Aim:

The aim of the research was to determine the percentage and reasons for cancelling elective procedures and provide adequate measure to reduce this number in the future and to identify ways to improve the patients’ satisfaction level.

Material and Methods:

This prospective study included all patients that were scheduled for surgery from March 2016 to November 2018 in the operating rooms at our Department of Surgery, including both performed and cancelled cases. Cases by different surgical departments (general surgery, gynecology, orthopedics, urology, plastic surgery, ophthalmology and otorhinolaryngology) were all included.

Results:

Out of 8201 planned elective procedures from March 2016 to November 2018 at the General Hospital “Abdulah Nakas”, 7825 cases were performed and 376 cases (4.58%) were cancelled on the day of surgery. The most common reasons for cancelling a surgical procedure on the day of surgery were: lack of time to perform surgery (33.51%), surgery cancelled due to medical/anesthetic reasons (31.38%), surgical procedure cancelled by the surgeon on the day of surgery (11.97%).

Conclusion:

This study has shown that the percentage of elective cases cancelled on the day of surgery at our institution stands at an acceptable 4.58%. The most common reasons for case cancellation on the day of surgery were identified. The majority of reasons for cancellation were avoidable, which means that appropriate steps could contribute to lowering the percentage of cancelled elective cases and an improved quality of healthcare services.

A random forest and simulation approach for scheduling operation rooms: Elective surgery cancelation in a Chinese hospital urology department

Many hospitals encounter surgery cancelations for various reasons. We present a methodology applying data mining and simulation to optimize operating room (OR) scheduling in a urology department in West China Hospital. To the best of our knowledge, this is 1 of the first efforts to seek an optimal schedule solution based on cancelation risk of elective surgeries as well as OR allocation between elective and nonelective surgeries. First, chi-square test and random forest prediction modeling were used to predict potential elective surgeries with high cancelation risk, and the factors, including surgeon, number of days since admission of patient, first surgery or not, etc., that influence elective surgery cancelation were identified. Second, a simulation technology was designed to compare 7 different scheduling strategies. The results demonstrated that for elective surgery, cancelation rate low surgery first outperformed the others and increased the productivity of the ORs from 72% to 83%, while for nonelective surgery performed in a separate OR, there was no improvement because the supply was greater than necessary at present. However, in total, the selected strategies led to 7% higher productivity.

Cancellation of Elective Cases in a Recently Opened, Tertiary/Quaternary-Level Hospital in the Middle East

Case cancellations have a negative financial impact due to revenue loss and the potential costs of underutilized time. The goals of this study at a recently opened hospital in the Middle East were to measure the cancellation rates for elective surgical or endoscopic cases and to identify the reasons for cancellation. During the 1-month study period, 170 (22.4%) of the 760 scheduled cases were cancelled. Cultural norms and patient no-shows on the day of surgery accounted for the majority of case cancellations. Understanding local factors on hospital functions may be vital for organizations expanding into new geographic areas.