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Reducing “over the cut-off time” as a cause of sudden cancellation of scheduled elective operations

 

Reynaldo O. Joson, MD, MHA, MHPEd, MS Surg

Redomir P. Roque, MD

Anita O. So, MD, DPBA, MHA

Antonio M. Almazan, MD

Elaine Mejia, RN

 

July, 2003

 

 

Abstract

 

Sudden cancellation of scheduled elective inpatient operations is a parameter of quality patient service and efficiency in administration of operations. Late 2001, the administration of the Department of Surgery, Department of Anesthesiology, and Operating Room Nurses of Ospital ng Maynila Medical Center (OMMC Surgery) took concern for this parameter.  This paper reports on the incidence and causes (with particular focus on “over the cut-off time”) of sudden cancellation done on day of scheduled elective operations in OMMC Surgery and the outcome after improvement measures were instituted.  In OMMC, the time allotted for elective operations is from 7 am to 5 pm, Monday to Friday.  The last case should be finished by about 5 pm (the cut-off time). From 2001 to June, 2003, there was a progressive decrease in cancellation rate from 10% in 2001 to 6% in 2002 and first 6 months of 2003.  The incidence of “over the cut-off time”, which was the major non-patient-health related cause of cancellation had likewise reduced from 19 and 21 cases in 2001 and 2002 to 11 cases in 2003. Various strategies were utilized.  In the end, the general factors which contributed to reduction of cancellation were willingness and commitment of staff; effective strategies which included a systematic, comprehensive and innovative problem-solving method with clear-cut preventive and resolution procedures and a multisectoral cooperation; and continual monitoring and improvement.  At present, the operating team of OMMC considered acceptable only those
”over the cut-time time” cancellations secondary to undue intra-operative findings and difficulty in operative procedure.  The consensus of the operating team on what remains to be done was to keep on reducing sudden cancellation rate until a zero incidence is reached.  

 

 

Introduction

 

Sudden cancellation of scheduled elective operations has been known to occur. 

Sudden cancellation means the cancellation was done on the day of the scheduled operation.  Reasons for the cancellation can be generally classified as patient-health-related and non-patient-health related factors.  Examples of the former factors include hypertension, asthmatic attacks, and allergic reactions occurring in the operating room which force the surgical team to cancel the scheduled operation.  Examples of the latter factors include absence of operating materials, lack of staff, and non-observance of “NPO” order.

 

Surpassing the “cut-off time” is also one of the possible causes of sudden cancellation of scheduled elective operations.  In most operating rooms, there is usually a fixed time allotted for elective operations.  Some would fix it at 7-3 pm; some at 7-5 pm; still others, some other time span during daytime and during weekdays.  Some would use the last cutting time as the basis or “cut-off” to cancel the remaining undone scheduled operation and some would use the approximate time the last operation would end as the “cut-off”.  

 

Sudden cancellation of scheduled elective operation is a quality service concern (1-10) especially those due to non-patient-health related factors.  A cancellation is a potential cause of patients’ and relatives’ dissatisfaction because of the anxiety, inconvenience, and expense usually associated with it.  A significant cancellation rate is also a sign of inefficiency on the part of the surgical team (surgeon, anesthesiologist, and operating room staff).

 

The administration of the Department of Surgery, Department of Anesthesia, and Operating Room of the Ospital ng Maynila Medical Center (OMMC) took cognizant of the importance of avoiding cancellation of elective operations late 2001.  It has done an action research on such a problem from 2002 to June, 2003 and has reduced the incidence of sudden cancellation from 10% in 2001, to 8% in 2002, and 6% in mid-2003. 

 

This paper reports on the incidence of “over the cut-off time” as a reason for sudden cancellation of scheduled elective operations, its multiple causes, and strategies to reduce it, and outcome of strategy implementation.  In OMMC, the time allotted for elective operations is from 7 am to 5 pm, Monday to Friday.  The last case should be finished by about 5 pm. 

 

Methods

 

A review of records in the operating room was done to determine and to monitor the incidence and causes of sudden cancellation of scheduled elective operations in OMMC Surgery from 2001 to June of 2003.  For the purpose of this paper, focus was then made on the incidence and causes of “over the cut-off time”.  Data prior to intervention and data during and after the intervention were gathered and analyzed as to changes, whether improvement was effected or not.

 

A review of records of OMMC Surgery from 2001 to June, 2003 was also done to determine the nature of strategies adopted to reduce the incidence of “over the cut-off time” as a cause of sudden cancellation of scheduled elective operations as well as factors that contributed and hindered reduction in incidence.  Through a focused group discussion among the staff in July, 2003, a consensus was made on what strategies and factors brought about any reduction, if any, and what still needed to be done.

 

Results 

 

Table 1 shows the incidence of sudden cancellation of scheduled elective cases in 2001, 2002, and January to June, 2003.

 

Table 1. Incidence of sudden cancellation of scheduled elective cases.

 

 

2001

2002

2003 (Jan – June)

Total no. of elective operations

890

913

423

Total no. of sudden cancellation of operations

108

85

25

% of sudden cancellation

108/998 (10.8%)

85/998 (8.5%)

25/448 (5.6%)

 

Table 2 shows the various causes of cancellation in 2001, 2002, and January to June, 2003.  “Over the cut-off time” was the most common non-patient-health-related cause.  The baseline relative incidence in 2001 was 26% (19/74).  With progressive reduction in the overall incidence and other avoidable specific causes of sudden cancellations, the relative incidence of  “over the cut-off time” remained to be the major cause with an incidence of 33% (21/64) in 2002 and 48%(11/23) by mid-2003.  In terms of absolute incidence in number, however, it had decreased, from 19 and 21 cases in 2001 and 2002 to 11 cases in 2003.

 

Table 2. Causes of sudden cancellation of scheduled elective operations.

 

Causes of cancellation

2001

2002

2003 (Jan – June)

Health-related causes

 

 

 

Hypertensive

15

5

0

Low protime

4

0

0

Low sodium

1

0

1

Fever

5

2

1

Tachycardia/Heart problem

2

2

0

Pneumonia

1

4

0

Wheezes/asthma

1

4

0

Ischemia

2

0

0

Hypotension

1

0

0

Anemia

2

3

0

BPH

0

1

0

 

34

21

2

 

 

 

 

Non-health related causes

 

 

 

NO C-P clearance

9

1

0

No endo clearance

2

0

0

No pedia clearance

2

4

0

Cut-off/estimated time of OR not met

19

21

11

Did not arrive

8

17

0

Ate

2

3

1

No OR packs

9

4

0

OR needs not available

4

2

5

No frozen section

3

0

0

Refused operation

1

1

1

No consent for OR

0

0

1

No sputum AFB

4

0

0

No lab work-up

3

1

0

No blood

2

1

0

No IM referral

0

1

0

No OR nurse

0

0

1

No CO2 absorber

0

0

1

Cancelled by consultants

1

1

0

Consultant did not arrive

5

7

2

 

74

64

23

 

108

85

25

 

 

 Table 3 shows the major factors leading to “over the cut-off time” as a cause of sudden cancellation of scheduled elective operations from 2001 to mid-2003 and their year by year status, qualitatively arrived by consensus of the members of the operating team (surgeons, anesthesiologists, and nurses).

 

Table 3. Major factors leading to “over the cut-off time.”

 

Factors

2001

(19)

2002

(21)

2003

(11)

No overall planning and foresight

No concern for sudden cancellation

No consideration/guide on average duration of

Surgeon’s operation

Anesthesiologist’s preparation

Nurse’s preparation

Totally

none

Present

Present

Refined

Wrong estimation of surgeon’s operating time

Worst

Better

Better

Refined

No cooperation among surgeons, anesthesiologists, and nurses

Little

More

More

Bumping off elective cases by stat operations

           Trauma

           Cesarian section

Frequent

+

+++

Frequent

+

+++

Less

+

++

Tardiness of operating team members

Worst

Better

Better

Inadequacy of OR nurses

Worst

Worst

Better

Inadequacy of operating rooms for stat cases

Worst

Worst

Better

No operating materials (OR packs, others)

Worst

Worst

Better

 

 

Table 4 shows the specific strategies and procedures adopted to reduce incidence of  “over the cut-off time” as a cause of sudden cancellation of scheduled elective operations.

 

Table 4. Strategies and procedures to reduce incidence of “over the cut-off time.”

 

Causes

Strategies and Procedures

No overall planning and foresight

No concern for sudden cancellation

No consideration/guide on average duration of

Surgeon’s operation

Anesthesiologist’s preparation

Nurse’s preparation

Memorandum of concern

Memorandum on planning

Formulation of a guide in estimating duration of operation, allotment for surgeons, anesthesiologists, and nurses (2002) (see Appendix 1)

Wrong estimation of surgeon’s operating time

Review of estimation during the regular Tuesday preoperative conference (2002)

No cooperation among surgeons, anesthesiologists, and nurses

Joint surgeon-anesthesiologist-nurse agreement and commitment to avoid cancellation of whatever cause

Activities to improve camaraderie

Regular meeting to monitor and to control  (2002)

Bumping off elective cases by stat operations

           Trauma

           Cesarian section

Joint-nurse-surgeon-anesthesiology-hospital administration cooperation and resolution on NO bumping off of elective cases by stat operations (2003)

Tardiness of operating team members

Memorandum, monitor, and control (2002)

Inadequacy of OR nurses

Support from hospital administration

Recruitment of a Department of Surgery volunteer nurse (2003)

Inadequacy of operating rooms for stat cases

Revision of system and procedures to provide operating rooms for stat cases (2003)

No operating materials (OR packs, others)

Contingency fund created by Department of Surgery (2002)

 

Discussion

 

Sudden cancellation rate of elective operations is a parameter of quality patient care and quality management system.  A cancellation is a potential cause of patients’ and relatives’ dissatisfaction because of the anxiety, inconvenience, and expense usually associated with it.  A significant cancellation rate is also a sign of inefficiency on the part of the surgical team (surgeon, anesthesiologist, and operating room staff).

 

The administration of the Department of Surgery, Department of Anesthesia, and Operating Room of the Ospital ng Maynila Medical Center (OMMC) took  cognizant of the importance of avoiding cancellation of elective operations late 2001 and did an action research.

 

From 2001 to June, 2003, the overall cancellation rate had progressively decreased from 10% to 6%.  The incidence of “over the cut-off time” as a cause of cancellation had likewise reduced from 19 and 21 cases in 2001 and 2002 to 11 cases in 2003.

 

Through a focused group discussion among the staff in July, 2003, a consensus was made on what factors brought about the reduction of cancellation secondary to “over the cut-off time” and what still needed to be done.

 

The consensus was that the following general factors contributed to the reduction of the overall cancellation rate as well as “over the cut-off time” as a cause :

 

  1. Willingness and commitment
  2. Effective strategies
  3. Continual monitoring

 

The departmental quality improvement program on sudden cancellation of elective operations started with an awareness of the staff on its importance followed by a willingness and commitment to avoid and reduce the incidence and causes.  Staff willingness and commitment was considered the prime factor that contributed to the reduction of the cancellation rate.  First, it started the ball rolling.  Second, it created an empowered staff who would maximally contribute to the attainment of the quality objective as well as look for innovative ways to avoid and reduce the cancellation rate, on top of a formulated set of strategies and procedures.  For examples, the contingency fund and presence of a volunteer nurse were products of resourcefulness.

 

As to strategies, effectiveness was due to the presence of a systematic, comprehensive and innovative problem-solving method with as clear-cut preventive and resolution procedures as possible (see Table 4), multisectoral cooperation (see Table 4), constant rallying of commitment of the operating team, and vigilance and continual improvement.

 

The weekly and monthly reporting of cancellations, every Tuesday, through the Joint Surgery-Anesthesiology Preoperative and Postoperative Conference and every first Thursday of the month, through the Department’s Monthly Service Performance Report, contributed to vigilance, continual improvement, and constant rallying of commitment.  As of July, 2003, after the consensus meeting of the staff, the only acceptable causes of “over the cut-off time” are now limited to undue intraoperative findings and difficulty in the operative procedure.

 

The consensus on what is still needed to be done is to keep on reducing the sudden cancellation rate until a zero incidence is reached.  Strategies that will be used will be vigilance and continual willingness and commitment to use innovative methods until a zero incidence target is reached.

 

 

 

References


1. Wildner M, Bulstrode C, Spivey J, Carr A, Nugent I. Avoidable causes of cancellation in elective orthopaedic surgery. Health Trends 991;23(3):115-6.

 

2. Koppada B, Pena M, Joshi A.  Cancellation in elective orthopaedic surgery.  Health Trends 1991;23(3):114-5.
 
3. Thomson PJ. Cancelled operations. A current problem in oral and maxillofacial surgery.  Br Dent J 1991 Oct 19;171(8):244-5.

4. Mangan JL, Walsh C, Kernohan WG, Murphy JS, Mollan RA, McMillen R, Beverland DE.  Total joint replacement: implication of cancelled operations for hospital costs and waiting list management.  Qual Health Care 1992 Mar;1(1):34-7.

5. Bruwer AM.  Monitoring the cost-effective use of operating theatres. Nurs RSA 1994 Mar;9(3):21-3.

 

6.Reed M, Wright S, Armitage F.  Nurse-led general surgical pre-operative assessment clinic.  J R Coll Surg Edinb 1997 Oct;42(5):310-3.

 

7. Tait AR, Voepel-Lewis T, Munro HM, Gutstein HB, Reynolds PI.  Cancellation of pediatric outpatient surgery: economic and emotional implications for patients and their families.  J Clin Anesth 1997 May;9(3):213-9.

8. Asimakopoulos G, Harrison R, Magnussen PA.  Pre-admission clinic in an orthopaedic department: evaluation over a 6-month period.  J R Coll Surg Edinb 1998 Jun;43(3):178-81.
 

9. Vinukondaiah K, Ananthakrishnan N, Ravishankar M. Audit of operation theatre utilization in general surgery.  Natl Med J India 2000 May-Jun;13(3):118-21.

10. Ivarsson B, Kimblad PO, Sjoberg T, Larsson S.  Patient reactions to cancelled or postponed heart operations.  J Nurs Manag 2002 Mar;10(2):75-81.

 

 

Appendix 1

 

Guide on operating time allotted for each type of operative procedure.

 

Operative Procedures

Hours allotted for operating team

Excision

2

Cheiloplasty

2

Herniotomy/herniorrhaphy

2

Hemorrhoidectomy

2

Fistulectomy

2

 

 

Mastectomy

3

Thyroidectomy

3

Cholecystectomy

3

Colostomy/closure of colostomy

3

Nephrectomy

3

Prostatectomy

3

Open reduction and internal fixation

3

Skin grafting

3

 

 

Cholecystectomy with IOC

4

Formal neck dissection

4

Gastrectomy

4

Colectomy

4

Anterior resection

4

Thoracotomy

4

 

 

Abdominoperineal resection

5

Pull-through operations

5

 

 

Pancreaticoduodenectomy

8

Esophagectomy

8

 

 

Craniotomy

8