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
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.
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.
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) |
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 :
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
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Carr A, Nugent I. Avoidable causes of cancellation in elective orthopaedic
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DE. Total joint replacement:
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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 |