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Sudden cancellation of scheduled elective inpatient operations in a government hospital - a quality service concern and strategies for reduction

 

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 of Ospital ng Maynila Medical Center (OMMC Surgery) took concern for this parameter.  This paper reports on the incidence and causes of sudden cancellation done on day of scheduled elective operations in OMMC Surgery and the outcome after improvement measures were instituted.  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 causes can be classified into health-related and non-health-related ones.  Hypertension was the most common health-related cause for cancellation whereas caught by the cut-off of allotted operating time at  5 pm for elective operations was the most common non-health-related cause.  Various strategies were utilized.  In the end, the general factors which contributed to reduction of cancellations 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 department considers acceptable only those causes due to health-related reasons such as undue perioperative development of adverse medical events and prolongation of operating time because of undue intraoperative findings and difficulty in operative procedure.  The consensus of the staff on what remains to be done was to keep on reducing sudden cancellation rate until a zero incidence is reached.  

 

 

Introduction

 

Elective or non-urgent surgeries or operations can be done on an outpatient or inpatient basis.  Patients who are to undergo elective operation under inpatient basis are usually admitted to the hospital a day or two before the scheduled date of operation.  A common problem occurring after admission to the hospital is a sudden cancellation of the scheduled operation.  Sudden cancellation means the cancellation was done on the day of the scheduled operation.  The causes of sudden cancellation can vary from being health-related or not and acceptable or not acceptable based on quality standards (1-10).  Cancellation of elective operations is a quality service concern that has been addressed formally in hospitals abroad (1-10).  In the Philippines, this is yet to be addressed formally.  The authors have not come across any publication on the topic.

 

Late 2001, the administration of the Department of Surgery of Ospital ng Maynila Medical Center (OMMC Surgery) took cognizant of the importance of avoiding sudden cancellation of scheduled elective operations.  It gathered and analyzed the 2001 data and early 2002, it formulated strategies to avoid sudden cancellation of scheduled elective operations and to keep the incidence to not more than 10%.

 

This paper reports on the incidence and causes of sudden cancellation of scheduled elective operations in OMMC Surgery and the outcome after improvement measures were instituted.

 

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.  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 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 causes of cancellation in 2001, 2002, and January to June, 2003.

 

Table 2. Causes of cancellation.

 

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 incidence of cancellation in pediatric and adult patients.  Majority of the cancellations affected adult patients.

 

Table 3. Incidence of cancellation by age.

 

 

2001

2002

2003 (Jan – June)

Pediatrics

16

17

3

Adults

92 (85%)

68 (80%)

22 (88%)

Total

108

85

25

 

 

Table 4 shows the specific strategies and procedures adopted for each cause of cancellation.

 

Table 4. Strategies and procedures for each cause of cancellation.

 

Causes of cancellation

2001

2002

2003 (Jan – Jun)

Strategies and procedures adopted

Health-related causes

 

 

 

 

Hypertension

15

5

0

Joint surgery-anesthesiology’s cooperation – a specific protocol was set up on how to avoid hypertension as a cause of cancellation (2002)

Low protime

4

0

0

Joint surgery-anesthesiology’s preop patient evaluation and preparation

All patients scheduled for elective operation must as much as possible have a physical status of I or II at most.

Open communication between surgeons and anesthesiologists on what to do if there is sudden undue development to avoid unnecessary cancellation

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

Benign Prostatic Hypertrophy

0

1

0

Surgeon’s responsibility for more thorough preop evaluation and preparation

 

34

21

2

 

Non-health related causes

 

 

 

 

NO cardiopulmonary clearance

9

1

0

Joint surgery-anesthesiology-internal medicine-administration agreement on NO routine cardiopulmonary clearance starting late 2001

No endocrine clearance

2

0

0

Joint surgery-anesthesiology-internal medicine-administration agreement on NO routine endocrine clearance starting late 2001

No pediatric clearance

2

4

0

Joint surgery-anesthesiology-pediatrics-administration agreement on NO routine pediatric clearance starting 2002

Cut-off/estimated time of OR not met (7am to 5 pm)

19

21

11

Formulation of a guide in estimating duration of operation

Joint nurse-surgeon-anesthesiology-administration cooperation and resolution on no bumping off of elective cases by emergency operations and stat cesarean section 

Avoidance of tardiness of operating team members (monitoring through a logbook)

Adequacy of OR nurses (Department of Surgery contributed an OR nurse to the hospital pool of staff).

Adequacy of OR rooms for emergency cases

Did not arrive

8

17

0

Surgeon’s responsibility to avoid (use of constant reminders, preschedule call or notice, and deadline for arrival in hospital for admission – 12:00 noon day prior to scheduled operation)

Ate

2

3

1

Joint ward nurse-surgeon-anesthesiologist’s effort to remind patient

 

 

 

 

 

No OR packs

9

4

0

Joint OR nurse-surgeon-administration cooperation to solve problem

OR needs not available

4

2

5

Joint surgeon-anesthesiologist’s responsibility and cooperation

Creation of Department of Surgery’s funds and stocks

No frozen section

3

0

0

Joint Pathology-Surgery cooperation

Refused operation

1

1

1

Surgeon’s responsibility to ensure informed consent or informed refusal is decided prior to scheduling

No consent for OR

0

0

1

Surgeon’s responsibility

No sputum AFB

4

0

0

Coordination between surgeon-anesthesiologist preop

No lab work-up

3

1

0

No blood

2

1

0

Surgeon’s responsibility to ensure blood is available one day prior to scheduled operation

No IM referral

0

1

0

Surgeon’s responsibility to ensure referral to specialist for evaluation, if indicated

No OR nurse

0

0

1

Joint OR nurse-hospital administration’s responsibility and cooperation

No CO2 absorber

0

0

1

Joint OR nurse-anesthesiologist’s responsibility and cooperation

Cancelled by consultants

1

1

0

Reminder to consultants on their participation in reducing cancellation rate

Consultant did not arrive

5

7

2

Reminder to consultants on their participation in reducing cancellation rate

 

74

64

23

 

 

108

85

25

 

 

 

Late 2001, the administration of OMMC Surgery took cognizant of the importance of avoiding sudden cancellation of scheduled elective operations.  It gathered the 2001 data that showed about10% cancellation rate which it considered should at least be maintained, if not improved.

 

March, 2002, two memorandi (m02-55 and m02-56) were issued by the

department chairperson that pertained to the problem of sudden cancellation. 

The first memorandum was entitled: Cancellations of Elective Operations – An

Analysis and Proposed Strategies.  The second memorandum was entitled:

Specific Measures to Avoid Cancellation of Elective Operations.  

 

The first memorandum initially tried to create awareness on the importance of reducing cancellation rate of elective operations.  It then proceeded to a description of the system flow of cancellation of elective operations, then causes, and lastly, strategies on how to avoid (see Appendix 1)

 

The second memorandum reinforced the first memorandum by adding more specific measures together with a monitoring system (see Appendix 2).

 

From April, 2002 up to the time of this report, every Tuesday, during the Surgery-Anesthesia Conference, essentially, a preoperative and postoperative conference, sudden cancellation of scheduled elective operations was constantly monitored, if present, discussed as to cause and measures for avoidance.

 

 

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 OMMC Surgery took cognizant of the importance of avoiding cancellation of elective operations late 2001.

 

From 2001 to June, 2003, the cancellation rate had progressively decreased from 10% to 6%.  

 

Through a focused group discussion among the staff in July, 2003, a consensus was made on what factors brought about the reduction and what still needed to be done.

 

The consensus was that the following general factors contributed to the reduction of the cancellation rate:

 

  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 surgical residents were able to reduce the causes of absence of OR packs and materials, patients’ eating meals, extended estimated operating time, patient not arriving, etc through ways and means that were not usually included in the formulated procedures, such as persuasion, constant reminders, and 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 Appendices 1 and 2), multisectoral cooperation (see Table 3), constant rallying of commitment from internal and external staff, 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 cancellations are now limited to health-related reasons, specifically, to undue development of adverse medical events prior to and during induction of anesthesia and during the operation and prolongation of operating time because of 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

 

Essential content of m02-55 memorandum

Cancellations of Elective Operations – An  Analysis and Proposed Strategies

 

 

Reasons for the memo:

 

“For the past 3 months, our cancellation rate of elective operation is going beyond our target.  For January, the rate was 15%. During the past 4 weeks, during the weekly postop conference, the figure was averaging 4 per week.”

 

“The urgency is that a high cancellation rate is a sign of poor quality medical care and poor quality management system.  Anytime, we may receive a formal complaint on this issue.”

 

Appeal to consultants and residents:

 

To the consultants:

 

  1. Avoid tardiness so as NOT to delay the schedule of your operation.  The delay of your case may cause cancellation of the next case.
  2. Assist residents in completing the operation on time.
  3. Assist residents in avoiding cancellation due to adverse medical events.

 

To the residents:

 

“I need your cooperation in all areas because you are in the front line.”

 

 

Cancellations of Elective Operations in OMMC Department of Surgery

An Analysis and Proposed Strategies

 

I. Definition

 

Cancellation of elective operations -

 

There is a completed schedule of elective operations in a particular day.  For one reason or another, operation/s listed in the schedule is/are cancelled and is/are NOT done in that particular day.

 

II. Importance of monitoring cancellation rate of elective operations

 

Cancellation rate of elective operations is a parameter of quality patient care and quality management system.

           

A cancellation is a potential cause of patient dissatisfaction because of the discomfort, inconvenience, anxiety, and expense usually associated with it.

 

A significant cancellation rate is a sign of inefficiency on the part of the surgical team (surgeon, anesthesiologist, and operating room staff).

 

 

III. System flow associated with cancellation of elective operations

 

Department puts up a list of patients for elective operations for a particular day

 

Department books or submits list to operating room

 

Operations are performed /NOT PERFORMED (CANCELLATIONS)

 

 

IV. Potential Causes of Cancellations of Elective Operations

 

Undue Development

            Patient Factor

            Nonpatient Factor

                        Surgeon Factor

                        Anesthesia Factor

                        Nurse Factor

                        Operating Room Factor

                        Administration Factor

 

            Patient Factor

                        Adverse medical events prior to or during induction of anesthesia

                        Others

 

            Nonpatient Factor

                        Prolonged operations in other patients

                        Tardiness of operating team

                        Bumped off by emergency cases  

                        Operating Room Factor

                                    Lack of personnel

                                    Lack of operating materials

                        Administration Factor

                                    Sudden directive to cancel operations      

                        Others

 

 

V. Proactive Measures to Minimize Cancellations of Elective Operations

 

Target: not more than 10% per annum

              

A. Day before the operation

 

1. Measures to avoid adverse medical events

            Take note of conditions that usually cause cancellations and avoid

hypertension

                        pulmonary problem in children

                        increase pulse rate

 

2. Measures to avoid lack of operating materials

            Advice patients properly to secure operating materials on time

                        Do not schedule patients with lack of operating materials

            Find ways to help indigent patients secure operating materials on time

 

 

3. Reliable schedule of elective operations

 

Include only “sure” cases

Make correct estimation of duration for each case

                        Use guides

 

 

B. Day of operation

 

1. No tardiness (surgeons –residents/consultants; anesthesiologists; nurses)

            Log-book for cases

 

2. Measures to avoid being bumped off by emergency cases

            Work out with OR Committee

 

3. Measures to tackle lack of personnel

            Innovative way

 

4. Measures to tackle lack of operating materials

            Prevent day before operation

 

5. Measures to prevent sudden administrative order to cancel operations

            Make administration aware of importance of avoiding cancellation

 

 

 

VI. Definite strategies in reducing cancellation rates

 

A. Creation of awareness of importance of cancellation rate of elective operations

 

B. Establishment of monitoring logbook 

 

            Schedule

            When operation started

            When operation ended

 

                        Causes of delay

 

            Cancellation

                        Causes of cancellation

 

C. Decentralization of responsibilities from Chief Resident

            Team Captain (not Chief Resident) responsible

                        For ensuring noncancellation of elective operations

                                    For scheduling

                                    For ensuring operative materials are available

                                    For ensuring there is adequate personnel

 

D. Negotiation with Operating Room Committee on a policy NOT to bump off elective operations by emergency cases

 

E. Establishment of 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

 

  

 

 

Appendix 2

 

Essential content of m02-56 memorandum

Specific Measures to Avoid Cancellation of Elective Operations

 


Effective April 1, 2002, the following measures will be tried to avoid cancellation of elective operations.

 

  1. There will a strict monitoring of the elective operations in terms of time started, time ended, causes of delay, and causes of cancellation. (A form is provided.)

 

  1. A guide on time allotment for elective operation will be used.  The time allotment takes into consideration factors from surgeon, anesthesiologists, and OR staff.  (A guide is provided).

 

  1. Monday will the operating day of Team I, Wednesday, Team II, and Friday, Team III.  The captain of each team will be responsible for all the elective operations taking place in his assigned operating day.  Specifically, he will see to it that NO delays and cancellations take place or kept to a minimum.  Each team captain will make a report on this matter during the weekly Preop and Postop Conference.

 

  1. The role of the Chief Resident  on operations will just be to oversee the implementation of the above policies by the team captains.  Even scheduling of elective operations on a particular day will be done by the team captains.