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

 

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

Chairperson

Department of Surgery

Ospital ng Maynila Medical Center

 

July, 2003

 

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.Cancellation of elective operations is a quality service concern that should be addressed by all hospital administrators.

 

In the Philippines, from personal experience and from communication with surgical colleagues, sudden cancellation of elective operations is more common in government than in private hospitals and more common among charity (non-paying) than among private patients.Among private patients, most likely, the only known cause for cancellation is the unexpected development of adverse medical events that prompt the surgical team to cancel the operation.For the charity patients especially in the government hospitals, beside the adverse medical events, there are a lot of other reasons, majority of which are usually not health-related and which by quality patient care standards, are not acceptable.Examples of the latter are no surgical packs, no operating instruments, no surgical materials, patient not following instruction on fasting prior to operation, being bumped off by emergency operations, being bumped off by emergency cesarean section, being bumped off by private operations (in government hospitals with charity and pay sections), insufficient operating personnel, etc.

 

Sudden cancellation of scheduled elective operations has the most dramatic negative effect on the anxiety of the waiting patient and his relatives.Other negative effects are the inconvenience, additional expense, and lost incomeresulting from the cancellation and delay of the operations.

 

As mentioned, sudden cancellation of scheduled elective inpatient operations is a quality service concern that should be addressed by all hospital administrators.Abroad, there are publications and discussions on this issue.Locally, there are none, which may mean, one, there is no problem, which is unlikely; two, it has been addressed but not publicized; and three, it has never been addressed at all.The author believes the problem exists.The extent of the problem and the experience of the different hospitals are not known because of absence of documentation and publication.The author believes that it is high time that the local hospital administrators look into this problem.

 

The OMMC Surgery Experience

 

Late 2001, the administration of the Department of Surgery of Ospital ng Maynila Medical Center (OMMC Surgery) took cognizant of the importance of 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%.

 

From 2001 to June, 2003, there was a progressive decrease in cancellation rate from 10% in 2001 to 8% in 2002 to 6% in mid-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 (see table below).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.††

The following table shows the specific strategies and procedures adopted for each cause of cancellation.

 

Causes of cancellation

2001

2002

2003 (Jan Ė Jun)

Strategies and procedures adopted

Health-related causes

 

 

 

 

Hypertension

15

5

0

Joint surgery-anesthesiologyís cooperation Ė a specific protocol was set up on how to avoid hypertension as a cause of cancellation (2002)

Low protime

4

0

0

Joint surgery-anesthesiologyís 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

Surgeonís 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

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

Ate

2

3

1

Joint ward nurse-surgeon-anesthesiologistís 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-anesthesiologistís responsibility and cooperation

Creation of Department of Surgeryís funds and stocks

No frozen section

3

0

0

Joint Pathology-Surgery cooperation

Refused operation

1

1

1

Surgeonís responsibility to ensure informed consent or informed refusal is decided prior to scheduling

No consent for OR

0

0

1

Surgeonís responsibility

No sputum AFB

4

0

0

Coordination between surgeon-anesthesiologist preop

No lab work-up

3

1

0

No blood

2

1

0

Surgeonís responsibility to ensure blood is available one day prior to scheduled operation

No IM referral

0

1

0

Surgeonís responsibility to ensure referral to specialist for evaluation, if indicated

No OR nurse

0

0

1

Joint OR nurse-hospital administrationís responsibility and cooperation

No CO2 absorber

0

0

1

Joint OR nurse-anesthesiologistís 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