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.
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.
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.
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.
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:
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:
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
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.
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
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
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.