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 income resulting 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.
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 – 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 |
|