The Causes of Cancelled Elective
Surgery Roger Hand, M.D., Philip Levin, B.S., and Alex Stanziola, B.S. The Section of General Internal Chicago, Illinois 60612 We reviewed in
causes
Medicine, Department
of Medicine,
of cancelled elective surgery
University
of Illinois at
Chicago College
of
Medicine,
cancellation we examined the operating room schedules and records and the charts of inpatients from a community hospital whose surgery was cancelled.
community hospital. Over a 6-month period, during which 4100 operating room procedures were completed, cancellations occurred in 13% of cases scheduled for outpatient surgery, 9% of cases scheduled for admission the same day, and 17% of cases scheduled for inpatient surgery. Dental procedures had significantly higher rates of cancellation among outpatient procedures, and cardiovascular surgical procedures had significantly higher rates among inpatient procedures. Chart review of cancelled inpaa
METHODS The
patients whose elective surgery 6-month period from July 1, 1987 to December 31, 1987 were obtained from the published daily operating room schedules or from records kept by the same-day surgery department. For purposes of this study, an elective case was defined as one scheduled sufficiently in advance to be included on the typed operating room schedule, which meant the case had to be phoned in before 2:00 p.m. on the day prior to surgery. For inpatients, we then went on to examine the hospital charts to determine the reason for cancellation. Detailed reasons for cancellations were not available for same-day surgery patients, and was
tient cases showed 43% due to administrative reasons with unsigned consent the most common cause. Medical factors were responsible in the remaining cases, with reevaluation of the surgical condition and associated medical illnesses equally common as reasons in this category. Appreciation of the usual reasons for cancellation can improve utilization by permitting administrators and providers to anticipate those cases in which problems might arise so that additional attention can be paid to them.
Cancellation of scheduled elective surgery can be wasteful for a hospital. At the worst, the operating room and its staff may be idle during a peak daytime period. At best, administrative personnel must devote time to rearranging schedules and there is the potential for inconvenience to staff and patients and their families. Although cancellation is not a major cost to hospitals (1,2), it is an easily avoidable one if correctable factors can be identified. Administrative matters relating to scheduling are one example; recent articles have addressed scheduling techniques aimed at reducing cancellations (3,4) and the literature on scheduling has been reviewed (5). Other factors that lead to cancellation have not been as thoroughly addressed. In order to learn more of the factors leading to
names
of all
cancelled over
a
they were grouped as cancelled by patient, cancelled by physician, no-show, insurance problem, or rescheduled. Records for ophthalmological outpatient surgery were maintained separately and were not available for analysis. To prevent unnecessary bias in the results, we excluded from analysis four inpatient cancellations of ophthalmologic surgery (of a total of 145 inpatient cancelled cases). Obstetrical cases were also excluded from the analysis. These cases were frequently pencilled into the schedule after publication, and it was not possible to distinguish the elective from emergency cases. Also 43 cases where an OR was held open on standby for a non-OR procedure such as coronary angioplasty were excluded from further analysis.
RESULTS
*
To whom requests for reprints should be addressed at Department of Medicine m/c 787, 840 S. Wood, Chicago, IL 60612 Research supported in part by an institutional grant from Department of Medicine, the University of Illinois at Chicago College of Medicine.
The setting was a 400-bed community teaching hospital in Chicago. Over 100 providers used the operating 2
Downloaded from ajm.sagepub.com at FUDAN UNIV LIB on May 5, 2015
3 and were from the following specialties: cardiology, cardiovascular surgery, dentistry, general surgery, gynecology, neurosurgery, orthopedics, otolaryngology, plastic surgery, podiatry, pulmonary medicine, and urology. The operating room suite comprised 11 rooms, one of which always remained empty for potential use for an emergency trauma case. Cases of all complexity up to and including open heart surgery were done routinely. During the 6-month study period, a total of 4100 operating room procedures were done. Of these, 2992 were considered elective (exclusive of ophthamology and obstetric cases). There were 1971 outpatient cases, 337 patients admitted the same day as their surgery, and 684 inpatient cases. The cancelled cases in each of these categories broken down by surgical specialties are presented in Table 1. There were 287 cancelled outpatient cases accounting for 13% of all scheduled outpatient cases. Cancellations of cases admitted the day of surgery were 33, or 9%, of those scheduled. Cancellations of inpatient cases were 141, or 17%, of those scheduled. For inpatient surgery, cardiovascular surgery had significantly more and gynecology and orthopedics significantly fewer cancellations than the total. For outpatient surgery, dentistry had significantly more cancellations, and otolaryngology, significantly fewer cancellations than the total. None of the other percentages differed significantly in these columns or in the column for same-day admissions. Of 287 outpatient surgeries that were cancelled (Table 2), 172 or nearly two-thirds were cancelled by the physician or patient. In 75 instances, the cases were rescheduled for a later date. In 27 cases, medical insurance problems caused the cancellation. In only
Table 2
rooms
Table 1 Cancelled Cases
*
by Surgical Specialty
Significantly different from the column total (p < 0.05).
Cancellation of
*
Includes 29
cases
Outpatient Surgery
rescheduled for
inpatient surgery.
Table 3 Patient and Administrative Factors
Cancellation of Inpatient
Leading
to
Surgery
13 cases did the patient not appear at the scheduled time. We were unable to review in detail the 33 cancellations among the same-day admissions. They were never admitted and therefore there was no record to review. Charts were unavailable for 21 out of the 141 inpatients whose procedures were cancelled. In some of these cases, it was because the information from the OR schedule was incomplete, i.e., no first name or mispelled last name. In other cases, the patient was scheduled for transfer from another hospital when the cancellation was made. Therefore the patient was never admitted. Of the 120 inpatient cancellations that we reviewed, 52 were attributed to patient or administrative factors (Table 3). The most common patient factor was unsigned consent. Patients scheduled for aortocoronary bypass were responsible for 10 of 30 cancellations. Administrative factors were infrequent. On three occasions, an operating room could not be made available the same day. On three occasions, the surgeon was unavailable (twice due to illness, once due to inclement weather precluding travel). On one occa-
Downloaded from ajm.sagepub.com at FUDAN UNIV LIB on May 5, 2015
4 was the cause when a CAT unavailable for a stereotaxic brain biopsy. Twice the patient was operated on 1 or 2 days earlier and the name not removed from the schedule, and once the patient was scheduled in error. On seven occasions, a case was rescheduled for 1 or more days later and no reason was documented on the chart. There were 68 cancellations for medical reasons (Table 4). In 28 cases, the underlying surgical condition was responsible, of which 12 were rescheduled and 16 were not. Of the 12 cases in which surgery was rescheduled, in four the primary surgeon requested an additional consultation to clarify a particular point before going on to surgery; in six, the evaluation raised a question which required additional testing prior to surgery; and in two the surgeon decided to delay the surgery to a more appropriate point in the patient’s course of illness. Of the 16 cases that were not rescheduled, all had a preoperative diagnostic procedure which showed the planned surgery was inappropriate. In eight cases, the procedure changed the diagnosis. The remaining eight cases had coronary artery disease. In these patients, all of whom were admitted with severe symptomatic disease, the preoperative evaluation included inpatient cardiac catheterization and angiocardiography. Final review of this information was necessarily as close to the planned surgery as possible, and in these eight cases the review showed lesions unsuitable for surgery. Twenty-eight cases were cancelled because of underlying medical conditions, of which 25 were eventually rescheduled. In seven cases the condition remitted without surgery. In three of these, acute uricleared spontaneously without nary retention urological procedures. In five cases the patient died before surgery. One of these was a patient transferred from a nursing home in coma who was scheduled for debridement of a pre-existing decubitus ulcer; one, a patient with severe coronary, cerebral and peripheral vascular disease, died of sepsis before a scheduled amputation of a gangrenous foot could be completed; one died of an unexpected cardiac arrhythmia before
sion, equipment failure scanner was
Table 4 Medical Factors Leading to Postponement Cancellation of Inpatient Surgery
or
Table 5
Twenty-eight Patients with Medical Causing Cancellation
scheduled
Conditions
laparotomy for a probable malignancy; and
two died of advanced head and neck
cancer before a scheduled palliative procedure. Of the 28 cases cancelled because of medical conditions (Table 5), eight were for pulmonary conditions and six of the eight were for acute conditions such as pneumonia and asthma. The other two were for poor
respiratory function secondary to chronic obstructive pulmonary disease. Seven were for renal conditions: three cases of urinary tract infections, two of poor renal function, one of severe dehydration, and one of hyponatremia. Five were for cardiac conditions: two cases of angina, two of severe hypertension, and one of supraventicular tachycardia. The remaining eight cases were distributed among five conditions, all of which were diagnosed or suspected from clinical evaluation. Twenty-five of the 28 were rescheduled. Of interest is one patient, scheduled for elective cholecystectomy, whose surgery was cancelled to control and evaluate elevated blood pressure. The patient was discharged to have this done in the outpatient setting and then was subsequently lost to follow-up with neither the hypertension nor the cholelithiasis receiving treatment.
DISCUSSION
here show that there are of cancelled surgery. Some are only minor disruptions to the operating room routine and staff. This would include almost all cancellations of The results
recurrent
presented
causes
Downloaded from ajm.sagepub.com at FUDAN UNIV LIB on May 5, 2015
5 surgery, since other cases on a waiting list often be scheduled. Of more concern are those that have the potential for causing an operating room or team to be idle. There are necessary causes-standby for surgery for complications of non-operating room procedures such as percutaneous transluminal coronary angioplasty is an example. Other causes might be reduceable, such as unsigned consent. Prospective utilization review might reduce some cancellations due to factors such as conditions remitting without surgery or preoperative evaluations showing surgical procedure not indicated. Cancellations because of medical conditions discovered during preoperative evaluation might be more difficult to eliminate. Of note is the high percentage of cardiac cases leading to cancellation. Of those cancelled for administrative reasons, the most common cause was unsigned consent. Many of these patients with acute complications of coronary artery disease were well until shortly before the admission and now find themselves suddenly extremely ill in a coronary care unit. On top of this, they are now asked to consent to open heart surgery by a surgeon whom they most likely have never met before. They often need more time to consult with family or to establish trust in the provider team. Cardiovascular surgical teams and hospital administrators, anticipating their problems, can provide additional educational and social services to ease the patients’ burden in making this difficult decision. Of those cardiac cases cancelled for medical factors, the most common cause was re-evaluation of the surgical lesion with subsequent decision to manage medically. Although the decision for or against surgery could theoretically be made at this hospital in a timely fashion so that only those whose diagnostic work-up showed a surgically correctable lesion would be scheduled, in practice a surgeon might be forced to make a &dquo;best-guess&dquo; before all the diagnostic information available in order to reserve the operating room time. This problem is most easily corrected by improving the administration of the operating room suite so that surgeons are not under pressure to call in reservations for cases before they have made the decision to oper-
same-day can
ate.
Dentistry had a high rate of cancellations for patient procedures. The hospital studied had a
out-
pro-
gram of dentistry for the handicapped. A number of their operating room procedures were on severely retarded children and adults, who were on many medications and had multiple medical problems. It was often difficult to have these patients and their families comply with the complex preoperative regimen for outpatient surgery. McLean and McLorie (6) have discussed the problem of compliance pre-operatively
outpatient surgery and provided data to show that preoperative telephone communication by a nurse practitioner will improve it. Agencies supporting such in
programs such
as
state
departments
of
public
aid
might keep in mind the difficulties in accomplishing even minor surgical procedures in these patients when setting up their guidelines for utilization.
Gynecology and orthopedics had lower rates of cancellations for inpatient procedures and otolaryngology a lower rate of cancellation for outpatient procedures. We could not identify a reason common to all three departments to explain the lower rate. The medical reasons for cancellation of inpatient surgery were largely pulmonary, cardiac and renal. Of note, however, are two of the patients in the miscellanous category with thrombocytopenia who had AIDS. These patients frequently have multiple medical and social problems related to their illness and administrators should anticipate the need for support services to make optimum their utilization of all hospital resources including surgery. There have been few previous studies on the reasons for cancellation of elective surgery. In a study that looked at cancellations for outpatient surgery, Knight (7) found that about half of the cancellations were for medical reasons and the majority of those were for cardiac problems and hypertension. Our data indicate that in inpatients, the overall percentage is lowerless then one quarter-and are more varied with a lower proportion being cardiac problems. The medical conditions were all clinically apparent from bedside examinations, and screening laboratory tests did not uncover previously unexpected conditions. Routine screening with laboratory tests has not been found useful in influencing pre-operative management (8, 9). However, selected testing in certain populations may be useful (10, 13). This may reduce cancellations if the testing is done prior to scheduling (14). The most
common
patient factor in cancellation
unsigned consent, responsible for over 15% of all cancellations. Applebaum and Roth (15) have studied patient refusals. Although they found refusal of surgery rare when compared with all types of refusals in a hospitalized population, there is no reason to suppose that the subset of surgical refusals had a different epidemiology than the group as a whole. In their study, once patients with mental illness are excluded, the most common causes of refusal were related to problems in communication to the patient. was
CONCLUSIONS This reasons
study why
shows that there are several common surgery is cancelled. Among inpatients,
Downloaded from ajm.sagepub.com at FUDAN UNIV LIB on May 5, 2015
6 failure to obtain consent was a frequent cause. Associated medical illness and re-evaluation of the surgical condition were almost as frequent. Among outpatients, a readily identifiable cause was inability of the patient to comply with complex preoperative instructions. The implications for quality of care and utilization are the following. 1. Those cases in which consent for the procedure might not be readily forthcoming can be anticipated. Our results suggest that patients hospitalized on an urgent basis with newly diagnosed coronary artery disease for whom bypass surgery is proposed might fall into this category. Operating room utilization could be improved if administration can provide extra educational and social services during the preoperative evaluation in an effort to make communications between patient and provider optimum. 2. Cancellations because of underlying medical condition can be kept to a minimum by thorough clinical evaluation and by timely use of indicated diagnostic tests for renal, cardiac, and pulmonary disease. In an environment where there is no pressure on the surgeon to schedule his OR cases prior to completion of this medical evaluation, improper utilization for this cause will also be reduced. 3. Cancellations because of re-evaluation of surgical conditions can also be kept at a minimum if surgeons are not under pressure to schedule their OR cases
Although direct effect
reduced cancellation rate has the most
utilization, it also affects quality in that the patient and patient’s family will be spared the uncertainty wrought by a change in plans and the inconvenience of prolonged or unnecessary hospitalization. on
References
JR, Leinhardt S. The cost and length of a hospital stay. Inquiry 1976;13:327-343. Herzlinger R. Can we control health care costs. Harvard Bus
1. Lave 2. 3. 4.
Rev 1978;56:102-110. Kelley M, Eastham A, Bowling G. Efficient OR scheduling: A study to decrease cancellation. AORN Journal 1986;41:565-567. Voss S. Ambulatory surgery scheduling: Assuring a smooth patient flow. AORN Journal 1986;43:1009-1012.
5.
Przasnyski Z. Operating
room scheduling: A literature review. AORN Journal 1986;44:67-79. 6. Mclean J, McLorie GA. Improving patient compliance in pedi-
7.
atric outpatient surgery. AORN Journal 1984;40:677-680. Knight C. Why elective surgery is cancelled. AORN Journal
1987;46:935-939. 8.
Kaplan EB, Sheiner LB, Boeckmann AJ et al. The usefulness of preoperative laboratory screening. JAMA 1985 ;253 :3576-
3581. 9. Johnston H, Knee-Ioli S, Butler TA et al. Are routine preoperative laboratory screening tests necessary to evaluate ambu10.
latory surgical patients. Surgery 1988;104:639-645. Ramsey G, Arvan DA, Stewart S et al. Do preoperative laboratory tests predict blood transfusion needs in cardiac operations ? J Thorac Cardiovasc 1983;85:564-569. RA, Kroener WF. Hypokalemia of various etiologies complicating elective surgical procedures. Am J Obstet Gynecol
11. Sack
1984;149:74-78. Reeling MM. Value of the preoperative history as an indicator of hemostatic disorders. Ann Surg 1984;200:648-
12. Berzotta AP,
early. 4. Identification of
patients who might have diffiwith culty complying preoperative instructions-in this study, retarded individuals undergoing dental procedures-can lead to measures to increase compliance such as preoperative telephone communication by a nurse
a
practitioner.
652. 13. 14.
Qalazka SS. Preoperative evaluation of the elderly surgical patient. J Family Practice 1988;25:622-632. Carel RS, Rahan E, Hart J et al. Preadmission testing in elective surgery -improving the process. Israel J Med Sci 1986; 22:564566.
15.
Appelbaum PS, Roth LB. Patients who refuse medical hospitals. JAMA 1983;250:1296-1301.
Downloaded from ajm.sagepub.com at FUDAN UNIV LIB on May 5, 2015
treatment in
Surgery Roger Hand, M.D., Philip Levin, B.S., and Alex Stanziola, B.S. The Section of General Internal Chicago, Illinois 60612 We reviewed in
causes
Medicine, Department
of Medicine,
of cancelled elective surgery
University
of Illinois at
Chicago College
of
Medicine,
cancellation we examined the operating room schedules and records and the charts of inpatients from a community hospital whose surgery was cancelled.
community hospital. Over a 6-month period, during which 4100 operating room procedures were completed, cancellations occurred in 13% of cases scheduled for outpatient surgery, 9% of cases scheduled for admission the same day, and 17% of cases scheduled for inpatient surgery. Dental procedures had significantly higher rates of cancellation among outpatient procedures, and cardiovascular surgical procedures had significantly higher rates among inpatient procedures. Chart review of cancelled inpaa
METHODS The
patients whose elective surgery 6-month period from July 1, 1987 to December 31, 1987 were obtained from the published daily operating room schedules or from records kept by the same-day surgery department. For purposes of this study, an elective case was defined as one scheduled sufficiently in advance to be included on the typed operating room schedule, which meant the case had to be phoned in before 2:00 p.m. on the day prior to surgery. For inpatients, we then went on to examine the hospital charts to determine the reason for cancellation. Detailed reasons for cancellations were not available for same-day surgery patients, and was
tient cases showed 43% due to administrative reasons with unsigned consent the most common cause. Medical factors were responsible in the remaining cases, with reevaluation of the surgical condition and associated medical illnesses equally common as reasons in this category. Appreciation of the usual reasons for cancellation can improve utilization by permitting administrators and providers to anticipate those cases in which problems might arise so that additional attention can be paid to them.
Cancellation of scheduled elective surgery can be wasteful for a hospital. At the worst, the operating room and its staff may be idle during a peak daytime period. At best, administrative personnel must devote time to rearranging schedules and there is the potential for inconvenience to staff and patients and their families. Although cancellation is not a major cost to hospitals (1,2), it is an easily avoidable one if correctable factors can be identified. Administrative matters relating to scheduling are one example; recent articles have addressed scheduling techniques aimed at reducing cancellations (3,4) and the literature on scheduling has been reviewed (5). Other factors that lead to cancellation have not been as thoroughly addressed. In order to learn more of the factors leading to
names
of all
cancelled over
a
they were grouped as cancelled by patient, cancelled by physician, no-show, insurance problem, or rescheduled. Records for ophthalmological outpatient surgery were maintained separately and were not available for analysis. To prevent unnecessary bias in the results, we excluded from analysis four inpatient cancellations of ophthalmologic surgery (of a total of 145 inpatient cancelled cases). Obstetrical cases were also excluded from the analysis. These cases were frequently pencilled into the schedule after publication, and it was not possible to distinguish the elective from emergency cases. Also 43 cases where an OR was held open on standby for a non-OR procedure such as coronary angioplasty were excluded from further analysis.
RESULTS
*
To whom requests for reprints should be addressed at Department of Medicine m/c 787, 840 S. Wood, Chicago, IL 60612 Research supported in part by an institutional grant from Department of Medicine, the University of Illinois at Chicago College of Medicine.
The setting was a 400-bed community teaching hospital in Chicago. Over 100 providers used the operating 2
Downloaded from ajm.sagepub.com at FUDAN UNIV LIB on May 5, 2015
3 and were from the following specialties: cardiology, cardiovascular surgery, dentistry, general surgery, gynecology, neurosurgery, orthopedics, otolaryngology, plastic surgery, podiatry, pulmonary medicine, and urology. The operating room suite comprised 11 rooms, one of which always remained empty for potential use for an emergency trauma case. Cases of all complexity up to and including open heart surgery were done routinely. During the 6-month study period, a total of 4100 operating room procedures were done. Of these, 2992 were considered elective (exclusive of ophthamology and obstetric cases). There were 1971 outpatient cases, 337 patients admitted the same day as their surgery, and 684 inpatient cases. The cancelled cases in each of these categories broken down by surgical specialties are presented in Table 1. There were 287 cancelled outpatient cases accounting for 13% of all scheduled outpatient cases. Cancellations of cases admitted the day of surgery were 33, or 9%, of those scheduled. Cancellations of inpatient cases were 141, or 17%, of those scheduled. For inpatient surgery, cardiovascular surgery had significantly more and gynecology and orthopedics significantly fewer cancellations than the total. For outpatient surgery, dentistry had significantly more cancellations, and otolaryngology, significantly fewer cancellations than the total. None of the other percentages differed significantly in these columns or in the column for same-day admissions. Of 287 outpatient surgeries that were cancelled (Table 2), 172 or nearly two-thirds were cancelled by the physician or patient. In 75 instances, the cases were rescheduled for a later date. In 27 cases, medical insurance problems caused the cancellation. In only
Table 2
rooms
Table 1 Cancelled Cases
*
by Surgical Specialty
Significantly different from the column total (p < 0.05).
Cancellation of
*
Includes 29
cases
Outpatient Surgery
rescheduled for
inpatient surgery.
Table 3 Patient and Administrative Factors
Cancellation of Inpatient
Leading
to
Surgery
13 cases did the patient not appear at the scheduled time. We were unable to review in detail the 33 cancellations among the same-day admissions. They were never admitted and therefore there was no record to review. Charts were unavailable for 21 out of the 141 inpatients whose procedures were cancelled. In some of these cases, it was because the information from the OR schedule was incomplete, i.e., no first name or mispelled last name. In other cases, the patient was scheduled for transfer from another hospital when the cancellation was made. Therefore the patient was never admitted. Of the 120 inpatient cancellations that we reviewed, 52 were attributed to patient or administrative factors (Table 3). The most common patient factor was unsigned consent. Patients scheduled for aortocoronary bypass were responsible for 10 of 30 cancellations. Administrative factors were infrequent. On three occasions, an operating room could not be made available the same day. On three occasions, the surgeon was unavailable (twice due to illness, once due to inclement weather precluding travel). On one occa-
Downloaded from ajm.sagepub.com at FUDAN UNIV LIB on May 5, 2015
4 was the cause when a CAT unavailable for a stereotaxic brain biopsy. Twice the patient was operated on 1 or 2 days earlier and the name not removed from the schedule, and once the patient was scheduled in error. On seven occasions, a case was rescheduled for 1 or more days later and no reason was documented on the chart. There were 68 cancellations for medical reasons (Table 4). In 28 cases, the underlying surgical condition was responsible, of which 12 were rescheduled and 16 were not. Of the 12 cases in which surgery was rescheduled, in four the primary surgeon requested an additional consultation to clarify a particular point before going on to surgery; in six, the evaluation raised a question which required additional testing prior to surgery; and in two the surgeon decided to delay the surgery to a more appropriate point in the patient’s course of illness. Of the 16 cases that were not rescheduled, all had a preoperative diagnostic procedure which showed the planned surgery was inappropriate. In eight cases, the procedure changed the diagnosis. The remaining eight cases had coronary artery disease. In these patients, all of whom were admitted with severe symptomatic disease, the preoperative evaluation included inpatient cardiac catheterization and angiocardiography. Final review of this information was necessarily as close to the planned surgery as possible, and in these eight cases the review showed lesions unsuitable for surgery. Twenty-eight cases were cancelled because of underlying medical conditions, of which 25 were eventually rescheduled. In seven cases the condition remitted without surgery. In three of these, acute uricleared spontaneously without nary retention urological procedures. In five cases the patient died before surgery. One of these was a patient transferred from a nursing home in coma who was scheduled for debridement of a pre-existing decubitus ulcer; one, a patient with severe coronary, cerebral and peripheral vascular disease, died of sepsis before a scheduled amputation of a gangrenous foot could be completed; one died of an unexpected cardiac arrhythmia before
sion, equipment failure scanner was
Table 4 Medical Factors Leading to Postponement Cancellation of Inpatient Surgery
or
Table 5
Twenty-eight Patients with Medical Causing Cancellation
scheduled
Conditions
laparotomy for a probable malignancy; and
two died of advanced head and neck
cancer before a scheduled palliative procedure. Of the 28 cases cancelled because of medical conditions (Table 5), eight were for pulmonary conditions and six of the eight were for acute conditions such as pneumonia and asthma. The other two were for poor
respiratory function secondary to chronic obstructive pulmonary disease. Seven were for renal conditions: three cases of urinary tract infections, two of poor renal function, one of severe dehydration, and one of hyponatremia. Five were for cardiac conditions: two cases of angina, two of severe hypertension, and one of supraventicular tachycardia. The remaining eight cases were distributed among five conditions, all of which were diagnosed or suspected from clinical evaluation. Twenty-five of the 28 were rescheduled. Of interest is one patient, scheduled for elective cholecystectomy, whose surgery was cancelled to control and evaluate elevated blood pressure. The patient was discharged to have this done in the outpatient setting and then was subsequently lost to follow-up with neither the hypertension nor the cholelithiasis receiving treatment.
DISCUSSION
here show that there are of cancelled surgery. Some are only minor disruptions to the operating room routine and staff. This would include almost all cancellations of The results
recurrent
presented
causes
Downloaded from ajm.sagepub.com at FUDAN UNIV LIB on May 5, 2015
5 surgery, since other cases on a waiting list often be scheduled. Of more concern are those that have the potential for causing an operating room or team to be idle. There are necessary causes-standby for surgery for complications of non-operating room procedures such as percutaneous transluminal coronary angioplasty is an example. Other causes might be reduceable, such as unsigned consent. Prospective utilization review might reduce some cancellations due to factors such as conditions remitting without surgery or preoperative evaluations showing surgical procedure not indicated. Cancellations because of medical conditions discovered during preoperative evaluation might be more difficult to eliminate. Of note is the high percentage of cardiac cases leading to cancellation. Of those cancelled for administrative reasons, the most common cause was unsigned consent. Many of these patients with acute complications of coronary artery disease were well until shortly before the admission and now find themselves suddenly extremely ill in a coronary care unit. On top of this, they are now asked to consent to open heart surgery by a surgeon whom they most likely have never met before. They often need more time to consult with family or to establish trust in the provider team. Cardiovascular surgical teams and hospital administrators, anticipating their problems, can provide additional educational and social services to ease the patients’ burden in making this difficult decision. Of those cardiac cases cancelled for medical factors, the most common cause was re-evaluation of the surgical lesion with subsequent decision to manage medically. Although the decision for or against surgery could theoretically be made at this hospital in a timely fashion so that only those whose diagnostic work-up showed a surgically correctable lesion would be scheduled, in practice a surgeon might be forced to make a &dquo;best-guess&dquo; before all the diagnostic information available in order to reserve the operating room time. This problem is most easily corrected by improving the administration of the operating room suite so that surgeons are not under pressure to call in reservations for cases before they have made the decision to oper-
same-day can
ate.
Dentistry had a high rate of cancellations for patient procedures. The hospital studied had a
out-
pro-
gram of dentistry for the handicapped. A number of their operating room procedures were on severely retarded children and adults, who were on many medications and had multiple medical problems. It was often difficult to have these patients and their families comply with the complex preoperative regimen for outpatient surgery. McLean and McLorie (6) have discussed the problem of compliance pre-operatively
outpatient surgery and provided data to show that preoperative telephone communication by a nurse practitioner will improve it. Agencies supporting such in
programs such
as
state
departments
of
public
aid
might keep in mind the difficulties in accomplishing even minor surgical procedures in these patients when setting up their guidelines for utilization.
Gynecology and orthopedics had lower rates of cancellations for inpatient procedures and otolaryngology a lower rate of cancellation for outpatient procedures. We could not identify a reason common to all three departments to explain the lower rate. The medical reasons for cancellation of inpatient surgery were largely pulmonary, cardiac and renal. Of note, however, are two of the patients in the miscellanous category with thrombocytopenia who had AIDS. These patients frequently have multiple medical and social problems related to their illness and administrators should anticipate the need for support services to make optimum their utilization of all hospital resources including surgery. There have been few previous studies on the reasons for cancellation of elective surgery. In a study that looked at cancellations for outpatient surgery, Knight (7) found that about half of the cancellations were for medical reasons and the majority of those were for cardiac problems and hypertension. Our data indicate that in inpatients, the overall percentage is lowerless then one quarter-and are more varied with a lower proportion being cardiac problems. The medical conditions were all clinically apparent from bedside examinations, and screening laboratory tests did not uncover previously unexpected conditions. Routine screening with laboratory tests has not been found useful in influencing pre-operative management (8, 9). However, selected testing in certain populations may be useful (10, 13). This may reduce cancellations if the testing is done prior to scheduling (14). The most
common
patient factor in cancellation
unsigned consent, responsible for over 15% of all cancellations. Applebaum and Roth (15) have studied patient refusals. Although they found refusal of surgery rare when compared with all types of refusals in a hospitalized population, there is no reason to suppose that the subset of surgical refusals had a different epidemiology than the group as a whole. In their study, once patients with mental illness are excluded, the most common causes of refusal were related to problems in communication to the patient. was
CONCLUSIONS This reasons
study why
shows that there are several common surgery is cancelled. Among inpatients,
Downloaded from ajm.sagepub.com at FUDAN UNIV LIB on May 5, 2015
6 failure to obtain consent was a frequent cause. Associated medical illness and re-evaluation of the surgical condition were almost as frequent. Among outpatients, a readily identifiable cause was inability of the patient to comply with complex preoperative instructions. The implications for quality of care and utilization are the following. 1. Those cases in which consent for the procedure might not be readily forthcoming can be anticipated. Our results suggest that patients hospitalized on an urgent basis with newly diagnosed coronary artery disease for whom bypass surgery is proposed might fall into this category. Operating room utilization could be improved if administration can provide extra educational and social services during the preoperative evaluation in an effort to make communications between patient and provider optimum. 2. Cancellations because of underlying medical condition can be kept to a minimum by thorough clinical evaluation and by timely use of indicated diagnostic tests for renal, cardiac, and pulmonary disease. In an environment where there is no pressure on the surgeon to schedule his OR cases prior to completion of this medical evaluation, improper utilization for this cause will also be reduced. 3. Cancellations because of re-evaluation of surgical conditions can also be kept at a minimum if surgeons are not under pressure to schedule their OR cases
Although direct effect
reduced cancellation rate has the most
utilization, it also affects quality in that the patient and patient’s family will be spared the uncertainty wrought by a change in plans and the inconvenience of prolonged or unnecessary hospitalization. on
References
JR, Leinhardt S. The cost and length of a hospital stay. Inquiry 1976;13:327-343. Herzlinger R. Can we control health care costs. Harvard Bus
1. Lave 2. 3. 4.
Rev 1978;56:102-110. Kelley M, Eastham A, Bowling G. Efficient OR scheduling: A study to decrease cancellation. AORN Journal 1986;41:565-567. Voss S. Ambulatory surgery scheduling: Assuring a smooth patient flow. AORN Journal 1986;43:1009-1012.
5.
Przasnyski Z. Operating
room scheduling: A literature review. AORN Journal 1986;44:67-79. 6. Mclean J, McLorie GA. Improving patient compliance in pedi-
7.
atric outpatient surgery. AORN Journal 1984;40:677-680. Knight C. Why elective surgery is cancelled. AORN Journal
1987;46:935-939. 8.
Kaplan EB, Sheiner LB, Boeckmann AJ et al. The usefulness of preoperative laboratory screening. JAMA 1985 ;253 :3576-
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