Impact Of Surgery Delay And Cancellation Of Elective Surgeries

Background and significance

Discuss about the Impact of Surgery Delay and Cancellation of Elective Surgeries.

Adverse consequences have been identified with preoperative treatment delays including prolonged wait times and rescheduling of surgeries (McIntosh, Cookson, & Jones, 2012). In the year 2007, hospitals in the United Kingdom were reimbursed £70 million for last minute postpone and cancellation of scheduled operations (McCook, 2015). These incidents have a major impact on the patient flow and resource utilization. Unexpected delay at the time of operation leads to frustration among patients and their families (Caesar, Karlsson, Olsson, Samuelsson & Hansson-Olofsson, 2014). Delay results in prolonged waiting time and extended hospital stay. It increases more pain and deterioration of the patient’s clinical condition which may consequently impair the recovery process. Delay or rescheduling surgeries affects the chain of events that the patient has preplanned or has been planning (Hovlid et.al, 2012). Extended hospital stays due to delay in operations lead to unnecessary occupancy of the hospital beds. The staff and the health care professionals also undergo significant stress due to decrease in morale, and difficulty in handling stressed patients (Cihoda et al., 2015). There are multiple clinical systems involved in the process of surgery such as day surgery unit, Intensive Care Unit (ICU), Operating room and associated scheduling time, Post Anesthesia Care Unit (PACU). Any change in the schedule if not informed to any of these systems increases the uncertainty of the patient’s waiting time. It is distressing to the corresponding staff being unable to prioritize the patient needs. Delay in ICU may extend the process in PACU. These have a psychological effect on the patient satisfaction (Magnusson, Fellander-Tsai, Hansson & Ryd, 2011).

In conclusion, the cancellation and rescheduling of surgeries significantly impact the patients’ health, hospital resources, a cost of the health care and quality of the care services. However, it is difficult to devise a solution without understanding the cause of delay or rescheduling of the surgeries. The purpose of this paper is to analyze the unanticipated delays and cancellation of the elective surgeries in the hospitals and to identify evidence-based interventions to address this issue.

A search was conducted to identify relevant articles and four databases were used which are PubMed, Embase, CINHAL, and Cochrane. Only full-text and peer reviewed articles on human research were used in this study. For this research, a total of 213 articles were summarized, and after screening the title, 103 articles were selected for abstract review. Some of these articles were eliminated from review due to duplication in databases and irrelevancy found after screening full text. Therefore, 20 articles were included after post-screening the reference list.

Search strategy

Articles published within the last five years (2011-2016) and had systematic, or meta-analysis literature was considered for this study. The search terms used for identifying relevant articles are “preoperative delay”, “elective surgical procedure”, “bed occupancy”, “delayed discharge”, “operation schedule”, “surgery cancellation”, “rescheduling of operation”. There was no limitation on the type of elective surgery, patient’s age, or classifying the patient as inpatient or outpatient. The articles that were not published in English and those published beyond the set range were excluded from the review.

In more than 10 studies 78.1% of cancellation was attributed to administrative and hospital factors which includes lack of theatre time, adequate theatre staff, inadequate resources, ineffective planning,  and lack of ICU beds (Garcia et al., 2013). Six of the studies indicated that 25% cancellations were due to patient’s financial constraints, self-cancellations, patient absenteeism, deterioration of clinical condition and inadequate preoperative assessments (Gaucher et al., 2013). Two studies showed that 2.1 cases of cancellations were due to lack of anesthesia facility (Singhal et al., 2013).

Five studies confirmed that most frequently cancelled surgeries are of general and orthopedic category due to high number of surgeries scheduled and patient’s related reasons respectively. One study explained that cancellation was due to lack of ICU beds. Two studies revealed patient’s no show on the scheduled day was the cause of the cancellation. One study showed that there was no financial impact on the productivity of the operating room due to number of cancelled cases and the duration of the cancellations. Six studies identified the adverse outcomes of cancellations including waste of resources, budget, burden of adjusting the cancelled cases. Administrative reasons were significant cause of the preoperative delays when compared to patient related causes. These reasons were mainly associated with higher number of cancellations in larger community hospitals and in rural areas. Only three studies evaluated the effectiveness of the preoperative telephone confirmation intervention. Cancellation incidence was significantly found to reduce by prior confirmation of attendance from the patients (Bathala et al., 2013).

The strength of the study constitutes significant patient input. There was a good focus on the negative impact of preoperative delays on the patient. There was sufficient data on the   causes of surgical delays. Three studies highlighted the effectiveness of the preoperative assessment in reducing the cancellations. Majority of the articles were based on retrospective and nonrandomized design. There was also existence of inconsistent definitions of measurement of preoperative instruction adherence. Neither of the reviews conducted any evaluation of the existing interventions or strategies to prevent preoperative delays and instruction adherence in staff.

Literature synthesis and review

There are several limitations in literature prohibiting the translation of the evidence into practice. Some of the researcher did not consider taking the surgical cancellations occurring due to seasonal illness or climatic factors such as snowy weather, which may be a barrier to patient’s transport to hospital. Most of the studies concerned taking nurses and manager’s data that categorized the delays or rescheduling under more than one category. Some of the studies did not indicate the reliability and validity of the data collected.

Scheduling a surgery is a complicated process due to multiple systems involved taking into accounts the priorities for service, the variety of surgical specialties, emergency services, and postsurgical capacity. It is essential to address preoperative delays by interventions to organize each step of surgery to improve the patient outcomes and increase the work efficiency. These interventions will improve the utilization of hospital resources and reduce the healthcare costs.

Literature evidence has shown a significant improvement in incidents of preoperative delays by the role played by the preadmission clinic in maintaining adherence to preoperative instructions. There is a need to establish a clear and consistent definition of the adherence to instructions of surgical schedule (Chalya et al., 2011). Applicability of various intervention method should be sought to improve adherence to preoperative instructions and surgical settings. Preoperative nurses play a positive role in educating the patients and their families about the system of organizing surgeries and required preparedness (Singhal et al., 2013). These nurses can detect any illness in the immediate preoperative period which will prevent cancellation. The other effective way to avoid cancellation is to standardize a pre-operative checklist. In this method, the surgical patient is called two days before the scheduled surgery to get confirmation, for surgical preparation, resolving patient queries, and check escort availability (Pohlman et al., 2012). There is a need of recruiting professionals who are more tactful in prioritizing the blocking of surgical slots so that most needed postoperative patient is not delayed in accessing ICU beds (Bathala et al., 2013).

There is a need to increase the scope of the study to multi-site ones. Further research can be expanded to bigger geographical areas and including the diverse group of patients.  Most of the studies were conducted in single site centers, and very few were found to be undertaken in Saudi Arabia. There were excellent qualitative studies that have obtained the perceptions of elicit patients regarding their experience of surgical delays. To strengthen the reliability and validity of the results triangulation method can be applied in the research.

Synthesis of evidence

This paper demonstrated that delay or cancellation in surgeries is a most common type of error in the operating rooms and the lessons from the analysis of this issue applies to all, the surgical disciplines. A vicious cycle is created by single delay and then additional subsequent delays associated with it. Surgical cancellations have a significant impact on the quality of the healthcare. Rescheduling and delayed surgeries are associated with the huge waste of hospital resources and increased health care cost due to cancellation rate. However, most cancellation cases are preventable. Evidence showed that most cancellation and delayed surgeries are due to lack of theater time in most cases, self-cancellation and no show of surgical patient at the time of operation, lack of anesthesia services, lack of sufficient staff, and equipment failures. The effective way to reduce surgical cancellation and delays is to take sufficient time for planning and reviewing an operation schedule. A collaborative effort is required at multiple levels to address the surgical system such as Porter systems, imaging departments, and patient registration processes. These findings are the useful way to devise a solution to improve the performance efficiency in the surgical room.

References

Bathala, S., Tardolli, A., Jaramillo, M., Morgan, N., & Thomas, M. (2013). Cancellations in elective ENT surgery. British Journal of Healthcare Management, 19(3), 136-139.

Caesar, U., Karlsson, J., Olsson, L. E., Samuelsson, K., & Hansson-Olofsson, E. (2014). Incidence and root causes of cancellations for elective orthopaedic procedures: a single center experience of 17,625 consecutive cases. Patient safety in surgery, 8(1), 1.

Chalya, P. L., Gilyoma, J. M., Mabula, J. B., Simbila, S., Ngayomela, I. H., Chandika, A. B., & Mahalu, W. (2011). Incidence, causes and pattern of cancellation of Elective surgical operations in a University Teaching Hospital in the Lake Zone, Tanzania. African health sciences, 11(3).

Cihoda, J. H., Alves, J. R., Fernandes, L. A., de Souza, N., & Pereira, E. (2015). The analysis for the causes of surgical cancellations in a Brazilian university hospital. Care Management Journals, 16(1), 41-47.

Garcia De Avila, M, & Mangini Bocchi, S. (2013). ‘Telephone confirmation of patient’s intent to be present for elective surgery as a strategy to reduce absenteeism. Scielo,47(1), 189-193.

Gaucher, S., Boutron, I., Marchand-Maillet, F., Baron, G., Douard, R., & Béthoux, J. (2016) . Assessment of a Standardized Pre-Operative Telephone Checklist Designed to Avoid Late. Cancellation of Ambulatory Surgery: The AMBUPROG Multicenter Randomized Controlled Trial. PLOS ONE, 11(2), e0147194.

Hovlid, E., Bukve, O., Haug, K., Aslaksen, A. B., & von Plessen, C. (2012). A new pathway for elective surgery to reduce cancellation rates. BMC health services research, 12(1), 1.