Improving patient care and enhancing surgical efficiency: strategies to reduce same-day surgical cancellations

Surgical cancellations on the day of scheduled surgery often reflect systemic problems and can result in harm to patients and inefficiencies in healthcare delivery. While some of these cancellations may be unavoidable (e.g. patients presenting with new illness or exacerbations of chronic disease on the day of surgery), most are not and rather are due to a variety of factors including incorrect pre-operative risk-stratification; insufficient work-up or optimisation of chronic conditions; institution-specific factors such as staffing shortages or lack of bed capacity; and failure to identify logistical or communication barriers (e.g. lack of transportation, misunderstanding fasting or medication withholding guidelines).

Patients whose surgeries are cancelled can experience significant delays in receiving necessary surgical care and a sizeable proportion may never have their surgeries rescheduled [1]. Healthcare systems also experience financial losses from same-day cancellations, as operating theatres often remain unused and thereby waste staffing resources and lose revenue from missed surgical procedures. Implementing scalable interventions to prevent same-day surgical cancellations, therefore, is important both in helping patients receive timely medical care and in optimising the efficiency of the health care system.

A recent study describes one successful approach to reducing same-day surgical cancellations. Wongtangman et al. present results of their intervention aimed at reducing same-day cancellations for elective, ambulatory otorhinolaryngology surgeries at their academic surgery centre [2]. The intervention, which was introduced in April 2022, consisted of three changes in pre-operative workflow: automated use of a validated instrument to estimate risk of same-day cancellation; automated use of a machine learning-derived tool to classify ASA physical status; surgeon responses to four health screening questions on patient medical comorbidities; hospitalisations in the previous three months; exercise tolerance; and history of previous anaesthetic complications. Patients classified as ASA physical status ≥ 3 or who had at least one positive health screening question, were scheduled for a pre-anaesthetic telehealth visit and underwent subsequent work-up as needed. Patients who did not meet these criteria but had > 20% chance of same-day cancellation were evaluated by a surgical navigation team and offered support. All other patients were evaluated on the day of surgery, as was standard in this health system. In addition to the three main pre-operative changes, the authors also developed and disseminated standardised criteria for pre-operative work-up of common chronic conditions, encouraged patients to sign up for an electronic messaging portal and text message reminders and cultivated interprofessional relationships across anaesthetists, surgeons, case schedulers and the surgical navigation team.

Employing an interrupted time-series analysis, the authors found an immediate, significant decline of approximately 2.7% in the rate of same-day cancellation in the month following implementation of their intervention. Over the subsequent 8 months, they found constant, ongoing declines in same-day cancellations by approximately 0.2% every month. Altogether, they estimated approximately 35% in cost-savings from averting same-day cancellations, relative to the cost of same-day cancellations for these same surgeries in a pre-intervention period. The primary source of savings from preventing same-day cancellations was reducing the no-show rate (i.e. the proportion of patients who did not show up on the day of surgery). Over 80% of patients also set up text message notifications and received contact from the surgical navigation team three times in the three weeks before surgery, including the day before surgery.

This study provides several important insights into strategies that other hospital systems could employ to reduce same-day cancellations. First, it suggests standardising and/or automating pre-operative risk stratification, rather than leaving risk stratification to the subjective assessment of the surgeon. While it is well established that anaesthetist-directed pre-operative clinics can reduce surgical cancellations [3] (in addition to preventing complications and mortality [4]), having an anaesthetist-designed and automated pre-operative risk stratification approach could be a particularly valuable strategy in hospital systems that do not have the resources to staff a pre-operative clinic that evaluates all patients before the day of surgery. Moreover, a key feature of standardisation is that it ensures that anaesthetists and surgeons are aligned regarding pre-operative workup and cancellation decisions. Second, and perhaps more importantly, the study emphasises the importance of pre-operative communication with patients in reducing same-day cancellations and corroborates similar reports in other hospital settings [5,6]. Text messages in particular represent a low-cost, accessible and potentially automatable way of ensuring that patients show up for scheduled surgery and may be especially impactful given that mobile telephone use is nearly ubiquitous globally, including in low- and middle-income countries [7].

At the same time, the present study has several features that limit its generalisability. First, as the authors acknowledge, it is a single-centre study focused on ambulatory otorhinolaryngology surgical patients. The root causes of same-day surgical cancellations vary widely across hospital types and patient populations [8,9], ambulatory vs. inpatient surgery [10] and surgical subspecialties [11]; thus, the success of this intervention may not apply to other settings. Second, the study evaluated the effect of an intervention relative to a standard that did not necessarily include anaesthetist-directed medical evaluation before the day of surgery. Before implementation of the intervention, patients undergoing surgery would be risk-stratified by the surgeon and then would either be scheduled for a telehealth appointment with an anaesthetist or nurse practitioner or would be scheduled for an in-person pre-operative internal medicine office visit. Other hospital systems that already have anaesthetist-directed pre-operative evaluations for all patients in the days to weeks before surgery – as is becoming more common worldwide, particularly as patients become more medically complex [12,13] – may not see the same magnitude of effect from the type of intervention tested in this study. Third, while the study evaluated the potential savings of the bundle, it did not evaluate the costs of implementation. Finally, because the intervention consisted of multiple changes applied simultaneously, it is not clear whether all changes would be necessary for others attempting to replicate this work.

Ultimately, the article by Wongtangman et al. provides evidence that some systemic changes to the pre-operative evaluation process can significantly reduce same-day surgical cancellations and may also be tied to cost savings for hospital systems. Their future work with additional surgical subspecialties will reveal the robustness of their findings within their hospital system. Other hospital systems can use this work as a starting point to investigate the root causes and potential solutions for their same-day surgical cancellations.