Abstract
Background
Unexpected surgical cancellation is common and can have significant adverse effects. Cancellation rates vary because of a lack of a standard definition, different patient populations and study methodology. We hypothesized that case cancellation has a different pattern in a dedicated ambulatory surgical center compared to a general operating room (OR) setting in a large academic center without an anesthesia preoperative evaluation center necessitating evaluation by the various surgeons.
Methods
Elective cases in general OR and in the ambulatory surgical center were included in this study. Elective cases are defined as the non-emergent cases scheduled before 8:00 am on the day of surgery. A cancelled case was defined as a scheduled procedure which is not performed on the scheduled procedure day. Case cancellation was monitored in real time using an electronic patient flow system (Navicare). As soon as the case is cancelled, the reason for the cancellation was obtained from the surgeon, the anesthesiologist, the OR coordinated nurses and/or the floor nurse. In the day surgical center, the cancelled cases were followed to determine whether/when they were rescheduled.
Results
4261 elective cases were included in this investigation, including 2751 cases in the general OR and 1510 cases in the ambulatory surgical center. A total of 283 cases (6.6%) were cancelled which include 206 cases from the general OR and 77 from the ambulatory surgical center. The cancellation rate in the general OR was 7.5%, among which inpatients have the highest cancellation rate of 18.1%, followed by outpatients at 4.6%, and same day admission at the lowest cancellation rate of 2.0%. The top 3 reasons for cancellation in general OR werein adequate preoperative preparation 29.4 ± 4.5%, medical condition change 28.5 ± 10.2%; and scheduling issue 20.2 ± 7.1%. Most (59.2 ± 8.9%) of the cancellations was considered preventable, 12.3 ± 5.9% was considered potentially preventable, and 28.5 ± 10.2% were not preventable (such as patient condition changes). The cancellation rate in the ambulatory surgical center was 5.1%. The major reason for cancellation was patient no show 75.8 ± 5.2 %, 61% of those no show patients were rescheduled and the mean delay in surgery was 18 days (range from 1 day to 84 days).
Conclusions
Case cancellation is not un-common in a large academic center without a preoperative evaluation clinic. The dynamics of case cancellation are different in an ambulatory surgical center as compared to the general OR. Inpatients have the highest cancellation rate associated with inadequate preoperative preparation and scheduling, this should be preventable via adopting proper systems of evaluation and preparation. Most of the case cancellations in the ambulatory surgical center are from patient no show, suggesting that administrative strategies to reduce this issue should be implemented. The patients admitted on the same day of surgery had the lowest cancellation rate requiring minimal intervention.
Introduction
Unexpected surgical cancellations are not uncommon, decrease patient satisfaction, waste medical resources, and undermine the morale of medical personnel [1–4]. Before seeking a strategy to reduce case cancellation rate, many medical providers and institutes investigate the cancellation rate and understand cancellation reasons. Due to a lack of standard case cancellation definition, and using different study methods [1–5], studies in the US have reported cancellation rates from as low as 0.21% [6] to as high as 26% [7]. Cancellation reasons also vary across studies including medical condition changes, patient no show, and scheduling issues.
Importantly, most of these studies are retrospective, which does not permit accurate assessment of time sensitive factors which might cause some inaccurate explanation of the cancellation; and the outcomes might have selection bias [2,5,8].
It is unclear whether the cause of case cancellation is different for the inpatient population and outpatient population. In this study, we hypothesized that case cancellation has a different pattern in dedicated ambulatory surgical center versus general operating room (OR). Using the same cancellation criteria, we prospectively investigated case cancellations in the general OR and an ambulatory surgical center of a large academic center without an anesthetic preoperative evaluation clinic and incorporating evaluation by the surgeon.
Methods
This study was approved by the institutional review board of the University of Pennsylvania. Selected elective case was defined as anonemergency case scheduled before 8:00 am on the day of surgery in both the General OR and ambulatory surgical center of the Hospital of the University of Pennsylvania. A cancelled case was defined as a scheduled procedure that is not performed on the scheduled day of procedure. Case cancellation was monitored in real time using an electronic patient flow system (Navicare). As soon as the case was cancelled, the reason for cancellation was obtained from the surgeon, the anesthesiologist, the OR coordinated nurses and/or the floor nurses. Patients who receive a surgical operation in general OR include inpatients, outpatients and same day admission patients while only outpatients receive surgical procedure at the ambulatory surgical center. The cancelled cases in ambulatory surgical center were followed by nurses to determine if they were rescheduled and they also determined the average delay. The delay was indicated by number of days from when the case was cancelled to the first rescheduled time.
Cancellation reasons were collected from residents, attendings or OR nurses. The reasons were then categorized into eight groups for data analysis purpose: inadequate preoperative preparation, medical condition changes, no show, no consent, scheduling issue, staff availability, and miscellaneous. In order to guide further OR efficiency study, cancellation reasons of general OR were further grouped as preventable which include: inadequate preoperative preparation, scheduling and consent; potentially-preventable which include: patient no show, staff availability, OR availability and miscellaneous; and Nonpreventable which is medical condition change.
Statistical analysis
The cancellation rate was calculated by the number of cancelled cases for certain reason divided by total cancelled elective cases in general OR or ambulatory surgical center; and indicated by mean ± SD (standard deviation). The cancellation rate between general surgical center and ambulatory surgical center were analyzed with chi-square, p< 0.05 is considered statistically significant. In the ambulatory surgical center, the average delay time was presented as median and range. Data were analyzed using Graph Pad Prism 6.0 (Graph Pad Software, Inc.) software.
Results
A total of 4261 elective cases were included in this study, of which, 2751 cases were from the general ORs and 1510 cases were from the ambulatory surgical center.283 cases (6.6%) were cancelled which includes 206 cases (7.5%) from the general OR and 77 (5.1%) from the ambulatory surgical center (Table 1). The general OR had a signification higher cancellation rate than the ambulatory surgical center (p<0.01).
Table 1.
Overall cancellation rate for the elective cases.
| General Operating Rooms | Ambulatory Surgical Center | Total | |
|---|---|---|---|
| Scheduled | 2751 | 1510 | 4261 |
| Canceled | 206 | 77 | 283 |
| Cancellation Rate | 7.5%* | 5.1% | 6.6% |
P=0.0049 as compared to that in the ambulatory surgical center
General OR Cancellations
In general OR, inpatients had the highest cancellation rate of 18%, 166 cancelled out of 918 scheduled cases; followed by outpatients at 4.6%, 28 cancelled out of 607 scheduled cases; and same day admission had the lowest cancellation rate of 2%, 13 cancelled out of 655 scheduled cases (Table 2).
Table 2.
Cancellation rate in general operating rooms.
| Inpatients | Outpatients | Same Day Admission | |
|---|---|---|---|
| Total cases | 918 | 607 | 655 |
| Cancelled cases | 166 | 28 | 13 |
| Cancellation rate | 18.1% | 4.6% | 2.0% |
The top 3 reasons for the high cancellation rate in general OR werein adequate preoperative preparation 29.4 ± 4.5%, (such as high International Normalized Ratio (INR), Nil per os status (NPO), and need for further workup); medical condition change 28.5 ± 10.2%, (such as fever, new onset stroke); and scheduling issue 20.2 ± 7.1% (Figure 1). Other reasons were no consent, no show and surgeon availability.
Figure 1.
Cancellation Reasons in general operating room. Major reasons were inadequate preoperative, medical condition change and scheduling issue. Data are presented as Mean ± SD.
59.2 ± 8.9% of the cancellations in general OR were considered preventable which includes inadequate preoperative preparation, scheduling and consent; 12.3 ± 5.9% potentially-preventable, such as no show, staff and OR availability; 28.5 ± 10.2% were Non-preventable, such as patient condition changes.
Ambulatory surgical center cancellations
In the ambulatory surgical center, patient no show was the most common reason 75.8 ± 5.2%, followed by inadequate preoperative preparation 8.6 ± 3.8%, and medical condition changes (7.1 ± 5.7%) (Figure 2).
Figure 2.
The preventability of cancellation reasons in general surgical center. Among which, 59.2 ± 8.9% were preventable (=inadequate pre-operative preparation+schedule+consent); 12.3 ± 5.9% were maybe preventable (=patient no show+staff availability+OR availability+miscellaneous); 28.5 ± 10.2% were non-preventable (=medical condition change). Data are presented as Mean ± SD.
Only 61% of the no show patients were rescheduled and the mean delay for surgery was 18 days, range from 1 day to 84 days.
Discussion
Case cancellation rate
Using the same cancellation criteria, the overall case cancellation in general OR is significantly higher than ambulatory surgical center, 7.5% versus 5.1% (p<0.01).
Patients in the general OR were dominantly inpatients. Inpatients in the general OR had the highest case cancellation rate of 18.1%, which is similar to other large academic surgical centers prior to establishing a preoperative clinic [5,9]. Outpatients operated in general OR or ambulatory surgical center have the same case cancellation rate although the reasons for cancellation were different. The outpatient case cancellation rate is within the range reported in settings in which a preoperative clinic exists (from 1.8% to 8.4%) [5,10]. Same day admission has the lowest cancellation rate at 2.0%.
Reasons of cancellation
General OR
Inadequate preoperative preparation was the top cancellation reason in the general OR (29.4 ± 4.5%). It was also the top reason in each of the individual subgroups: inpatient, outpatient and same day admission. High INR, NPO violation and “not cleared by internal medicine” were often included in the inadequate preoperative preparation category as noted by medical staff on the day of surgery. Due to the late notice of the patient’s medical condition, these patients need further workup which leads to cancellation. Inadequate preoperative preparation should be prevented.
A medical condition change was the second most common reason for cancellation in general OR (28.5 ± 10.2%). It was also the second most common reason in inpatient, outpatient and same day admission. Usually, a sudden medical condition change leads to an unavoidable cancellation, however, if patients are under close monitoring, the risk can be reduced and this will also lead to decrease in case cancellation rate.
We found scheduling was another common reason for case cancellation rate in general OR. Lack of adequate communication between surgical staffs and overbooking might contribute to scheduling issues.
Ambulatory surgical center
Patient no show was the single most common reason (75.8 ± 5.2%) for cancellation in the ambulatory surgical center. Argo’s study in Veterans Health administration system during 2006 also found that the top cancellation reason is patient no show [2]. Most often, a patient not showing is due to patient’s changing their mind at the last moment, or could not make to the hospital due to the traffic and/or weather. While it seems that patient no show is difficult to avoid, Tentamen reported there was no single no show case at the Mayo Clinic in Arizona over one year during June 2009 to July 2010, and the author attribute the reason to a good schedule system and thorough preoperative evaluation, a shared medical record, and timely communication [11].
The second most common cancellation reason is inadequate preparation, which should be avoidable.
Only 61% cancelled cases were rescheduled within one year follow up period. Boudreau [12] reported that reschedule rate might be associated with the national economic recession based on the findings that year 2010 had lower reschedule rate (56%) than year 2008 (76%) even overall case cancellation rate was decreased.
Potential Strategies to reduce case cancellation
Our results agree with many studies, in which most cancellations (59.2 ± 8.9%) are preventable [11]. Attempts should be made to decrease case cancellation starting with the most prevalent preventable reasons. For example, in general OR, the leading causes of case cancellation are inadequate preoperative preparation and scheduling related issues which can be and should be prevented.
It has been shown that the preoperative clinic can effectively bring down the cancellation rate, and therefore increase the OR efficiency. A preoperative clinic dramatically decreased cancellation rate from >10% to <5%, and for some hospital to as low as <1% through anesthesiologists reducing cancellation rate caused by inadequate preparation [5, 11,13–15]. However, these are for outpatients who went through preoperative clinic. Theoretically, inpatients should have best preoperative preparation since they are already in the hospital and have access to readily available services. However, this study demonstrates an opposite occurrence in our hospital. The question is whether an inpatient preoperative clinic/unit operated by the department of anesthesiology is cost-effective, through which anesthesiologists could involve patient care for preoperative evaluation and preparation as early as possible to have a proper plan in place if a patient is scheduled for an elective procedure during the hospitalization.
Other than preoperative evaluation, Boudreau [12] found it important to educate patients to take simple and proper precaution before procedure to reduce potential cancellation. For example avoiding contact with sick individuals to prevent upper respiratory infection diseases can significantly decrease the case cancellation rate caused by a medical condition change [16].
To reduce the patient no show in ambulatory surgical center, Basson [17] suggested an adjustment of patient scheduling to book the incompliant patients at the end of the surgical day. This is a simple strategy to put in practice. Providing help to patients with transportation to the hospital and timely communication may also help to decrease case cancellation rate. Moreover, preoperative evaluation can dramatically decrease no show.
Conclusions
Case cancellation is not un-common in a large academic center. The dynamics of case cancellation is different in an ambulatory surgical center compared to the general OR settings for inpatients. Inpatients have the highest cancellation rate associated with inadequate preoperative preparation and scheduling which should be preventable via adopting proper systems of early evaluation and preparation. Most of the case cancellations in the ambulatory surgical center are from patient no-show, suggesting that administrative strategies to reduce this issue should be implemented. The patients admitted on the same day of surgery had the lowest cancellation rate requiring minimal intervention.
Acknowledgments
The authors thank the gracious support from James Mullen, M.D. at the Department of Surgery and Shanique Brown, M.D. at the Department of Anesthesiology and Critical Care at the Hospital of University of Pennsylvania, Philadelphia, PA. The authors also thank Mr. Felipe Matsunaga for his outstanding technical support, and thank Mary S. Hammond, BSN, for her work on IRB approval and waiver.
Footnotes
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Institution
Perelman School of Medicine at the University of Pennsylvania and Emory University School of Medicine.
Disclosure of Funding
This study was supported by departmental funding from the Department of Anesthesiology and Critical Care at the University of Pennsylvania and by NIH grants K08-GM093115 (RL).
References
- 1.van Klei WA, Moons KG, Rutten CL, Schuurhuis A, Knape JT, et al. The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg. 2002;94:644–649. doi: 10.1097/00000539-200203000-00030. [DOI] [PubMed] [Google Scholar]
- 2.Argo JL, Vick CC, Graham LA, Itani KM, Bishop MJ, et al. Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement. Am J Surg. 2009;198:600–606. doi: 10.1016/j.amjsurg.2009.07.005. [DOI] [PubMed] [Google Scholar]
- 3.González-Arévalo A, Gómez-Arnau JI, delaCruz FJ, Marzal JM, Ramírez S, et al. Causes for cancellation of elective surgical procedures in a Spanish general hospital. Anaesthesia. 2009;64:487–493. doi: 10.1111/j.1365-2044.2008.05852.x. [DOI] [PubMed] [Google Scholar]
- 4.Sanjay P, Dodds A, Miller E, Arumugam PJ, Woodward A. Cancelled elective operations: an observational study from a district general hospital. J Health Organ Manag. 2007;21:54–58. doi: 10.1108/14777260710732268. [DOI] [PubMed] [Google Scholar]
- 5.Ferschl MB, Tung A, Sweitzer B, Huo D, Glick DB. Preoperative clinic visits reduce operating room cancellations and delays. Anesthesiology. 2005;103:855–859. doi: 10.1097/00000542-200510000-00025. [DOI] [PubMed] [Google Scholar]
- 6.Fischer SP. Development and effectiveness of an anesthesia preoperative evaluation clinic in a teaching hospital. Anesthesiology. 1996;85:196–206. doi: 10.1097/00000542-199607000-00025. [DOI] [PubMed] [Google Scholar]
- 7.Pollard JB, Zboray AL, Mazze RI. Economic benefits attributed to opening a preoperative evaluation clinic for outpatients. Anesth Analg. 1996;83:407–410. doi: 10.1097/00000539-199608000-00035. [DOI] [PubMed] [Google Scholar]
- 8.Seim AR, Fagerhaug T, Ryen SM, Curran P, Saether OD, et al. Causes of cancellations on the day of surgery at two major university hospitals. Surg Innov. 2009;16:173–180. doi: 10.1177/1553350609335035. [DOI] [PubMed] [Google Scholar]
- 9.Schmiesing CA, Brodsky JB. The preoperative anesthesia evaluation. Thorac Surg Clin. 2005;15:305–315. doi: 10.1016/j.thorsurg.2005.02.006. [DOI] [PubMed] [Google Scholar]
- 10.Barnes PK, Emerson PA, Hajnal S, Radford WJ, Congleton J. Influence of an anaesthetist on nurse-led, computer-based, pre-operative assessment. Anaesthesia. 2000;55:576–580. doi: 10.1046/j.1365-2044.2000.01377.x. [DOI] [PubMed] [Google Scholar]
- 11.Trentman TL, MJ, Fassett SL, Dormer CL, Weinmeister KP. Day of Surgery Cancellations in a Tertiary Care Hospital: A One Year Review. J Anesthe Clinic Res. 2010;1:109. [Google Scholar]
- 12.Boudreau SA, Gibson MJ. Surgical cancellations: a review of elective surgery cancellations in a tertiary care pediatric institution, Journal of perianesthesia nursing: official journal of the American Society of PeriAnesthesia Nurses / American Society of PeriAnesthesia. Nurses. 2011;26:315–322. doi: 10.1016/j.jopan.2011.05.003. [DOI] [PubMed] [Google Scholar]
- 13.Lau HK, Chen TH, Liou CM, Chou MC, Hung WT. Retrospective analysis of surgery postponed or cancelled in the operating room. J Clin Anesth. 2010;22:237–240. doi: 10.1016/j.jclinane.2009.10.005. [DOI] [PubMed] [Google Scholar]
- 14.Knox M, Myers E, Hurley M. The impact of pre-operative assessment clinics on elective surgical case cancellations. Surgeon. 2009;7:76–78. doi: 10.1016/s1479-666x(09)80019-x. [DOI] [PubMed] [Google Scholar]
- 15.Bhavsar T, Saeed-Vafa D, Harbison S, Inniss S. Retroperitoneal cystic lymphangioma in an adult: A case report and review of the literature. World J Gastrointest Pathophysiol. 2010;1:171–176. doi: 10.4291/wjgp.v1.i5.171. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.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;9:213–219. doi: 10.1016/s0952-8180(97)00032-9. [DOI] [PubMed] [Google Scholar]
- 17.Basson MD, Butler TW, Verma H. Predicting patient nonappearance for surgery as a scheduling strategy to optimize operating room utilization in a veterans’ administration hospital. Anesthesiology. 2006;104:826–834. doi: 10.1097/00000542-200604000-00029. [DOI] [PubMed] [Google Scholar]