One in seven operations cancelled on day of surgery, study findsBMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3767 (Published 06 September 2018) Cite this as: BMJ 2018;362:k3767
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The operating room (OR) is a key, resource intensive department in major hospitals. ORs are a part of a patient’s hospital journey and inefficiencies here can have significant implications (1). Inefficient workings of the OR that include day of surgery (DOS) cancellations are problematic for many reasons including delays to patient care, potential for adverse clinical outcomes, administrative inefficiency, added expense to healthcare systems and poor patient and staff experience (2). We read Torjesen’s article with interest, in particular noting that for more than half of all cases cancelled or postponed on the day of surgery, no reason was specified.
In order to achieve process improvement, we need to understand the factors behind DOS cancellations. We have considered within our organisation, which also had a similar rate of day of surgery cancellations, a detailed list of all possible reasons. Cancellations can be traced to various patient and hospital associated factors, a number of which may be potentially avoidable through changes in hospital processes (1). Through detailed analysis, we were able to identify that nearly three quarters of all cancellations or postponements in the OR were potentially avoidable. By far the majority of these were hospital systems related, offering opportunities for quality and process improvements. Whilst we accept that there may be some differences between public and private hospitals, we identified administrative inefficiencies and incomplete perioperative workup as being the most common avoidable hospital related factors. Patient related factors tended to be less predictable thus potentially less avoidable and included unexpected change in clinical status or refusal to proceed.
Using quality improvement tools of Pareto analysis and virtuous learning cycle methodologies, an agile and multimodal process improvement was implemented within our organisation with success. This included standardisation of preoperative assessments with the use of clinical decision support tools, reminder phone calls, centralisation of booking and a surgical list manager. These have been used effectively along with predictive modelling to revise and reallocate available surgical slots based on performance data of different specialists and procedures (3,4).
Elective surgical waiting lists and OR efficiencies are key metrics of hospital performance. A substantial gap exists in many jurisdictions globally that requires patient centred, comprehensive and multimodality approaches to address DOS cancellations.
(1) Operating Theatre Efficiency Guideline. Clinical Excellence Division. Queensland Health. Brisbane,2017.[Internet] Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0022/640138/qh-gdl-...
(2) Perroca, Márcia Galan, Jericó, Marli de Carvalho, & Facundin, Solange Diná. (2007). Surgery cancelling at a teaching hospital: implications for cost management. Revista Latino-Americana de Enfermagem, 15(5), 1018-1024. https://dx.doi.org/10.1590/S0104-11692007000500021
(3) Macario, A; Are Your Hospital Operating Rooms “Efficient”?: A Scoring System with Eight Performance Indicators. Anesthesiology 2006;105(2):237-240.
(4) Van Klei WA, Moons KG, Rutten CL, Schuurhuis A, Knape JT et al. (2002). The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesthesia and Analgesia. 94(3):644-9
Competing interests: No competing interests