Incidence and causes of cancellations of elective operation on the intended day of surgery at a tertiary referral academic medical center in Ethiopia

Analysis of the Incidence and Reasons for Temporary Cancellation of Day Surgery: A Retrospective Study

PURPOSE

To investigate the incidence and causes of cancellation of day surgery.

DESIGN

This study was a retrospective, observational study and the clinical data were obtained from electronic medical records.

METHODS

Data of day surgery from March 1, 2023 to February 29, 2024 were collected in the major operating room in Xiangya Hospital of Central South University, including patients' general conditions, diagnoses, anesthesia methods, and whether surgery was performed. The incidence of surgery cancellation in different ages, genders, departments, and anesthesia methods was analyzed comprehensively.

FINDINGS

A total of 6,397 cases were scheduled, 211 cases were canceled after scheduling; the cancellation rate was 3.3%. The cancellation rate among different age groups (P < .01) was statistically significant with 6 to 17 years old as the lowest 1.30% (11/844), and over 65 years old as the highest 3.74% (20/535). The cancellation rate among different departments was statistically significant (P < .01) with plastic surgery as the lowest 2.06% (2/97) and neurosurgery as the highest 10.13% (8/79). The cancellation rate between different anesthesia methods was statistically significant (P < .05) with general anesthesia as 3.01% (140/4,654) and local anesthesia as 4.07% (71/1743). There was no statistically significant difference between different genders (P > .05). Medical reasons were the main reason for cancellation 65.2% (138/211).

CONCLUSIONS

The rate of cancellation is higher in elderly patients and local anesthesia patients and neurosurgery patients with day surgery. Medical reasons were the main cause of these cancellations, most of which could be avoided.

Global strategies to reduce elective surgery waiting times for sustainable health outcomes: a systematic review

OBJECTIVE

Long waiting times for elective surgery reflect not just backlog issues but systemic inefficiencies that disrupt the smooth flow of patients through the surgical care pathway. This systematic review adopts a holistic approach to summarize global policies, strategies, and interventions aimed at reducing elective surgery wait times.

METHOD

A comprehensive electronic search was performed in PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane Library from December 2019 to January 2020 and updated in April 2022. Eligible studies, published after 2013, focused on waiting lists for major elective surgeries in adults, excluding cancer-related surgeries. Both randomized and non-randomized studies and systematic reviews were included. Study quality was assessed using ROBINS-I, AMSTAR 2, and CASP tools, as appropriate. The review was registered in PROSPERO (CRD42019158455) and reported using a PRISMA flow diagram.

RESULTS

From 7543 records, 92 articles met the inclusion criteria. Evidence was categorized into seven strategic areas: referral management, patient prioritization, preventing scheduled surgery cancellations, perioperative time management, quality improvement methods for surgical care pathways, and waiting time targets for hospitals. Strategies such as referral management, patient prioritization, and preventing cancellations had the most significant impact on reducing waiting times, while perioperative time management and waiting time targets proved less effective.

CONCLUSION

The review highlights that targeted interventions at different stages of the surgical care pathway yield variable impacts on overall waiting times. While individual measures had limited effects, combining multiple short-term strategies may be more beneficial, particularly for health systems recovering from the COVID-19 pandemic.

Methods families use to raise funds for anorectal malformation treatment at a single public referral hospital in Southwestern Uganda

Background

In Uganda, only two public hospitals provide pediatric surgery services. With less than 10 pediatric surgeons serving approximately 20 million children in Uganda, most patients with anorectal malformations (ARMs) must make several trips to the hospital before undergoing surgery. As a result, households borrow money, sell assets, or solicit contributions from friends and relatives to meet healthcare expenses. We used a cross-sectional study to examine methods families use to raise funds for the treatment of ARMs at a single institution in Southwestern Uganda.

Methods

This cross-sectional study was conducted in the pediatric surgery unit at a Regional Referral Hospital/University Teaching Hospital in Southwestern Uganda from June 2021 to July 2023. Participants included caretakers of children presenting with ARMs for treatment at our referral hospital.

Results

A total of 157 participants were enrolled. Mothers were the main caregivers (77.9%) present at the hospital. Out of a median monthly household income of UGX200 000 (US$51.68), families spent a median of UGX50 000 (US$12.92) to travel to the hospital. To raise funds for healthcare expenses, 68% of households reported selling assets.

Conclusion

Families sell household assets to afford ARMs treatment in Southwestern Uganda. Financial protection by the government through a national child health insurance policy would shield families from substantial health-related expenditures and decrease this burden. In addition, targeted policy to strengthen pediatric surgical capacity through workforce expansion and skills training such as the Pediatric Emergency Surgery Course, may minimize costs, improve timeliness of care, and prevent case cancellations.

Unexpected Events That Occur in Patients on the Day of Surgery: A Single-center, Prospective Observational Study

PURPOSE

The purpose of this study is to investigate the reasons for case cancellations on the day of surgery and determine the rates of unexpected events and case cancellations.

DESIGN

This is a prospective, cross-sectional study conducted at a single hospital.

METHODS

The patients' reasons for surgical cancellation were classified as preventable or nonpreventable. Patient data were obtained in the operating room after standard anesthesia monitoring by anesthesiologists. Unexpected problems that emerged in patients and cases canceled due to these problems were recorded. We evaluated blood pressure values according to the American College of Cardiology and American Heart Association guidelines.

FINDINGS

Elective surgery was planned for a total of 4,287 patients. The incidence of an unexpected event detected on the day of surgery was 5.8% (n = 250), and the case cancellation rate was 2.16%. Examination or medical condition-related factors (n = 78, 83.9%) were the most common reason for case cancellation. Among the 250 unexpected events, patients with undiagnosed hypertension were in the majority (n = 130, 52%). Severe hypertension was observed in 30 patients (12%) who were previously diagnosed with hypertension, and the surgery was canceled in 25 (83.3%) of these (P < .001).

CONCLUSIONS

Preventable causes (60.2%) were more common than nonpreventable ones among case cancellations. Our findings showed that many patients had high blood pressure and were unaware of this condition. Our study allowed referral of patients to a cardiologist to begin the follow-up process. Additionally, our study highlights the need for adequate preoperative anesthesia preparation and comprehensive nursing care.

Effectiveness of primary repair for low anorectal malformations in Uganda

BACKGROUND

Anorectal malformations (ARMs) have an incidence of up to 1 in 4000 live births and can require immediate neonatal surgery due to associated intestinal blockage. Due to limited surgical access, Ugandan children present late and undergo three separate staged operations: (1) initial colostomy formation; (2) repair of the ARM (called anoplasty); and (3) colostomy closure. Three operations result in long treatment duration, potential complications with each procedure, delays in care, and stigmata associated with colostomies. By offering primary repair for ARMs in a resource-limited setting, we expect to: reduce healthcare expenditure by families, length of treatment, length of hospital stay, frequency of hospital visits, and social rejection.

MATERIALS AND METHODS

A pragmatic clinical trial was performed examining the effectiveness of primary repair (prospective arm) and comparing it with the three-stage repairs (retrospective arm).

RESULTS

Of the 241 patients included for analysis-157 patients had a three-stage repair, whereas 84 patients had one- or two-stage repair. The median [IQR age at the last surgery (days) was 730.0 (365.0, 1460.0) vs 180.0 (90.0, 285.0)] in three-stage and one- or two-stage repairs, respectively. There was no difference in postoperative complications compared to patients who had three-stage repair. Patients who had a two-stage repair had less time with colostomy than those with three-stage repair. Non-inferiority analysis demonstrated that the primary repair approach was non-inferior to the three-stage approach.

CONCLUSIONS

Primary repair for ARM is effective in low-income settings. It allows for less time with colostomy with no difference in post-operative complications. The decision on approach for treatment depends on the surgeon's experience and clinical judgment.

Perioperative Process Mapping to Identify Inefficiencies at a Tertiary Hospital in Malawi

INTRODUCTION

Same-day surgical case cancellation consumes resources, disrupts patient care, and has a global prevalence of 18%. A retrospective analysis found that 44% of scheduled elective surgeries were canceled at a public tertiary hospital in Lilongwe, Malawi. To better characterize these cancellations, this study defines a process map for surgical case completion and investigates hospital staff and patient perspectives on contributing factors and burdens of cancellation.

METHODS

We conducted participatory process mapping and in-depth interviews with hospital staff (n = 23) and patients (n = 10) to detail perioperative processes and perspectives on cancellations. We used purposive sampling to recruit staff by hospital role and patients whose surgery had been canceled. Interviews were audio-recorded, translated, and transcribed for process mapping accuracy and thematic analysis using the constant comparative method and NVivo software.

RESULTS

Staff delineated specific steps of the perioperative process, generating a process map that identifies inefficiencies and opportunities for intervention. Hospital staff described unavoidable causes of case cancellation, such as unreliable water supply and material shortages. Modifiable causes linked to wasted time and resources were also evident, such as chronic tardiness, communication barriers, and inadequate preoperative assessment. Thematic analysis of perceived impacts of cancellation revealed compromised provider-patient relationships, communication breakdown, and emotional distress. Staff and patients expressed frustration, embarrassment, fear, and demoralization when planned surgeries were canceled.

CONCLUSIONS

We demonstrate the use of process mapping as a tool to identify implementation targets for reducing case cancellation rates. Hospital systems can adapt this approach to address surgical case cancellation in their specific setting.

Surgical System Efficiency and Operative Productivity in Public and Private Health Facilities in Ethiopia: A Cross-Sectional Evaluation

BACKGROUND

Global and local health organizations track surgical system efficiency to improve surgical system performance using various efficiency metrics, such as operating room (OR) output, surgical incision start time (SIST), turnover time (TOT), cancellation rate among elective surgeries, and in-hospital surgery wait time. We evaluated the surgical system efficiency and factors affecting the efficiency in health facilities across Ethiopia.

METHODS

A cross-sectional study design with retrospective record review was used to evaluate the surgical system efficiency in 163 public and private health facilities in Ethiopia from December 2020 to June 2021. Experienced, trained surgical clinicians abstracted efficiency data from service registers and patient charts using a pretested tool. A bivariable and multivariable regression analysis was conducted.

RESULTS

In the study facilities, 84.11% of the operating tables were functional, and 68,596 major surgeries were performed. The aggregate OR output in both public and private health facilities was 2 surgeries per day per OR table. Operating productivity was shown to be affected by first-case SIST (P=.004). However, of the total 881 surgery incision times audited, 19.86% of the first-of-the-day elective surgeries started after 10:01 am. The SIST was strongly associated with an in-hospital wait time for surgery (P=.016). The elective surgery cancellation rate was 5.2%, and aggregate mean TOT was 50.25 minutes. The mean in-hospital surgery wait time was 45.40 hours, longer than the national cutoff for wait time. In a bivariable analysis, the independent variables that demonstrated association operating room productivity were then inputted into a multivariable regression analysis model. However, none of the predictor/independent variables showed significance in the multivariable regression analysis model.

CONCLUSION

The volume of surgery and overall OR productivity in Ethiopia is low. This calls for concerted action to optimize OR efficiency and improve access to timely and safe surgical care in Ethiopia and other LMICs.

Surgical System Efficiency and Operative Productivity in Public and Private Health Facilities in Ethiopia: A Cross-Sectional Evaluation

BACKGROUND

Global and local health organizations track surgical system efficiency to improve surgical system performance using various efficiency metrics, such as operating room (OR) output, surgical incision start time (SIST), turnover time (TOT), cancellation rate among elective surgeries, and in-hospital surgery wait time. We evaluated the surgical system efficiency and factors affecting the efficiency in health facilities across Ethiopia.

METHODS

A cross-sectional study design with retrospective record review was used to evaluate the surgical system efficiency in 163 public and private health facilities in Ethiopia from December 2020 to June 2021. Experienced, trained surgical clinicians abstracted efficiency data from service registers and patient charts using a pretested tool. A bivariable and multivariable regression analysis was conducted.

RESULTS

In the study facilities, 84.11% of the operating tables were functional, and 68,596 major surgeries were performed. The aggregate OR output in both public and private health facilities was 2 surgeries per day per OR table. Operating productivity was shown to be affected by first-case SIST (P=.004). However, of the total 881 surgery incision times audited, 19.86% of the first-of-the-day elective surgeries started after 10:01 am. The SIST was strongly associated with an in-hospital wait time for surgery (P=.016). The elective surgery cancellation rate was 5.2%, and aggregate mean TOT was 50.25 minutes. The mean in-hospital surgery wait time was 45.40 hours, longer than the national cutoff for wait time. In a bivariable analysis, the independent variables that demonstrated association operating room productivity were then inputted into a multivariable regression analysis model. However, none of the predictor/independent variables showed significance in the multivariable regression analysis model.

CONCLUSION

The volume of surgery and overall OR productivity in Ethiopia is low. This calls for concerted action to optimize OR efficiency and improve access to timely and safe surgical care in Ethiopia and other LMICs.

Case cancellations and associated factors on the day of surgery in hospitals of Wolaita Zone, South Ethiopia

BACKGROUND

Cancellations of elective surgery cases are frequent and have significant negative consequences. It causes wasting of valuable resources, patient unhappiness, and psychological stress of patients. Despite this, little is known about the case cancellation and associated factors on the day of surgery in Ethiopia, particularly in the study area.

OBJECTIVE

This study aimed to assess the magnitude of case cancellation and associated factors on the day of surgery in hospitals in Wolaita zone, South Ethiopia, from May 17 to June 17, 2023.

METHODS

A hospital-based cross-sectional study involving 322 patients was conducted at Wolaita Sodo Zone, South Ethiopia. All elective surgical cases scheduled during the study period were included. The entire number of participants was selected using a systematic random sampling process. Epidata V.3 was used to enter data, and SPSS V.25 was used to analyze it. Binary logistic regression was used to check for a possible association. P-values < 0.05 and 95% CI were used on multi-variable analysis as the threshold for the significant statistical association.

RESULT

A total of 313 study participants were scheduled for elective surgical procedures during the study period and gave a response rate of 97.2%. The mean (± SD) age of the study participants was 39.18 (± 10.64) years. The two-third of patients, 53(64%) were rural residents, and more than half (178, or 55.3%) of the participants were female. This finding showed that the case cancellation was 22.4% (95% CI: 19.3 -25.9%). Among the total canceled cases, 49(58.3%) were males. Variables like rural residence (AOR = 3.48 95% CI: 1.22-9.95), Lack of lab result (AOR = 2.33, 95%CI:1.20-4.51), ophthalmology dept. (AOR = 2.53 95% CI:1.52-4.49), HTN (AOR = 2.53, 95% CI:1.52-4.49), patient refusal (AOR = 3.01 95% CI:1.22-5.05), and age b/n 31 and 43 (AOR = 1.50, 95% CI:1.02-2.01) were significantly associated factors with cancellation of elective surgical cases.

CONCLUSION

In this study schedule of case cancellation was high. The contributing factors of case cancellation were rural residence, Lack of lab results, ophthalmology dept, HTN, patient refusal, and age. To decrease unnecessary cancellations and increase cost efficiency, hospital administration and medical staff must plan ahead carefully, communicate effectively, and make efficient use of hospital resources.

Pull-Through for Hirschsprung's Disease: Insights for Limited-Resource Settings From Mbarara

INTRODUCTION

In many resource-limited settings, patients with Hirschsprung's Disease (HD) undergo initial diverting colostomy, followed by pull-through, and finally, colostomy closure. This approach allows for decompression of dilated and thickened bowel and improved patient nutritional status. However, this three-stage approach prolongs treatment duration, with significant stoma morbidity, costs, and impact on quality of life. Our aim was to determine whether pull-through for HD can safely be performed with simultaneous stoma closure, reducing treatment approach from three to two stages.

METHODS

Children with HD and diverting colostomy were prospectively followed as they underwent pull-through with simultaneous stoma closure. Their in-hospital course and 3-mo outpatient course were assessed for postoperative complications. Patients with total colonic HD, redo pull-through, and residual dilated colon were excluded from the study.

RESULTS

Of the 20 children, 17 were male (n = 17, 85%). All patients had rectosigmoid HD. The median weight, age at colostomy formation, and age at pull-through were 11.05 kg (interquartile range [IQR] 10-12.75), 0.9 y (IQR 0.25-2.8), and 2.08 y (IQR 1.28-2.75), respectively. Mean duration with colostomy before pull-through was 1.1 y (standard deviation 1.51). Median hospital length of stay was 6 d (IQR 5-7). Early complications included anastomotic leak (n = 1), perianal skin excoriation (n = 2), surgical site skin infection (n = 3), and fascial dehiscence (n = 1). Longer-term complications included stricture (n = 1, 5%) and enterocolitis (n = 2, 10%).

CONCLUSIONS

In this small case series, we have demonstrated that pull-through with simultaneous stoma closure can be safely performed in resource-constrained settings. Further studies are needed to understand the quality of life and economic impact of this change in management for HD patients.

Gynaecologic oncology surgical cancellations in Zambia

Introduction

Cancellations of elective surgery in low-and middle-income countries (LMIC) are common and a major hindrance for patients who are in need of surgical therapeutic modalities. This is especially important in the context of scaling up needed surgical interventions for gynaecological cancer care. There is a knowledge gap in the literature related to cancellation of gynaecologic oncology surgeries in LMIC, where there is enormous need for this specific cancer surgical capacity. We report in an observational descriptive fashion, our experience at the UTH/CDH in Lusaka, Zambia, on the causes of surgical cancellations in gynaecologic oncology.

Methods

From January 1, 2021 through June 31, 2023, we retrospectively evaluated the surgical registry for gynaecologic oncology at the UTH/CDH in Lusaka, Zambia to assess the number and causes of surgical cancellations.

Results

There were a total of 66 (16.96%) surgical cancellations out of 389 scheduled gynaecologic oncology cases. Lack of available blood and/or low haemoglobin was the most frequent cause of surgical cancellations, 27 cases (40.90%).

Conclusion

We highlight in our series that the lack of blood, leading to surgical cancellations was the most frequent impediment related to performing scheduled gynaecologic oncology surgical procedures. As gynaecologic oncology services scale up in LMIC, given the radical nature of surgery and its association with blood loss, it is incumbent on the entire clinical ecosystem to address this issue and to develop mitigating strategies, specific to their respective resource setting.

Cancellation of elective surgery and associated factors among patients scheduled for elective surgeries in public hospitals in Harari regional state, Eastern Ethiopia

Background

Canceling elective surgeries is a significant problem in many hospitals leading to patient dissatisfaction, increased costs, and emotional trauma for patients and their families. Despite this, there is limited information about the cancellation of elective surgeries in Ethiopia, mainly in the study area.

Objective

This study aimed to assess the magnitude of cancellation and associated factors among patients scheduled for elective surgeries in public hospitals in the Harari Regional State, Eastern Ethiopia, from 1 August to 30 August 2021.

Methods

A hospital-based cross-sectional study was conducted on 378 patients scheduled for elective surgeries. Data were gathered using a non-random sequential sampling approach. In addition, a structured face-to-face interviewer-administered questionnaire was employed. The gathered information was input into Epidata version 3.1 and then exported to Statistical Package for Social Software version 26. To find the variables associated with the cancellation of elective surgeries, binary and multi-variable logistic regression analyses were conducted. In the binary analysis, all variables with a p-value of less than 0.25 were included in the multivariable analysis. Finally, a 0.05 p-value with a 95% confidence interval and an adjusted odds ratio was used to declare a significant association.

Results

This study included 378 patients scheduled for elective surgeries. Among those, 35.2% of the surgeries were canceled (95% confidence interval: 29.4–39.6). Being female (adjusted odds ratio: 2.46; 95% confidence interval: 1.44–4.203), lack of formal education (adjusted odds ratio: 2.03; 95% confidence interval: 1.15–3.58), place of residence (adjusted odds ratio: 1.70; 95% confidence interval: 1.03–2.81), increase in blood pressure (adjusted odds ratio: 5.09; 95% confidence interval:1.90–13.59), and ophthalmologic surgery (adjusted odds ratio: 3.76; 95% confidence interval: 1.41–10.0) were factors associated with the cancellation of elective surgeries.

Conclusion

In this study, nearly one third of scheduled elective surgery was canceled. The primary contributing variables to the surgery cancellations were being female, lack of formal education, place of residence, ophthalmologic surgery, and increased blood pressure. Therefore, timely evidence-based reporting through the supervision team was advised to decrease cancellations.

An In-Depth Analysis of Providers and Services of Cancellation in Anesthesia Reveals a Complex Picture after Systemic Analysis

The variances in operating room (OR) cancellation rates between different service lines and operators within these service lines were assessed by reviewing the electronic medical record (EMR) covering 34,561 cases performed by 199 OR operators in 2018. We assumed that cancellations would differ between different service lines, but the between-operators variance was minimal within the service line. We hypothesized that most variability would be secondary to patient-specific (weekdays, time of year, and national holidays), seasonal and administrative issues. Of 4165 case cancellations, the majority (73.1%) occurred before the patient arrived at the hospital. A total of 60% of all cancellations were within gastroenterology, interventional cardiology, and orthopedics. Cancellation rate variability between surgeons operating within the same service line greatly varied between services from very homogenous to very diverse across providers. The top reasons for cancellation were: date change, canceled by a patient, or "no show". The highest cancellation rates occurred on Mondays and Tuesdays, in January and September, and during weeks associated with national holidays. In summary, cancellation variability must be analyzed at the level of individual specialties, operators, and time variability.

Prevalence and Causes of Elective Surgical Cancellations: Findings from a Rural Tertiary Hospital in the Eastern Cape, South Africa

Background: Cancellations of elective surgeries adversely affect the patient, hospital staff, facility, and health system. Cancellations potentially result in hospital financial losses, theatre inefficiency, and substandard patient care. A common benchmark for the cancellation rate of elective surgeries is less than five percent, and most operating rooms fall short of this standard. There is a paucity of data on the rates and causes of elective surgical cancellations in rural, resource-limited settings. This study aimed to determine the prevalence of elective surgery cancellations, the causes for such cancellations, and the surgical disciplines most affected at Nelson Mandela Academic Hospital (NMAH). Methodology: This was an observational, descriptive, cross-sectional review of operating theatre records from January 2019 to July 2019. The prevalence and main causes of elective case cancellations were determined. The causes were classified, and the most affected surgical departments and patient characteristics were identified. Results: The prevalence of elective surgical case cancellations was 14.4% in our hospital, higher than the international benchmark of 5%. Patient-, facility-, and surgical-related factors were the leading causes of cancellations, and avoidable cancellations were mostly surgical- and anaesthetic-related. Ophthalmology was the most affected, followed by gynaecology and general surgery, with plastic surgery being the least affected. The most common patient-related factors were nonattendance and uncontrolled medical conditions, while overbooking was the most common surgical reason. Abnormal investigatory results and unfit status were the most common anaesthetic reasons. Facility-related issues included the lack of theatre time, equipment scarcity or malfunction, and staff unavailability. Most cancellations were unavoidable, but with careful planning, could be avoided. Conclusion and recommendations: This study identified challenges with theatre efficiency in a rural, resource-limited setting that call for the cooperation of multidisciplinary teams of surgeons, anaesthetists, nursing staff, and health care policymakers.

Education for Registered Nurses Completing Preoperative Anesthesia Interviews: A Quality Improvement Project

PURPOSE

This quality improvement project implemented job-related education for registered nurses (RNs) completing preoperative anesthesia interviews (PAIs) to increase their knowledge and confidence, improve completeness of documented preoperative interviews, and decrease day of surgery (DOS) cancellations.

DESIGN

Pre/post implementation design and retrospective chart review.

METHODS

An educational module on PAIs was created and RNs working in the pre-admission testing (PAT) clinic were asked to complete the module. Pre and post implementation data was collected on RN knowledge and confidence, assessment completeness, and DOS cancellations.

FINDINGS

Knowledge and confidence increases were not statistically significant, although several interview components within PAI documentation improved with statistical significance. Overall DOS cancellations, although not statistically significant, were found to decrease, 1.3% to 1.2%.

CONCLUSIONS

Registered nurses' knowledge, confidence and PAI completeness improved after completing the educational module with anesthetic considerations. Patients seen at the PAT clinic for PAIs before the DOS allowed for patient optimization and education leading to decreased preventable DOS cancellations.

Magnitude and reasons of surgery cancellation among elective surgical cases in Wolaita Sodo University Comprehensive Specialized Hospital, Southern Ethiopia, 2021

Background

Cancellations of cases are common; most of those cancellations are due to avoidable causes. It is a major cause of psychological trauma for patients and their families. Although little is known in Ethiopia, the aim of this study is aimed to assess the prevalence and the cause of elective surgery cancellation.

Methods

A cross-sectional prospective study design was conducted on 326 patients scheduled for elective surgery from October 1 to December 1st. All consecutive elective surgical cases scheduled during the study period were included in the study. Data were collected using a prepared and pretested questionnaire and entered into SPSS version 23 for analysis. The result of the study was reported in the form of text, tables, and graphs.

Result

During the study, 326 patients were scheduled for elective surgery, among those, 83(25.6%) of surgery was canceled. Patient-related (31.32%) and administrative-related (26.5%) factors were the two most causes of cancellation.

Conclusion

Patient-related and administrative-related factors were the leading causes of cancellation of elective surgical operations in our hospital. Concerned bodies should bring a sustainable change and improvement to prevent unnecessary cancellations and enhance cost-effectiveness through communications, careful planning and efficient utilization of the available hospital resources.

Outcomes and Disposition of Patients After Case Cancellation on Day of Surgery for Reasons Attributed to Medical or Anesthetic Care: A Retrospective Cohort Analysis

BACKGROUND

Many day-of-surgery cancellations are avoidable, and different strategies are used to prevent these costly adverse events. Despite these past analyses and evaluations of positive interventions, studies have not examined the final disposition of patients whose cases were canceled in this late manner. This study sought to determine whether surgical procedures canceled for medical or anesthetic reasons were ultimately rescheduled, and the time elapsed between cancellation and completion. In addition, the resolution of the underlying issue leading to cancellation was examined.

METHODS

Two years of surgical case data were reviewed in the electronic health record to isolate all procedures canceled on the intended operative date. These cases were then filtered by the documented reason for cancellation into 2 categories: 1 for cases related to medical or anesthetic care and 1 for unrelated cases. Medical- or anesthetic-related cases were further categorized to better elucidate the underlying reason for cancellation. Cases were then traced to determine if and when the procedure was ultimately completed. If a case was rescheduled, the record was reviewed to determine whether the underlying reason for cancellation was resolved.

RESULTS

A total of 4472 cases were canceled in the study period with only 20% associated with medical or anesthetic causes. Of these, 72% were rescheduled and 83% of all rescheduled cases resolved the underlying issue before the rescheduled procedure. Nearly half of all cases (47.8%) canceled on the day of surgery for reasons linked to medical and/or anesthetic care were due to acute conditions.

CONCLUSIONS

Nearly a fifth of cases that are canceled on the date of surgery are never rescheduled and, if they are rescheduled, the delay can be substantial. Although the majority of patients whose procedure are canceled for reasons related to medical or anesthetic care have resolved the underlying issue that led to initial postponement, a significant portion of patients have no change in their status before the ultimate completion of their surgical procedure.

Incidence and Risk Factors for Patient-related Short-term Cancellation of Elective Arthroscopic Surgery: A Case-matched Study

Introduction:

Short-term cancellation of elective ambulatory orthopaedic surgery can result in disruption to the process flow of the operating room, with resultant negative financial implications for the health system. The risk factors for patient-related short-term cancellations within 24 hours of the surgical date have not been well defined.

Methods:

A retrospective review of a single orthopaedic surgery electronic internal database was done to identify all cancellations from January 1, 2016, through December 31, 2019, which were made within 24 hours of the surgical date. Inclusion criteria included elective arthroscopic procedures canceled solely for patient-related issues. Any cancellation for surgeon-related or ambulatory center–related reasons was excluded. Demographic patient and surgical data, including insurance type, employment status, previous history of cancellation for the same surgery, socioeconomic status based on the Area Deprivation Index, and surgery type, were tabulated. Each cancellation was matched 1:2 with noncanceled cases based on the anatomic site of the arthroscopy scheduled. Multivariable logistic regression was used to examine associations of patient demographic and medical characteristics with surgical cancellation.

Results:

There were 4,715 total arthroscopic procedures done during the study period, of which 126 (2.7%) were canceled within 24 hours of the surgery date. The mean age of the canceled cases was 44.9 ± 16.1 years (range, 14 to 77 years), with 46 females (43%) included. The presence of MRI of the involved joint within 6 months of surgery (adjusted odds ratio [aOR], 0.39, 95% confidence interval [CI], 0.17 to 0.91) and current employment (aOR, 0.56, 95% CI, 0.33-0.94) were independently predictive of noncancellation. Current smokers were more likely to cancel within 24 hours of surgery (aOR, 2.63, 95% CI, 1.4-4.9). Finally, having previously canceled the same surgery was significantly associated with a current surgical cancellation (P = 0.004).

Discussion:

Identification of the factors associated with short-term patient-related cancellation of elective arthroscopy may serve as the basis for preoperative interventions aimed specifically at those more likely to cancel. In turn, these interventions can minimize preventable cancellations.

Pediatric Plastic Surgery Operating Room Block-Time Utilization: A Casualty of Illness

BACKGROUND

Optimizing operating room (OR) utilization is a critical component of health care system efficiency. The purpose of our study was to analyze the extent of OR cancellation and its effect on raw utilization of OR block time allotted to surgeons in the pediatric plastic surgery department.

METHODS

The authors retrospectively reviewed the cases of 4 plastic surgeons at a tertiary pediatric hospital between 2018 and 2019. Data collected included patient demographics, type of surgery, time of cancellation, reason for cancellation, length of surgery, and minutes of block time allotted to each surgeon per year. Percent of cases canceled, scheduled times lost, and block times lost were calculated.

RESULTS

Surgeons A, B, C, and D scheduled 170, 416, 305, and 474 cases, respectively. Overall, 7% of cases were canceled, 9.1% of scheduled time was lost, and a total of 5.1% of block time was lost due to cancellation. Patients of surgeon A and D were more likely to cancel due to reasons classified as "other," including causes such as failure of nil per os or a family's last-minute decision to forego elective surgery (33.3% and 37.2%, respectively), whereas patients of surgeon B and C were more likely to cancel due to illness (67.9% and 36.4%, respectively).

CONCLUSIONS

Cancellations negatively impact raw utilization times; if fewer cases are performed, allotted block times are redistributed. Communication with patients in the week prior to surgery may allow for earlier identification of likely cancellations. Future directions include exploring whether particular surgeon characteristics are linked to rate of cancellations.

Assessing the Rates and Reasons of Elective Surgical Cancellations on the Day of Surgery: A Multicentre Study from Urban Indian Hospitals

BACKGROUND

Cancellations of elective surgeries on the day of surgery (DOS) can lead to added financial burden and wastage of resources for healthcare facilities; as well as social and emotional problems to patients. These cancellations act as barriers to delivering efficient surgical services. Optimal utilisation of the available resources is necessary for resource-constrained low-and-middle-income countries (LMIC). This study investigates the rate and causes of cancellations of elective surgeries on the DOS in various surgical departments across ten hospitals in India.

METHODS

A research consortium 'IndSurg' led by World Health Organisation Collaboration Centre (WHOCC) for Research in Surgical Care Delivery in LMICs, India conducted this multicentre retrospective cross-sectional study to analyse the cancellations of elective/planned surgical operations on DOS across urban secondary and tertiary level hospitals. We audited surgical records of a pre-decided period of six weeks for cancellations, documented relevant demographic information and reasons for cancellations.

RESULTS

We analysed records from the participating hospitals, with an overall cancellation rate of 9.7% (508/5231) on the DOS for elective surgical operations. Of these, 74% were avoidable cancellations. A majority (30%) of these 508 cancellations were attributed to insufficient resources, 28% due to patient's refusal or failure to show-up, and 22% due to change in patient's medical status.

CONCLUSION

We saw a preponderance of avoidable reasons for elective surgery cancellations. A multidisciplinary approach with adequate preoperative patient counselling, timely communication between the patients and caregivers, adequate preoperative anaesthetic assessment, and planning by the surgical team may help reduce the cancellation rate.

Operating room efficiency in a low resource setting: a pilot study from a large tertiary referral center in Ethiopia

BACKGROUND

The operating room (OR) is one of the most expensive areas of a hospital, requiring large capital and recurring investments, and necessitating efficient throughput to reduce costs per patient encounter. On top of increasing costs, inefficient utilization of operating rooms results in prolonged waiting lists, high rate of cancellation, frustration of OR personnel as well as increased anxiety that negatively impacts the health of patients. This problem is magnified in developing countries, where there is a high unmet surgical need. However, no system currently exists to assess operating room utilization in Ethiopia.

METHODOLOGY

A prospective study was conducted over a period of 3 months (May 1 to July 31, 2019) in a tertiary hospital. Surgical case start time, end time, room turnover time, cancellations and reason for cancellation were observed to evaluate the efficiency of eight operating rooms.

RESULTS

A total of 933 elective procedures were observed during the study period. Of these, 246 were cancelled, yielding a cancellation rate of 35.8%. The most common reasons for cancellation were related to lack of OR time and patient preparation (8.7% and 7.7% respectively). Shortage of facilities (instrument, blood, ICU bed) were causes of cancelation in 7.7%. Start time was delayed in 93.4% (mean 8:56 am ± 52 min) of cases. Last case completion time was early in 47.9% and delayed in 20.6% (mean 2:54 pm ± 156 min). Turnover time was prolonged in 34.5% (mean 25 min ± 49 min). Total operating room utilization ranged from 10.5% to 174%. Operating rooms were underutilized in 42.7% while overutilization was found in 14.6%.

CONCLUSION

We found a high cancellation rate, most attributable to late start times leading to delays for the remainder of cases, and lack of preoperative patient preparation. In a setting with a high unmet burden of surgical disease, OR efficiency must be maximized with improved patient evaluation workflows, adequate OR staffing and commitment to punctual start times. We recommend future quality improvement projects focusing on these areas to increase OR efficiency.

Shared surgery blood reserve reduces surgery suspension rate due to blood unavailability

The hemotherapy service in health units with high surgical demand has been pointed out as a challenge, especially concerning storage management simultaneously with transfusion demand attendance. The objective of this study is to analyze service efficacy after the implementation of a new strategy to meet storage and transfusion demands. The present study analyzed the records of the hemotherapy service related to blood components management in surgeries where blood reserve was necessary for RhD positive patients at the National Institute of Traumatology and Orthopedics. A shared compatibility test and surgery reserve from the first semester of 2018 was compared to an equivalent period in 2017, prior to its implementation, under an individualized protocol to each patient scheduled on the surgery map. After the implementation of the shared protocol, the transfusion demand was higher, due to an increase in the percentage of surgeries that required transfusion, as well as to the augmented number of blood components used in the surgeries. Even in the presence of a slight decrease in storage, the hemotherapy assistance was considered efficient, since the percentage of surgery suspension reduced from 2 % to 0.2 % after the implementation of the shared protocol. This improvement resulted in an adjustment in the classification of reasons for surgical procedure cancellations, so that the reason "blood shortage" was repositioned from the first to the seventeenth position. This is the first record of a shared compatibility protocol and surgery reserve and we hope to contribute to the development of the hemotherapy service and surgical patient healthcare.

Prevalence and factors associated with cancellation and deferment of elective surgical cases at a rural private tertiary hospital in Western Uganda: a cross-sectional study

Introduction

the cancellation of elective surgery is still a worldwide challenge and this is associated with emotional and economical trauma for the patients and their families as well as a decrease in the efficiency of the operating theatre. This study aimed at determining the prevalence and factors associated with cancellation and deferment of elective surgery in a rural private tertiary teaching hospital in Western Uganda.

Methods

a cross-sectional study design was conducted. Data was collected from 1^st July 2019 to 31^st December 2019. Patients scheduled for elective surgery and either cancelled or deferred on the actual day of surgery were included in the study. Statistical analysis was done using STATA version 15.

Results

four hundred patients were scheduled for elective surgery during the study period, among which 90 (22.5%) were cancelled and 310 (78.5%) had their surgeries as scheduled. The highest cancellation of elective surgical operations was observed in general surgery department with 81% elective cases cancelled or deferred, followed by orthopedic department 10% and gynecology department 9%. The most common reasons for cancellation were patient-related (39%) and health worker-related (35%) factors. Other factors included administrative (17%) and anesthesia related factors (9%). Cancellation was mainly due to lack of finances which accounted for 23.3% of the patients, inadequate patient preparation (16.6%) and unavailability of surgeons (15.5%). Major elective surgeries were cancelled 1.7 times more than minor electives surgeries [adjusted prevalence ratio 1.7 (95%CI: 1.07-2.73) and p-value: 0.024].

Conclusion

cancellation and deferment of elective surgeries is still of a major concern in this private rural tertiary hospital with most of the reasons easily preventable through proper scheduling of patients, improved communication between surgical teams and with patients; and effective utilization of available resources and man power.

Magnitude and causes of cancelation for elective surgical procedures in Debre Tabor General hospital: A cross-sectional study

Objectives:

Elective surgical case cancelation is a common problem and can cause prolonged wait times, harm to patients, and is a waste of scarce resources. Reasons for cancelations are complex and change place to place because they are related to patients, organizational issues, and clinical staff. So, this study is aimed to assess the magnitude and causes of the case cancelation among elective surgical cases in a general hospital.

Methods:

A cross-sectional prospective study design was conducted on 221 patients scheduled for elective surgery from March 1 to May 30 2019 G.C. All consecutive elective surgical cases scheduled during the study period were included in the study. Data were collected using prepared and pretested questionnaire and entered in the SPSS version 20 for analysis purpose.

Results:

During the study, 221 patients were scheduled for elective surgical operations, among these 150 (67.9%) patients were operated on the planned date of surgery whereas 71 (32.1%) operations were canceled. The decision for the cancelation was done by the anesthetist due to preoperative coexisting disease findings and inadequate preparation of the patient for the intended operations were 33 (46.5%) followed by administrative-related issues which account 26 (36.6%).

Conclusion:

Cancelation of elective surgical procedures on the day of surgery was high in this study due to different reasons. Cancelation can be minimized if all the responsible bodies can communicate early regard to the patient.

Canceled Total Joint Arthroplasty: Who, What, When, and Why?

BACKGROUND

Unexpected cancelation of scheduled total joint arthroplasty (TJA) procedures creates patient distress and disruption for the clinical team. The purpose of this study is to identify the etiology and fate of cancelations for scheduled TJAs.

METHODS

A consecutive series of 11,670 patients at a single institution from 2013 to 2017 was reviewed in March 2020. All patients who were scheduled for a primary total hip arthroplasty or total knee arthroplasty and subsequently canceled were identified. The etiology of cancelation and time to rescheduling were recorded.

RESULTS

Of the 505 (4.3%) canceled patients, 209 (42%) were due to medical reasons. Three hundred ninety-one patients (77%) eventually underwent their procedure at a mean delay of 165 days (19-1908). Only 53 (25%) patients canceled for a medical reason underwent further diagnostic or therapeutic intervention for their medical condition. When compared to patient-driven cancelations, those canceled for medical reasons had a higher mean Charlson Comorbidity Index (0.82 vs 0.39, P < .001), were canceled closer to the scheduled surgery date (8.55 vs 18.1 days, P < .001), and were more likely to eventually undergo surgery (86% vs 73%, P = .004).

CONCLUSION

Canceled elective TJA surgeries are most often due to a medical concern, however only a minority of these patients undergo intervention for that medical condition. To minimize the risk of cancelation, healthcare providers may consider early referral of medically complex patients to the patient's primary care physician. After cancelation, patients should have a clearly defined path to return to the operative schedule to prevent further delays.

Root causes of elective surgical case cancellation in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Cancellation of elective surgical operation recognized as a major cause of emotional trauma to patients as well as their families. In Ethiopia, prevalence and root causes for elective surgical case cancellation varies from time to time in different settings. This systematic review and meta-analysis aimed to find the pooled prevalence and root causes for elective surgical case cancellation in Ethiopia.

METHODS

The databases for the search were Web of Science, PubMed, and Google Scholar. The last literature search was performed on February 8, 2020. To assess publication bias Egger's regression analysis was applied. The pooled estimation was estimated using random-effects model meta-analysis. Subgroup analysis was also done based on the root causes of surgical case cancellation.

RESULTS

This meta-analysis included a total of 5 studies with 5591 study participants. The pooled prevalence of elective surgical case cancellation was 21.41% (95% CI: 12.75 to 30.06%). Administration-related reason (34.50%) was the most common identified root cause, followed by surgeon (25.29%), medical (13.90%), and patient-related reasons (13.34%).

CONCLUSION

The prevalence of elective surgical case cancellation was considerable. The most common root cause for elective surgical case cancellation was administration-related reasons, followed by the surgeon, medical and patient-related reasons. The causes for the surgical cancellations are potentially preventable. Thus, efforts should be made to prevent unnecessary cancellations through careful planning.

An examination of difficulties accessing surgical care in Canada from 2005-2014: Results from the Canadian Community Health Survey

Background

Difficulties accessing surgical care (e.g., related to wait times, cancellations, cost, receiving a diagnosis) are understudied in Canada. Using population-based data, we studied difficulty accessing non-emergency surgical care, including (1) the incidence and annual changes in incidence, (2) types of difficulties, and (3) associated factors (e.g., sociodemographics, surgery characteristics).

Methods

Cross-sectional data from the Canadian Community Health Survey annual components were analyzed from 2005–2014. Weighted frequencies established the annual incidence of difficulty accessing surgical care, and total incidence of types of difficulties. Chi-square analyses, independent samples t-tests, and a multivariable logistic regression examined sociodemographic and surgery-related characteristics associated with difficulty accessing surgical care.

Results

Among individuals who required past-year non-emergency surgery between 2005–2014 (weighted n = 3,052,072), 15.6% experienced difficulty accessing surgical care. The most common difficulty was “waited too long for surgery” (58.5%). There were significant differences in the incidence of difficulty according to year (Χ² = 83.50, p < .001) from 2005–2014. The incidence of difficulty accessing surgery varied according to sex (Χ² = 4.02, p < .05), surgery type (Χ² = 96.09, p < .001), party responsible for cancellation/postponement (Χ² range: 4.36–19.01, p < .05), and waiting time (t = 10.59, p < .001). In particular, males, orthopedic surgery, and surgery cancelled by the surgeon or hospital had the highest rates of difficulty.

Conclusion

Results provide insight into the difficulties experienced by patients accessing elective surgery, and the associated factors. These results may inform targeted healthcare interventions and resource reallocation to reduce these occurrences.

Global prevalence and reasons for case cancellation on the intended day of surgery: A systematic review and meta-analysis

BACKGROUND

Cancellation of operation on the intended day of surgery affects the efficiency of Operation Room which incurs a significant financial loss for the patient, hospital, and health care cost of a country at large. This systematic and Meta-Analysis was intended to provide evidence on the global prevalence and determinants of case cancellation on the intended day of surgery.

METHODS

A comprehensive search was conducted in PubMed/Medline; Science direct and LILACS from January 2010 to May 2020 without language restriction. The Heterogeneity among the included studies was checked with forest plot, χ2 test, I2 test, and the p-values. All observational studies reporting prevalence and determinants were included.

RESULTS

A total of 1207 articles were identified from different databases with an initial search. Fort-eight articles were selected for evaluation after the successive screening. Thirty-three Articles with 306,635 participants were included. The Meta-Analysis revealed that the global prevalence of case cancellation on the intended day of surgery was 18% (95% CI: 16 to 20). The Meta-Analysis also showed that lack of operation theatre facility accounted for the major reason for cancellation followed by no attendant and change in medical condition.

CONCLUSION

The meta-analysis revealed that the prevalence of case cancellation was very high in low and middle-income countries and the majorities were avoidable which entails rigorous activities on operation theatre facilities, preoperative evaluation and preparation, patient and health care provider communications.

REGISTRATION

This Systematic Review and Meta-Analysis was registered in a research registry (researchregistry5746) available at https://www.researchregistry.com/browse-the-registry#home/.

Evaluation of the Reasons for the Cancellation of Elective Procedures at Level 3 University Hospital on the Day of Surgery

PURPOSE

Unexpected cancellations of planned elective procedures are a global problem for hospitals, causing a waste of hospital resources and manpower, and reduces the efficiency of hospitals. In this study, we tried to identify the causes of cancellations of elective procedures, and to examine the relationship between the causes.

DESIGN

A retrospective, descriptive single-center study.

METHODS

Nine thousand five hundred sixty-six elective procedures scheduled between January 2015 and December 2015 were retrospectively examined. Reasons for cancellation, the associated surgical clinic, and the day and season of the canceled procedures were recorded.

FINDINGS

Of the total 9,566 procedures, 496 (5.2%) were canceled. Of the cancellations, 31.3% were due to patient-related reasons, 29.2% because of inadequate anesthesia preparation, and 19% because of nonavailability of operating rooms.

CONCLUSIONS

Cancellation of elective surgeries causes a waste of time and resources. Determining the reasons for cancellations to reduce cancellation rates is important for each hospital.

Predicting Elective Orthopaedic Sports Medicine Surgical Cancellations Based on Patient Demographics

Purpose

To evaluate whether patient demographics are associated with cancellation of elective orthopaedic sports medicine surgical procedures.

Methods

We retrospectively reviewed the electronic medical records of 761 patients who were scheduled to undergo an elective sports medicine orthopaedic operation from January 1, 2015, to December 31, 2017. The patients were divided into 2 groups: those who underwent the scheduled procedure (group A) and those in whom the operation was canceled for any reason prior to the surgical date and not rescheduled (group B). Univariate analysis assessed patient factors consisting of age, sex, race, language, marital status, occupation status, type of insurance (Medicaid or Medicare vs private), smoking history, employment status, and history of surgery to determine which demographic factors led to an increased risk of elective case cancellation.

Results

Patients who canceled were significantly older (46.5 years vs 41.5 years, t = 2.432, P = .015) than those who do not. In addition, current smokers (22.5% vs 10.9%, χ² = 10.85, P = .001), patients with Medicare or Medicaid versus private insurance (16.7% vs 10.0%, χ² = 5.35, P = .021), non–English-speaking patients (29.5% vs 11.6%, χ² = 11.43, P = .001), and patients without a history of surgery requiring anesthesia (18.8% vs 9.6%, χ² = 9.96, P = .002) were all more likely to cancel. When all studied variables were examined in a logistic regression analysis, of the above demographic variables, only insurance status was no longer significant, given its correlation with age and language.

Conclusions

Increased age (≥46.5 years), non-English speaking, smoking, lack of a history of surgery requiring anesthesia, and Medicaid or Medicare insurance were found to contribute to an increased risk of elective orthopaedic surgery cancellation.

Level of Evidence

Level III, case-control study.

Winter cancellations of elective surgical procedures in the UK: a questionnaire survey of patients on the economic and psychological impact

OBJECTIVES

To quantify the economic and psychological impact of the cancellation of operations due to winter pressures on patients, their families and the economy.

DESIGN

This questionnaire study was designed with the help of patient groups. Data were collected on the economic and financial burden of cancellations. Emotions were also quantified on a 5-point Likert scale.

SETTING

Five NHS Hospital Trusts in the East Midlands region of England.

PARTICIPANTS

We identified 796 participants who had their elective operations cancelled between 1 November 2017 and 31 March 2018 and received responses from 339 (43%) participants.

INTERVENTIONS

Participants were posted a modified version of a validated quality of life questionnaire with a prepaid return envelope.

MAIN OUTCOME MEASURES

The primary outcome measures were the financial and psychological impact of the cancellation of elective surgery on patients and their families.

RESULTS

Of the 339 respondents, 163 (48%) were aged <65 years, with 111 (68%) being in employment. Sixty-six (19%) participants had their operations cancelled on the day. Only 69 (62%) of working adults were able to return to work during the time scheduled for their operation, with a mean loss of 5 working days (SD 10). Additional working days were lost subsequently by 60 (54%) participants (mean 7 days (SD 10)). Family members of 111 (33%) participants required additional time off work (mean 5 days (SD 7)). Over 30% of participants reported extreme levels of sadness, disappointment, anger, frustration and stress. At least moderate concern about continued symptoms was reported by 234 (70%) participants, and 193 (59%) participants reported at least moderate concern about their deteriorating condition.

CONCLUSIONS

The cancellation of elective surgery during the winter had an adverse impact on patients and the economy, including days of work lost and health-related anxiety. We recommend better planning, and provision of more notice and better support to patients.