R Arun Kumar^1*, C Ganesan²

¹Associate Professor, ²Professor and HOD, Department of Anaesthesiology, PSG Institute of Medical Sciences and Research, Peelamedu, Coimbatore-641004, Tamil Nadu, INDIA.

Email: shivaaniarun76@gmail.com

DISCUSSION

The National Health Service (NHS), UK through its Modernization Agency Theater Program has defined case cancellation as those that occur after the patient has been notified of operation date⁸. Few define it as the procedures that were cancelled either on the day on which the surgery was scheduled, or cases which appeared in the definitive scheduled list but ultimately was not performed. Out of 10,306 patients during the scheduled period in our audit, 532 (5.16%) patients had cancellation on the elective list. Rakesh Garg et al^5,17 in a north Indian government hospital reported 30.3 % cancellation list followed by, Ezike et al⁷ stated 25.3 % cancellations, Rajendra Kumar et al¹⁶ in an government hospital showed 17.6 % cancellation, Abderrazak Sahraoui and Mohammed Elarref et al² observed 13.4 % and JimEnez et al⁹ noted with 3.9 % as cancellation comparable to a study in a Jordanian hospital¹¹ with 3.6% cancellation on the elective list respectively. The cancellations at a teaching hospital in south india was found to be 4.4 % which was in accordance with our study (5.16%). In our audit, the frequency of cancellations was pronounced more in pre operative or surgical preparation related factors accounting for 265 patients (49.81%), followed by facility related factors in 142 patients (26.69%) and 125 patients (23.49%) in patient related factors respectively. On categorizing Surgical (or pre operative) preparation related factors which includes patients presenting with active respiratory infections, acute exacerbation of any medical conditions, electrolyte disturbances, uncontrolled blood sugar or blood pressure; the overall cancellation was maximum with abnormal laboratory values (21%) on the day of surgery. URI-related cancellations was reported by Palomero Rodriguez et al¹³, however this decreased from 12.9% in 2001 to 7.2% in 2003 through enhanced communication of simple and appropriate information to parents resembling with 7.54% in our audit. Knox et al reported a significant reduction in medical-related surgical cancellations after the establishment of a preoperative assessment clinic (P = 0.013).¹² Patients unwillingness for surgery accounted for 53% with regard to patient related factors for cancellation of surgery. Patients not willing for surgery at the last moment prior to surgery were due to fear, unfavorable conditions existing in the family or unawareness about the importance of surgeries. Female patients who were menstruating on the day of surgery were also considered in our study. Study by Fayed et al showed that 9% of patients decided not to undergo elective surgery on the day of surgery⁴. Being a teaching medical institution, few reasons for lack of operating time such as teaching and training the junior residents and interns could not be avoided. There was no issues with administrative or logistic causes such as power failure in operating room, failure of air conditioners, availability of oxygen source, usage of anaesthetic drugs, availability of blood and blood products, suture materials, linen, supply of water, bed availability and hospital workers strike in our audit. Cancellation by Insurance sanctioning availed by government scheme and private insurance peaked maximum cause due to delayed clearance or failure of obtaining the insurance. In general, surgeons took longer than estimated time to finish the procedure and was especially true for less-experienced surgeons and trainees. Surgeons are sometimes too optimistic and aware of the long waiting lists, but they want to operate as many patients as possible. This reason can be avoided by a better internal organization of work as well as planned use of staff breaks and the adequate preoperative preparation of the patients. Patient non compliance regarding medication regimens. Schofield et al¹⁸ reported bed availability and theatre time management as a main reason for cancellation; which was not an issue in our audit. Pandit JJ, Carry A¹⁴ estimated that over-booking of operation list is the common cause for postponement due to waiting list pressures. Windokun et al²⁰ reported surgeon’s un-availability as main reason. Dufek et al³recommended the improvement in protocol for pre-op patients’ evaluation to address these problems. Most of the reasons for cancellation were debatable as an issue of health care quality and was avoidable by judicious scheduling of lists and careful planning by the team involved in surgeries. We justified with improving following recommendations in our institution :

1. Calm, smooth, pleasant and noiseless pre operating assessment room can avoid missing major clinical findings
2. Closed loop communication and good rapport with the patient helps to instill confidence preventing the patient’s bias regarding the anesthesia and surgery
3. Follow appropriate pre operative instructions to improve the health care system avoiding major issues on the day of surgery
4.  Alleviation of the psychological distress of cancelling the surgery
5. Early start of the first case in the operating room
6. Surgical patients were adequately counseled, optimized their medical condition, appropriate continuation of medications and obtained informed consent regarding all relevant procedures
7. Inter departmental coordination in managing complicated and high risk cases
8. Increased utility of operating time in the theatre complex during the working hours
9. Following the medical ethics and to practice in accordance with the law

LIMITATIONS

Our study was related to inherent bias in categorizing the cancellation of cases due to varied reasons on behalf of multi factorial components leading to cancellation. The study was confined only to our institution and may not be standardized since the hospital policies varies in other teaching institutions.

CONCLUSION

Although cancellations were only 532 (5.16%) out of 10,306 patients of total elective surgeries, this can even be reduced by implementing and following the recommendations as per guidelines proposed, so that the potential causes can be avoided. To improve the better quality of life we recommend that the cancellations of surgeries can be reduced by improving pre operative assessment, requesting patient information on inter current illnesses between preadmission and surgery, better inter departmental coordination and adequate optimization prior to surgery, improving man power availability, availability of adequate resource sources and increasing the operation theatre utilization time to avoid cancellation of surgery on the scheduled day. Frequent conduct of audits, rectifying the pitfalls in the institution will definitely improve the better healthcare facility in the teaching hospital.

REFERENCES