Cancellation of elective surgical procedures in the GenitoUrinary section of National Hospital of Sri Lanka – can we do better ?

Conclusion and Recommendations Ideally there should be no cancellations. Cancellations can be minimized if the patients with medical problems were detected early and referred for an anaesthetic assessment soon after they are scheduled for surgery. Cancellation due to lack of theatre time should be minimised with proper planning. It is worth looking at why nearly 17% of patients defaulted. There may have been problems with communication. Minimising cancellations will improve operating room efficiency and reduce wastage of time and money.


Introduction
An operation theatre is the heart of a hospital requiring considerable human resources and expenditure from the hospital budget.However, operation theatres are underutilized and lie idle some of the time and many patients who are called for operation from waiting lists are not operated upon.Planned operations that are cancelled reflect inefficiency in management and causes inconvenience to patients.
Cancellation of operations presents a major problem in most hospitals.There are many reasons for cancellation of elective surgical cases.Cancellation of cases on the scheduled day of surgery leads to inefficient utilization of manpower and scarce resources.It also leads to prolonged hospital stay, and in many cases, repetition of the various aspects of preoperative preparation and management.All of these inconvenience the patient as well as increase patients' treatment expenses.This leads to emotional distress and economic ramification for both patients and institution.There is evidence that preoperative assessment in an anaesthesia clinic can reduce the cancellation of elective patients.An exception would be a patient who experiences an adverse medical event or illness between the time of evaluation and the time of the planned surgery.Avoidance of unnecessary cancellation of elective surgery, therefore, should lead to a reduction in the overall cost of treatment.
We conducted a prospective study to determine the reasons for cancellation of genitourinary surgical inpatients on the day of surgery in the National Hospital of Sri Lanka.The purpose of this audit was to assess the incidence, causes and pattern of cancellation of elective surgery in the genito-urinary section of our hospital.Our aim was to suggest improvements to the system to reduce such cancellations which will enhance efficiency and minimize wastage of already limited resources and manpower.

Material and methods
This study was conducted over a period of four months from May to August 2012 in the genitourinary section of the National Hospital of Sri Lanka.Majority of our surgical patients undergo a preoperative assessment in the wards the day before surgery.Patients that are booked by the surgeon are admitted a day before or on the day of surgery.Preoperative assessment of these patients is then done in the operation theatre.A data collection form was distributed to the operating theatre and attending medical officers and nurses were asked to fill it up.The data recorded included the total number of operations performed in the study period, the number cancelled and reasons for cancellation.Cancellation reasons were entered into the database as coded variables.

Discussion
The decision to postpone surgery has psychological, social and economic implications.An efficient surgical service should have a low rate of cancellation of operations.If operations are cancelled, the operation theatres are underused; efficiency is jeopardized, waiting lists increases and costs rise.It is a well-known fact that if resources are not properly utilized, the general population suffers especially the lower income groups, who depend more on public or government services for most of their healthcare needs.The cost of facilities and equipment which is underutilized adds to the cost of its services which is ultimately passed on to patients.
In our study, the most common cause of cancellation was coexisting medical problems 38.7% (41/106).This was the commonest reason in some of the studies done in London. 1 Majority of elective patients were seen by the anaesthetist only on the day prior to surgery.So the preoperative optimization is done over a short period of time.
Studies have shown that preoperative anaesthesia assessment of patients in anaesthetic assessment clinics significantly reduces operative room delays and cancellations. 2 From the administrative causes of cancellation 17.9% (19/106) were due to lack of theatre time.This was the commonest cause for cancellations in the Indian studies which was about 60%. 2,3We did not analyse the contributing factors for inadequate theatre time.Yet we realize that time management can be optimized by good communication and team effort.6% (6/106) of patients did not need surgical interventions though admitted.Some surgical audits have demonstrated that urgent operations reduce the number of available beds, decrease the rate of treatment of elective patients and thereby reduce the efficiency of surgical services. 4In addition unnecessary admissions in a surgical unit may cause cancellation of elective cases.Several delays were due to equipment failure.Equipment malfunction and breakdown is a In India the percentage of cancellation vary from 7-30%. 2,3,5The commonest causes were patient not attending and lack of theatre time. 2 In UK around 8% of scheduled elective operations are cancelled nationally within 24 hours of surgery.
In our study, although for a short duration of 4 months done in a specialized unit, 6% of surgical cases were cancelled on the day of surgery.This is lower than in many other studies.
This study shows that most causes for cancellation of operations are avoidable and steps must be taken to avoid these to enhance the utilization of operation theatre facility.Our audit had several limitations: Short duration of study (4 months), performed in a specialized single unit, and lack of a proper database of records.
We propose that frequent audits should be carried out at regular intervals to find out effective functioning of the OT, and we plan to do a reaudit in the future to assess the efficiency of the system after the suggestions we made from the analysis.

Conclusion
The goal of every healthcare team in the new millennium should be to minimize cost of treatment by encouraging cost effectiveness in every aspect of patient care.Efforts should be made to prevent cancellation of elective surgery by careful planning, bearing in mind the local constraints in human and material resources.
There is no point in preparing an operation list, which the available manpower and logistics cannot accomplish.Operation lists should be efficiently loaded to avoid under or overutilization of theatre facilities.

Figure 1 :Figure 2 :
Figure 1: Complexity of surgery Major Intermediate Minor Figure 3: Operations performed and cancellations