1.4. DISCUSSION
Cancellations of cardiac operations have a lasting impact on patients and the hospitals at which they are treated. There is a lack of national data on the rates of same-day cardiac surgery cancellations in the UK. The available data is limited to the GIRFT (Getting It Right First Time) Specialty Report 2018, which reports the mean cancellation rate of cardiothoracic surgery cancellation as 7.5% (range 2.6%-18.2%) across 31 UK centres.2 This study aimed to establish the rate of cancellation in our centre, its’ impact on patient outcomes and to formulate possible solutions to decrease cancellation rates, if deemed high. This is the first prospective study on same-day cancellations of elective and urgent cardiac surgeries in Europe and North America.
The cancellation rate at our centre during the study period was 16.6% (9.1% higher than that reported by GIRFT). In part, this could be related to the definitions of a cancellation. In this study all patients cancelled on the day of surgery, including those cancelled and operated within 24 hours, were considered cancelled. Our results showed that patients undergoing urgent cardiac surgery were more likely to have their procedures cancelled compared to those undergoing elective procedures. Additionally, this study revealed the five major reasons for cancellations to be in line with those previously reported.
ITU bed unavailability was the most common reason for cancellations at our centre. This may be improved by ring-fencing ITU beds for elective and urgent cases, whereby any same-day emergency case cannot take a scheduled case’s space.13, 14 ITU bed security may facilitate same day of surgery admission, reducing pre-surgery ward bed occupancy and patient flow, and limit cancellations due to ITU bed unavailability. However, ring-fencing of beds can result in a waste of resources as it is dependent on the stable flow of elective and urgent procedures and a predictable length of post-operative stay.
Patients being unfit for surgery and patient-related issues were other major reasons for cancellations at our centre. Previous studies by Whiteley et al.15 and Hines et al.16reported that specialist-nurse led pre-admission clinics or nurse-led clinics with anaesthetist’s supervision resulted in better patient optimisation and reduced surgery cancellation rates. The pre-admission clinics at our centre are carried out by advanced nurse practitioners who assess patients and escalate abnormal clinical findings to the appropriate teams. Various timings of the pre-admission clinic have been described in the literature and its’ optimal timing is disputed. A study by Pollard et al.17 found no difference in cancellation rates between patients pre-assessed 30 days compared to those assessed 24 hours before the surgery in a cohort of patients undergoing upper abdominal and intra-thoracic surgeries. However, Kaddoum et al.4 reported that the clinic should be held days before the surgery to achieve the best results. It is critical that the assessment is not carried out too early as the patient’s health status may change, yet if performed too close to the surgery date there may not be enough time to carry out necessary investigations. At our centre pre-admission clinic and surgery slots are allocated by the Single Point of Contact (SPOC) office, dedicated to cardiac surgery planning. The goal set by the Trust to see patients in the pre-admission clinics between 2-4 weeks prior to surgery date was achieved for 51.5% of patients.
We found that patients who had their pre-operative clinic within 28 days prior to the scheduled surgery were significantly less likely to be cancelled. This critical finding reflects our centre’s policy for pre-operative review timing. Measures that focus on ensuring patients are assessed within this timeframe will be important to reducing cancellations associated with poor preoperative health and significant preoperative findings. A 28-day period enables appropriate time for outstanding investigations to be performed and optimising patients prior to surgery.
The length of the waiting list may impact overall cancellation rates. Long-waiters may develop new problems resulting in their procedures being cancelled when they eventually come to surgery. They may become urgent, leading to cancellation of elective procedures. A further mechanism in place to optimise efficiency at our centre is the ‘short notice waiting list’. In this analysis, the majority of patients were waiting for over two months.
A solution to decreasing cancellations linked to patients being unfit and patient-related reasons may be pre-operative telephone reminders.18 Calling patients is an opportunity to ensure the medications have been stopped, that the patient is willing to continue with the operation, that the patient remains fit for surgery and is an opportunity for any patient concerns to be addressed. Current practice in our hospital involves a letter to patients with their surgery date.
Scheduling errors were another common reason for cancellations at our centre. Seventy-seven percent were due to overrunning cases and operating room overbooking. At our centre, the scheduling of operating lists is arranged by the SPOC office and individual surgeons. Pandit et al.19 reported that the surgical forecasting of the length of the operation was more adequate than the scheduled duration. Additionally, monitoring and auditing of theatre time according to operation type and individual surgeons could help improve surgery planning in the future.
We found that 30.7% of cancellations were potentially preventable, with the top five reasons accounting for over 60% of cancellations at our centre. Although the lack of ITU staffing may be a complex and difficult problem to solve, we believe that addressing these issues would result in a significant decrease in cancellation rates.
Previous studies reported that patients whose surgeries are cancelled at short notice experience disappointment and anxiety. From our Patient Satisfaction Questionnaire, only a small percentage of patients reported feeling upset, anxious, and confused. In keeping with previous literature reports, cancellations negatively affected patient well-being in 27% cases.3 Sixty-four percent of patients admitted that it had no significant impact on well-being and 9% reported that the cancellation improved their well-being because it allowed more time to mentally prepare.
Association of Anaesthetists of Great Britain and Ireland Theatre Efficiency guidance suggest that patients whose operations have been cancelled should undergo their procedures within 28 days, provided there are no reasons not to proceed. Nearly all (99.1%) cancelled patients at our centre subsequently underwent surgery within the 28-day period as suggested. In addition, over 70% of cancelled patients were operated within 24 hours of the cancellation. This is reflected in patients’ feedback with 80% reporting the waiting time for rescheduled surgery as ‘adequate’.
Our study revealed multiple reasons for surgical cancellations, some of which are potentially avoidable. In order to succeed in reducing the rate of same-day cancellations each problem must be addressed individually and systematically. Every stage of the patient journey from the decision to operate, the pre-admission clinic, the booking and organisation of the surgery slot, the consent process and even the surgery itself must be optimised. During the data collection period we found that there were gaps in the online medical records especially with regards to timing of pre-operative assessment, follow-up care, transfer status of patients and EuroSCORE II components. An additional limitation is the number of patients completing the questionnaire. Although the questionnaire’s content validity and internal consistency was tested in a pilot study and an attempt to avoid acquiescence bias was made by avoiding an agree/disagree choice, only 43.7% patients completed the survey. Non-responses to our survey may have led to an underestimation of negative responses, potentially introduced bias, impacting the representativeness of the sample and skewing results.