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.