The cancellation of same-day elective and urgent cardiac surgery procedures: a single centre experience

Sara Jasionowska, Rory F L Hammond, Wael I Awad

St Bartholomews’ Hospital

Barts Health NHS Trust

Purpose

• Operation cancellation for scheduled surgery is a major cause of inefficiency and poses significant pressure on the National Health Service

• Setback for patient and families

• Risks complications for the patients

• Objectives

• Establish the frequency of same-day elective and urgent cardiac surgical cancellation at the Barts Heart Centre

• Determine the reasons for cancellations and patient outcomes

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Methods

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• Prospective review of all same-day elective and urgent inpatient cardiac surgeries

• 21st August – 30th March 2018

• Data sources: theatre register, printed theatre lists, PACS, Dendrite

• Data collected on all patients

• Patient characteristics, procedure, outcomes

• Cancelled patients:

• Reasons for, timing of cancellation, and outcomes

• Patients divided into 2 groups: Cancelled (C) and Non-Cancelled (NC)

Results • 1388 patients were scheduled for cardiac surgery

• 981 (70.7%) were elective, 407 (29.3%) urgent

• Patient characteristics

• the only significant difference between C and NC was MI status (C=82/204 (40.2%), NC = 336/1121 (30.0%)) (p =0.004)

• Overall, 16.6% were cancelled on the day of surgery

• 143 (14.6%) of the electives

• 88 (21.6%) of the urgent (p= 0.001)

• Overall in hospital mortality: 41/1388 (3.0%)

• C n = 8/231 (3.5%)

• NC n=33/1157 (2.9%) (p= 0.62)

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0 10 20 30 40 50 60 70 80 90 100

overruning case

intra-op TOE findings

death preop

electrical system failure

theatre staff shortage

transfer issue

surgeon unavailable

incomplete investigations

lack of perfusionist

procedure no longer needed

emergency intervened

patient related issues

schedulling error

medically unfit

no ITU beds/nurses

Reasons for cancellation

90 ( 39.0%)

50 (21.6%)

21 ( 9.1%)

7 (3.1%)

7 ( 3.1%)

5 ( 2.6%)

4 (1.7%)

4 (1.7%)

3 (1.3%)

3 (1.3%)

1 (0.4%)

1 (0.4%)

1 (0.4%)

18 (7.8%)

16 (6.9%)

Results

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• Timing of cancellation

• Pre-operative for 222 (96.1%)

• Intraoperative for 3 (1.3%) patients

• Anaesthetic room for 2 (0.9%)

• 61/231 (26.4%) of cancelled procedures were undertaken by a different surgeon

• 19/231 (8.23%) patients were cancelled twice

• Out of these 15/19 (78.9%) were operated on by a different surgeon

• In-hospital transfer cancellations significantly higher if

scheduled for surgery <24hrs from admission (25% vs

13.6%) p=0.00001

0 10 20 30 40 50 60 70

no data available

not performed

>28 d

4-28 d

7-14 d

3-7 d

24-72 hrs

24 hrs

Time from cancellation to operation

46 (19.9%)

53 (23.0%)

64 (27.7%)

19 (8.2%)

19 (8.2%)

2 (0.9%)

20 (8.7%)

8 (3.5%)

0 10 20 30 40 50 60 70 80 90 100

>30 d

14-30 d

7-14 d

3-7 d

48-72 hrs

24-48 hrs

<24 hrs

Hospital stay post cancellation

92 (39.8%)

6 (2.6%)

4 (1.7%)

39 (16.9%)

54 (23.4%)

23 (10.0%)

1 (0.4%)

Summary

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• Our cancellation rate of 16.6% is above average national rates of 7.5%

• Higher cancellation rates within urgent patient group compared to elective

• The most common reasons for cancellation were no ITU beds/nurses (39.0%), patient medically unfit (21.6%) and

scheduling errors (9.1%)

• 46/223 (19.9%) of patients cancelled were operated within 24 hours

• However, 40/223 (17.9%) were operated after 7 days from the cancellation

• 61/231 (26.4%) of cancelled procedures were undertaken by a different surgeon

• 20/231 (8.7%) of cancellations did not subsequently undergo surgery

• In-hospital transfer cancellations significantly higher if scheduled for surgery <24hrs from admission

• Recommendations: detailed pre-op workup, day of surgery admission, sending patient reminders, urgent referral system,

surgery for transfer patients after 24h from admission

• Target potentially preventable reasons for cancellation eg. ITU staff shortage, lack of perfusionist, inadequate workup

THANK YOU

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0

50

100

150

200

250

300

350

400

450

isolated CABG isolated valve combinedvalve and

CABG

other

Operative procedures

urgent

elective

22.4%

26.3%

15.0%

29.0%

10.4%

28.6%

11.9%

33.3%

*

**

P=0.04

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0

20

40

60

80

100

120

surgeon A surgeon B surgeon C surgeon D surgeon E surgeon F surgeon G surgeon H surgeon I surgeon J surgeon K surgeon L surgeon M surgeon N surgeon O surgeon P surgeon Q

Cancellations according to the Consutant Surgeon

n performed n cancelled

5.9%

8.0%

8.1%

13.2%

14.0% 14.3% 15.1%

14.5%

16.3%

17.0%

19.5%

19.8%

20.0%

20.7%

20.8%

22.2%

31.7%

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0

10

20

30

40

50

60

70

80

90

<24hrs 24-48 hrs >48 hrs

Cancellations within in-hospital transfers

25%

13.6%

18%

Cancellations: ITU beds/nurses - 39.0%

• 71/90 (78.9%) lack of ITU beds

• 19/90 (21.1%) lack of ITU staff

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Cancellations: Medically unfit – 21.6%

• loose stool

• gastric bleed

• Haematuria

• hyponatraemia/hypokalaemia

• new angiography findings

• Respiratory failure

• pneumonia, allergic reaction to reoperative antibiotics

• Flu

• Rash

• leg ischaemia UTI

• Pyrexia

• cellulitis

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Cancellations: ‘Scheduling error’ - 9.1%

• 13/21 (61.9%) overrunning case

• 4/21 (19.0%) operating room overbooked

• 3/21 (14.3%) late start to the operation

• 1/21 (4.8%) IT scheduling error

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Cancellations: Patient related issues –7.8%• 5/18 (27.8%) DNA

• 4/18 (22.2%) warfarin not stopped

• 3/18 (16.7%) treatment refusal

• 3/18 (16.7%) self-cancellation

• 1/18 (5.6%) late Jehovah cancellation

• 1/18 (5.6%) private treatment chosen

• 1/18 (5.6%) incorrect consent form signed

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Recommendations

• Ring – fenced beds

• Continual assessment of bed availability

• Better planning

• Detailed pre-op workup (checklist)

• Day of surgery admission

• Calling/texting patients before the surgery

• Urgent referral system (standardised referral form)• Separate coordinator to deal with urgent cases

• Try to reschedule the surgery within 24 hrs (affects patient satisfaction)

• Surgery planned for transfer patients after 24hrs from admission

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Steps towards preventing cancellations

• Unavoidable reasons for cancellation:• ITU bed numbers

• Intervening emergency case

• Patient seeking private treatment

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27%

10%

10%

7%

7%

6%

6%

6%

6%

4%

4%

4%

1% 1% 1%

Potentially preventable reasons for cancellation 71/231 (30.7%)

ITU staff shortage

surgery no longer needed

lack of perfusionist

inadequate work up

patient DNA

transfer issues

medication not stopped

theatre overbooked

surgeon unavailable

electrical system failure

threatre staff shortage

late start

dentist appointment

late Jehovah witness declaration

scheduling error