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Cancellation of elective oral and maxillofacial operations
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British Journal of Oral and Maxillofacial Surgery 45 (2007) 656–657
Cancellation of elective oral and maxillofacial operations K. Sundaram ∗ , S. Sankaran, P. Amerally, C.M.E. Avery Department of Oral and Maxillofacial Surgery, University Hospitals of Leicester, United Kingdom Accepted 5 June 2007
Abstract Our aim was to assess whether the Commission for Health Improvement Performance Indicator value of 0.5% of cancellations on the day of operation or less had been achieved. We reviewed 912 consecutive elective operations, both day case and inpatient over an 8-month period (January–August 2003). A total of 117 procedures (13%) were cancelled for non-clinical or logistical reasons, of which 39 (4%) were cancelled on the day of the operation. Only 3 of the 39 patients who wanted a new admission date within 28 days of cancellation could not be accommodated. The performance indicator value of 0.3% was below the target threshold. An additional 60 (7%) patients had their admissions cancelled the day before operation and 18 (2%) had their operations deferred for a day before they were cancelled. However, these patients have been specifically excluded from the performance indictor. © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Operations; Cancellation; Performance indicator
Introduction Operations are cancelled for clinical, non-clinical, or logistical reasons.1 Cancellations may have a profound adverse effect on both the service and the patients,2 but there are few published data on the incidence of the problem within oral and maxillofacial surgery.3 We present the results of an audit of the cancellation of elective oral and maxillofacial operations, and compared the findings with the Commission for Heath Improvement Performance Indicator (PI). This applies to patients whose elective operations under general anaesthesia were cancelled on the appointed day for non-clinical reasons, and who could not be provided with a readmission date within 28 days.4 The threshold for this indicator is 0.5% or less. Methods Data were collected retrospectively on elective admissions listed for day case and inpatient operations under general ∗
Corresponding author. Tel.: +44 1162586953. E-mail address: [email protected] (K. Sundaram).
anaesthesia between January and August 2003. Information was collected from waiting lists, theatre lists, and the Hospital Information Support System at the Leicester Royal Infirmary. The data included: age, operation, time of cancellation, reason for cancellation, and proposed date of readmission. Results We studied 912 admission records 117 of which (13%) were cancelled; these were mainly minor procedures (Table 1). None of the operations on patients admitted to the day case ward were cancelled. Lack of a postoperative bed and insufficient operating time were the most common reasons for cancellation (Table 2). Thirty-nine had their operations cancelled on the day of operation (4%), the main reason being insufficient time on the operating list (Table 2). Ten of the 39 patients were readmitted after the 28-day period, but in seven cases this was the patient’s choice, so only three patients breached the 28-day period. This yields a PI value of 0.3%. An appreciable number of patients had their operations cancelled the day before operation (60/912, 7%) or had their operations deferred for a day before they were cancelled (18/912, 2%).
0266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2007.06.001
K. Sundaram et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 656–657 Table 1 Type of operation cancelled Type of operation cancelled
Number of patients
Dentoalveolar Oncological Orthognathic Salivary gland Others
106 2 1 1 7
Table 2 Reasons for cancellation Reason for cancellation
All cancellations (n = 117)
On the day of operation (n = 39)
No post-operative bed Insufficient time on the list Surgeon absent Shortage of Theatre equipment Previous operating list running late
77 26
7 18
8 4
8 4
2
2
Discussion The incidence of cancelled operations, covering several surgical specialties, ranges from 20% to 40%,6–9 mainly down to the shortage of beds and over-running of the previous operating list. The shortage of beds was the result of the admission of emergency or medical patients. Additional reasons were numerous and included absence of the patient or surgeon, inadequate preparation of the patient, or deterioration in the patient’s condition, or administrative errors. In 1991 a prospective study at the University of Manchester Dental Hospital indicated that financial restrictions and shortages of nurses were the main reasons for cancellation at that time.3 Better liaison with general practitioners, preadmission clinics, and appropriate booking of cases by consultants may reduce cancellations for clinical reasons.1 In the present study the main reasons were not enough beds or operating time, partly a result of the admission of medical patients, and partly because of the need to operate on maxillofacial emergencies. We speculate that the latter reason has become increasingly important as fewer emergencies are operated on out of hours by trainee surgeons since the report of the National Confidential Inquiry on Perioperative Deaths.5 We do not have a dedicated maxillofacial trauma list, and the irregularity of emergency procedures
657
makes planning for a single specialty inefficient. The surgeon absenteeism (eight operations) in our study is due to prolonged intermittent sickness of one colleague. Our PI of 0.3% was below the 0.5% threshold for failure, but by definition it excluded an appreciable number of patients whose operations had been cancelled the day before the planned procedure. The PI may therefore be manipulated relatively easily. To maintain a low incidence of cancellation the following measures have been taken: regular checking of surgical equipment, more frequent ward rounds, a “bed status” meeting to facilitate the discharge of patients as early as possible, and the reservation of some inpatient beds for maxillofacial surgery. The effect of these measures will be audited in future. Further potential improvements include the provision of a dedicated maxillofacial trauma list or better provision of emergency lists, and a dedicated maxillofacial day-case ward to reduce the incidence of cancellation of minor procedures from inpatient lists.
References 1. Wildner M, Bulstrode C, Spivey J, Carr A, Nugent I. Avoidable causes of cancellation in elective orthopaedic surgery. Health Trends 1991;23:115–6. 2. Ivarsson B, Larsson S, Sjoberg T. Postponed or cancelled heart operations from the patient’s perspective. J Nurs Manag 2004;12:28–36. 3. Thomson PJ. Cancelled operations. A current problem in oral and maxillofacial surgery. Br Dent J 1991;171:244–5. 4. Cancelled operations not admitted within 28 days. Commission for Health Improvement; 2002/03. Available from URL: http://www.chi. nhs.uk/Ratings/Trust/Indicator/indicatorDescriptionFull.asp?indicatorId =1011. 5. NCEPOD report, who operates when? II; 2003. Available from http://www.ncepod.org.uk/pdf/2003/03 s07.pdf. 6. Robb WB, O’Sullivan MJ, Brannigan AE, Bouchier-Hayes DJ. Are elective surgical operations cancelled due to increasing medical admissions? Ir J Med Sci 2004;173:129–32. 7. Nasr A, Reichardt K, Fitzgerald K, Arumugusamy M, Keeling P, Walsh TN. Impact of emergency admissions on elective surgical workload. Ir J Med Sci 2004;173:133–5. 8. Schofield WN, Rubin GL, Piza M, et al. Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust 2005;182:612–5. 9. Paschoal ML, Gatto MA. Tasa de suspension de cirug´ıa en un hospital universitario y motivos de absentismo del paciente con cirurgia programada (Rate of surgery cancellation at an university hospital and reasons for patients’ absence from the planned surgery). Rev Lat Am Enfermagem 2006;14:48–53 [in Portugese].
British Journal of Oral and Maxillofacial Surgery 45 (2007) 656–657
Cancellation of elective oral and maxillofacial operations K. Sundaram ∗ , S. Sankaran, P. Amerally, C.M.E. Avery Department of Oral and Maxillofacial Surgery, University Hospitals of Leicester, United Kingdom Accepted 5 June 2007
Abstract Our aim was to assess whether the Commission for Health Improvement Performance Indicator value of 0.5% of cancellations on the day of operation or less had been achieved. We reviewed 912 consecutive elective operations, both day case and inpatient over an 8-month period (January–August 2003). A total of 117 procedures (13%) were cancelled for non-clinical or logistical reasons, of which 39 (4%) were cancelled on the day of the operation. Only 3 of the 39 patients who wanted a new admission date within 28 days of cancellation could not be accommodated. The performance indicator value of 0.3% was below the target threshold. An additional 60 (7%) patients had their admissions cancelled the day before operation and 18 (2%) had their operations deferred for a day before they were cancelled. However, these patients have been specifically excluded from the performance indictor. © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Operations; Cancellation; Performance indicator
Introduction Operations are cancelled for clinical, non-clinical, or logistical reasons.1 Cancellations may have a profound adverse effect on both the service and the patients,2 but there are few published data on the incidence of the problem within oral and maxillofacial surgery.3 We present the results of an audit of the cancellation of elective oral and maxillofacial operations, and compared the findings with the Commission for Heath Improvement Performance Indicator (PI). This applies to patients whose elective operations under general anaesthesia were cancelled on the appointed day for non-clinical reasons, and who could not be provided with a readmission date within 28 days.4 The threshold for this indicator is 0.5% or less. Methods Data were collected retrospectively on elective admissions listed for day case and inpatient operations under general ∗
Corresponding author. Tel.: +44 1162586953. E-mail address: [email protected] (K. Sundaram).
anaesthesia between January and August 2003. Information was collected from waiting lists, theatre lists, and the Hospital Information Support System at the Leicester Royal Infirmary. The data included: age, operation, time of cancellation, reason for cancellation, and proposed date of readmission. Results We studied 912 admission records 117 of which (13%) were cancelled; these were mainly minor procedures (Table 1). None of the operations on patients admitted to the day case ward were cancelled. Lack of a postoperative bed and insufficient operating time were the most common reasons for cancellation (Table 2). Thirty-nine had their operations cancelled on the day of operation (4%), the main reason being insufficient time on the operating list (Table 2). Ten of the 39 patients were readmitted after the 28-day period, but in seven cases this was the patient’s choice, so only three patients breached the 28-day period. This yields a PI value of 0.3%. An appreciable number of patients had their operations cancelled the day before operation (60/912, 7%) or had their operations deferred for a day before they were cancelled (18/912, 2%).
0266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2007.06.001
K. Sundaram et al. / British Journal of Oral and Maxillofacial Surgery 45 (2007) 656–657 Table 1 Type of operation cancelled Type of operation cancelled
Number of patients
Dentoalveolar Oncological Orthognathic Salivary gland Others
106 2 1 1 7
Table 2 Reasons for cancellation Reason for cancellation
All cancellations (n = 117)
On the day of operation (n = 39)
No post-operative bed Insufficient time on the list Surgeon absent Shortage of Theatre equipment Previous operating list running late
77 26
7 18
8 4
8 4
2
2
Discussion The incidence of cancelled operations, covering several surgical specialties, ranges from 20% to 40%,6–9 mainly down to the shortage of beds and over-running of the previous operating list. The shortage of beds was the result of the admission of emergency or medical patients. Additional reasons were numerous and included absence of the patient or surgeon, inadequate preparation of the patient, or deterioration in the patient’s condition, or administrative errors. In 1991 a prospective study at the University of Manchester Dental Hospital indicated that financial restrictions and shortages of nurses were the main reasons for cancellation at that time.3 Better liaison with general practitioners, preadmission clinics, and appropriate booking of cases by consultants may reduce cancellations for clinical reasons.1 In the present study the main reasons were not enough beds or operating time, partly a result of the admission of medical patients, and partly because of the need to operate on maxillofacial emergencies. We speculate that the latter reason has become increasingly important as fewer emergencies are operated on out of hours by trainee surgeons since the report of the National Confidential Inquiry on Perioperative Deaths.5 We do not have a dedicated maxillofacial trauma list, and the irregularity of emergency procedures
657
makes planning for a single specialty inefficient. The surgeon absenteeism (eight operations) in our study is due to prolonged intermittent sickness of one colleague. Our PI of 0.3% was below the 0.5% threshold for failure, but by definition it excluded an appreciable number of patients whose operations had been cancelled the day before the planned procedure. The PI may therefore be manipulated relatively easily. To maintain a low incidence of cancellation the following measures have been taken: regular checking of surgical equipment, more frequent ward rounds, a “bed status” meeting to facilitate the discharge of patients as early as possible, and the reservation of some inpatient beds for maxillofacial surgery. The effect of these measures will be audited in future. Further potential improvements include the provision of a dedicated maxillofacial trauma list or better provision of emergency lists, and a dedicated maxillofacial day-case ward to reduce the incidence of cancellation of minor procedures from inpatient lists.
References 1. Wildner M, Bulstrode C, Spivey J, Carr A, Nugent I. Avoidable causes of cancellation in elective orthopaedic surgery. Health Trends 1991;23:115–6. 2. Ivarsson B, Larsson S, Sjoberg T. Postponed or cancelled heart operations from the patient’s perspective. J Nurs Manag 2004;12:28–36. 3. Thomson PJ. Cancelled operations. A current problem in oral and maxillofacial surgery. Br Dent J 1991;171:244–5. 4. Cancelled operations not admitted within 28 days. Commission for Health Improvement; 2002/03. Available from URL: http://www.chi. nhs.uk/Ratings/Trust/Indicator/indicatorDescriptionFull.asp?indicatorId =1011. 5. NCEPOD report, who operates when? II; 2003. Available from http://www.ncepod.org.uk/pdf/2003/03 s07.pdf. 6. Robb WB, O’Sullivan MJ, Brannigan AE, Bouchier-Hayes DJ. Are elective surgical operations cancelled due to increasing medical admissions? Ir J Med Sci 2004;173:129–32. 7. Nasr A, Reichardt K, Fitzgerald K, Arumugusamy M, Keeling P, Walsh TN. Impact of emergency admissions on elective surgical workload. Ir J Med Sci 2004;173:133–5. 8. Schofield WN, Rubin GL, Piza M, et al. Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust 2005;182:612–5. 9. Paschoal ML, Gatto MA. Tasa de suspension de cirug´ıa en un hospital universitario y motivos de absentismo del paciente con cirurgia programada (Rate of surgery cancellation at an university hospital and reasons for patients’ absence from the planned surgery). Rev Lat Am Enfermagem 2006;14:48–53 [in Portugese].