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Reducing Surgery Cancellations at a Pediatric Ambulatory Surgery Center
Reducing Surgery Cancellations at a Pediatric Ambulatory Surgery Center CHELSEA M. LEE, DNP, RN; CHERYL RODGERS, PhD, RN, CPNP, CPON; ALBERT K. OH, MD; VIRGINIA C. MUCKLER, DNP, CRNA, CHSE
ABSTRACT Surgery cancellations are costly and can be frustrating for patients, their families, and the surgical team. Because of the inherent nature of an ambulatory surgery center, which only performs scheduled elective procedures, surgical cancellations typically result in wasted time and resources. Pediatric surgery cancellations can be mitigated with proper preoperative screening and communication between nurses and patients’ guardians. To reduce the rate of cancellation at our pediatric ambulatory surgery center, we implemented a Nurse-Patient Preoperative Call Log. Preoperative nurses called patients or their guardians on two separate occasions during the two weeks before surgery to review health history and instructions and answer questions about the upcoming surgery. Three months after implementing the call log, surgery cancellation rates significantly decreased from 16.8% to 8.8% (P < .05). Nurses used the call log for all patients, with 85.6% of patients receiving two calls in the two weeks before their surgery. AORN J 105 (April 2017) 384-391. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2017.01.011 Key words: surgery cancellation, ambulatory surgery center, pediatric, outpatient surgery, preoperative communication.
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urgery cancellations are a significant problem for many health care organizations. These events cause distress and inconvenience to patients and their families, interfere with OR use and efficiency, and add to the overall cost of care delivery by significant loss of revenue and wasted resources.1 According to Pohlman et al,2 unproductive OR time in the United States costs hospitals an estimated $1,430 to $2,025 per hour for each cancelled procedure. The estimated cost may vary depending on the type of procedure and may be lower in the ambulatory surgery center (ASC) setting because of the difference in insurance reimbursement. However, there are similar losses from costs associated with cancellation of procedures, such as the cost of supplies and labor. Although reported OR rates of cancellation in the adult population range from 5.6% to 23.8% depending on various
factors, the rate of cancellation in the pediatric population is not well known.2 A significant number of cancellations are preventable, including unreported changes in patient condition, insurance status, or misunderstanding of the preoperative NPO requirement.2 Examples of preventable reasons for procedure cancellation include the following:
lack of preoperative instructions, NPO violations, changes in insurance coverage, legal issues (eg, name change, guardianship), miscommunication regarding the date and time of surgery, lack of necessary documents, and transportation issues. http://dx.doi.org/10.1016/j.aorn.2017.01.011 ª AORN, Inc, 2017
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Nonpreventable surgery cancellations are those that are out of staff member control such as patient illness and other health conditions. Pohlman et al2 examined contributing factors for cancellations of outpatient pediatric urology procedures and found that the most common cause of surgical cancellation in the pediatric setting is patient illness.2 Examples of nonpreventable reasons for surgery cancellation include the patient being medically unfit to undergo surgery or a sudden onset or exacerbation of an illness or a health condition that affects surgery (eg, respiratory infections, flu-like symptoms, gastrointestinal symptoms). Whether cancellations are for preventable or unpreventable reasons, they affect the surgical team and may cause significant disappointment and frustration to patients and their guardians. Preparing for surgery may require special arrangements with a child’s school and the guardian’s workplace. Cancelling surgery has significant psychological, social, and financial implications. According to a study by Dimitriadis et al,3 the overall rate of same day elective surgery cancellation varied significantly, ranging from 5% to 40%. The researchers investigated the various reasons for same day surgery cancellations and proposed various examples of strategies to reduce them.3 One of the examples they emphasized was the importance of a wellestablished preassessment service and the patient’s compliance with preoperative instructions. Different strategies and changes in process can help to reduce surgery cancellations.
SETTING AND PROBLEM DESCRIPTION This quality improvement (QI) project was reviewed by the Duke University Internal Review Board, Durham, North Carolina, and was deemed exempt. A multidisciplinary team that consisted of five preoperative nurses, two surgical schedulers, an ASC administrator, and two anesthesiologists performed a pilot QI project at Pediatric Specialists of Virginia Ambulatory Surgery Center (PSV-ASC) in Fairfax. The newly accredited ASC has two ORs, and staff members perform an average of 50 elective procedures per month on patients who range from infants to 21 years of age. Emergency or urgent add-on procedures are not performed at this ASC, and most procedures are scheduled at least two weeks in advance to comply with insurance-approval procedures. Therefore, procedures that are cancelled with less than a one-week notice typically result in unproductive OR time and personnel. Despite the low volume, the ASC’s OR rate of cancellation was more than 16% during a three-month assessment period. Excessive cancellation of surgeries, resulting in unproductive OR time, was the impetus for this QI project.
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Reducing Surgery Cancellations
A well-established preoperative protocol may facilitate effective preoperative communication among nurses, patients, and patients’ families and can reduce preventable cancellations. To reduce and prevent unnecessary cancellations, it was important for the project team to establish a clear, consistent, and standardized preoperative process using an approved questionnaire and call log. The goal of this QI project was to prevent unnecessary surgical cancellations at PSV-ASC by improving communication among preoperative nurses, patients, and patients’ families using a call log. The specific aims of the project were to decrease surgical cancellations to a rate of less than 10% per month at PSV-ASC during the three-month postimplementation data-collection period, complete the call log on 100% of patients, and complete 80% of logs with 100% accuracy.
LITERATURE REVIEW Nurses have an important responsibility to communicate effectively, educate, and prepare patients and their families for surgery. Pohlman et al2 retrospectively reviewed 114 cancelled outpatient pediatric urologic procedures and found that approximately 25% of the cancellations were the result of preventable reasons, and only 22% of patients and families correctly understood the NPO instructions. The authors concluded that compliance with the preoperative instructions may be improved by adequate patient and family education.2 Haufler and Harrington4 reported that preoperative nurses at a North Carolina ASC successfully decreased the daily rate of cancellation by 53%, increased patient satisfaction scores from 89% to 94%, and increased OR use from 72.4% to 75.8% by employing a nurse-to-patient phone call protocol.5 In this protocol, the nurses used a script explaining to patients the importance of restrictions, the reasons for the guidelines, and the likelihood that a procedure would be cancelled if the instructions were not followed. The nurses subsequently communicated with the surgical team, anesthesia team, and the surgeon about any significant health history and patient needs that were identified during this call.4 A similar process was implemented successfully by a surgical team in Nebraska to reduce procedure delays and cancellations.5 Preoperative nurses used a 14-question telephone screening tool to identify high-risk patients and to collect health history from the clinical assessment. They were able to reduce first-procedureof-the-day delays from 50% to less than 20% and same day procedure cancellations from 2.6% to 1.3%.5 Several of these studies suggested that patient and guardian education and use of an effective tool in gathering important AORN Journal j 385
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health information, performance of a complete preoperative assessment, and effective communication with patients and families all contributed to positive patient outcomes and prevention of surgical cancellations. Muckler et al6 created a focused anesthesia interview resource (FAIR) tool to improve efficiency and quality in the perioperative setting. Muckler et al6 used the FAIR tool to educate nurses about how to conduct effective anesthesia preoperative interviews, which helped nurses relay important information to the anesthesia and surgical teams. By using this tool, they were able to decrease the surgical cancellation rates from 3.33% to 2.31%. Another study assessed surgery cancellations among patients scheduled for elective surgery who had visited the preadmission clinics.7 Although the researcher stated that the most common reasons for surgery cancellations were nonpreventable reasons related to patient illness (33%), preventable reasons for cancellations included nonadherence to medication guidelines (10%) and NPO violations (9%).7 The author concluded that preadmission clinics are helpful in minimizing surgical cancellations, but, overall, the cancellation rate could be improved further by clarifying NPO guidelines and providing easily understood preoperative medication instructions.7 It is not always possible to control all events that can cause cancellation of surgical procedures, but nurses can mitigate and prevent some of these events by addressing the most common causes for cancellations. The preoperative phone call made by the nurse is the best opportunity to review the preoperative instructions with the patient and his or her guardian. The nurse should allow adequate time to review preoperative instructions and to answer questions that the patient or guardian may have. This is also a good time for the nurse to initiate the discharge instructions, confirm the patient’s arrival time, and ensure that the responsible parties know the location of the ASC. The more prepared and comfortable the patient and family are before the surgery, the less likely surgery will be cancelled, and the more likely that patients will experience better postoperative outcomes.8 A study on the effect of preoperative education on patient outcomes after joint replacement surgery showed that patients who attended preoperative education classes felt more prepared for surgery than patients who did not attend.9 The knowledge gained from the preoperative education class affected patient experiences.9 The literature we reviewed shows that nursing preoperative assessments, preoperative instructions, patient education, and nurse-to-patient phone calls in preparation for surgery are
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important measures in preventing unnecessary surgical cancellations. If there are commonly known causes for surgical cancellations in pediatric surgery, the nurses can emphasize those points during preoperative assessments.
PROJECT DESIGN During two separate sessions of the monthly hour-long educational inservice meetings at PSV-ASC, the educator instructed all nurses on the purpose and process of the NursePatient Preoperative Call Log (Figure 1). The PSV-ASC administrator explained the importance of establishing a routine preoperative process and the use of call log protocol. In this preoperative protocol, preoperative nurses used the log to provide preoperative assessments, instructions, teaching, and time for questions. The preoperative process consisted of a nurse calling the patient or guardian one to two weeks before the scheduled surgery and one to two days before surgery using a 38-item call log. The call log includes a comprehensive assessment checklist that the nurse reviews with the patient or his or her guardian and a script to read during the presurgical phone call. Children’s National Health System in Washington, DC, is the parent organization of PSV-ASC and follows similar practices and processes. Therefore, the content for the preoperative assessment and information communicated during these calls was similar to that of the parent organization with minor process changes. The team believed that the use of shared and familiar resources would lead to a smooth transition. Nurses used a single call log for each patient, using the front page of the form for the first phone call and the back page of the same form for the second phone call. If a procedure was scheduled less than two weeks before the day of surgery, a nurse made a single phone call that covered both front and back pages of the call log. The educator provided the two surgery schedulers at PSV-ASC with a separate inservice session on the importance of identifying surgical cancellations and logging the cancellation reasons in the Microsoft Excel cancellation log.
Sample The team used sample data from the children who underwent surgery at PSV-ASC from June 2015 to November 2015. The preimplementation and postimplementation phases each lasted three months, June through August and September through November, respectively. The team included all procedures performed and cancelled during this six-month period, and there were no exclusions in the sample.
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Reducing Surgery Cancellations
Figure 1. Nurse-Patient Preoperative Call Log. Reproduced with permission from the Pediatric Specialists of Virginia Ambulatory Surgery Center, Fairfax. Editor’s notes: Children’s National is a trademark of Children’s National Medical Center, Washington, DC. INOVA is a registered trademark of Inova Diagnostics, Inc, San Diego, CA. Gatorade is a trademark of Stokely-Van Camp, Inc, Chicago, IL.
Data Collection Methods The team collected the necessary data from the electronic medical record (EMR), the Epic and EMR software currently used at PSV-ASC, and from a cancellation log recorded by the surgery schedulers in an Excel flow sheet. The Epic software generated a monthly report with the total number of procedures and total number of cancellations. The Epic report
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lacked detailed information that explained reasons for cancellations; therefore, the team documented all surgical cancellations and entered detailed reasons for each cancellation in the Excel cancellation log. The team kept the call logs in the designated preoperative room, where preoperative nurses make phone calls in a quiet, AORN Journal j 387
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Figure 1. (continued).
private setting. Because nurses access these call logs several times between scheduling of the procedure until the day of the surgery, they kept the documents in a locked drawer in the preoperative room until the patient underwent surgery. After the patient had undergone surgery and the preoperative call log was no longer needed, the nurse placed the log in the locked drawer in the preoperative room until the administrator 388 j AORN Journal
collected them. All completed preoperative call logs were collected at the end of the week by the administrator and scored for completeness. The call logs were scored on completeness of the 38 items. Team members discarded all project documents in the Health Insurance Portability and Accountability Actecompliant waste bin on completion of the project.
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Data Analysis The team entered all data (ie, total number of procedures, number of cancellations, reasons for cancellation) collected from the Epic EMR into an Excel spreadsheet for analysis. They grouped cancellation reasons into seven categories that were marked in percentages:
insurance issue, patient illness, NPO violation, scheduling change by guardian, scheduling change by surgeon, condition improved and surgery no longer needed, and other (eg, unfit to have surgery in the ASC setting).
The administrator counted and scored call logs for completeness on a weekly basis. The administrator used McNemar’s test to evaluate cancellation rates before and after implementation of the call log. Significance was set at P < .05.
Implementation The preoperative nurses called the patient or the designated contact guardian, as determined at the time of surgery scheduling, two weeks before the scheduled surgery date to conduct a thorough preoperative assessment following the call log protocol. During this first call, the nurse discussed preoperative policies and preparedness for the surgery with the patient or guardian(s) and completed a preoperative assessment that gathered details about the patient’s health history. After the assessment, the nurse communicated with the anesthesia team members and the surgeon about any particular needs that were identified during this call. If the nurse could not reach the guardian by phone, he or she continued to make daily phone calls until the day before the surgery; if unable to contact the guardian, the nurse left a detailed voice message or sent an e-mail to the guardian. Personnel made preoperative calls of sufficient duration one to two weeks before surgery to provide adequate time to resolve any problems, answer questions, and gather all necessary information before the day of surgery. One to two days before surgery, the preoperative nurse contacted the patient’s guardian to remind him or her of the upcoming surgery and provide detailed preoperative instructions using a script provided on the preoperative call log. If a direct conversation was not possible because the guardian was unavailable, the nurse left a detailed voice message or sent an e-mail with all necessary information to the guardian. In either situation, the communication method and message were documented on the call log.
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Reducing Surgery Cancellations
Table 1. Preimplementation Surgery Cancellation Data Total Number of Procedures
Number of Cancellations Within 2 Wk of Surgery
Cancellation (%)
June
55
9
16.4
July
64
15
23.4
August
54
5
9.3
173
29
16.8
Month
Total
Results After implementing the call log, cancellation rates decreased from a preimplementation three-month average of 16.8% to a postimplementation three-month average of 8.8%. This was a significant decrease in cancellations based on the number of procedures (P < .0001). Preimplementation data (Table 1) included 173 procedures, 29 of which were cancelled within two weeks of surgery; postimplementation data (Table 2) included 137 procedures, 12 of which were cancelled within two weeks of surgery. As shown in Table 3, the call log was used for 100% of patients. There were 137 call logs completed, and 118 of the 137 logs (85.6%) were 100% complete. Nineteen of the 137 logs (14.4%) were incomplete, missing a single item that was most commonly the “respondent” (ie, the family member who provided the information). Cancellation reasons included insurance issues, patient illness, NPO violation, schedule change by the guardian, schedule change by the surgeon, condition improved and surgery was no longer necessary, and significant medical history precluding ASC care that was discovered less than two weeks before the day of surgery. As shown in Table 4, with both preimplementation and postimplementation periods, most of the Table 2. Postimplementation Surgery Cancellation Data Month
Total Number of Procedures
Number of Cancellations Within 2 Wk of Surgery
Cancellation (%)
September
48
5
10.4
October
48
5
10.4
November
41
2
4.9
137
12
8.8
Total
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Table 3. Completion of Nurse-to-Patient Call Log Month
Number of Total Number Number of of Procedures Call Logs Call Logs with a Used, n (%) Score of 38/38, n (%)
September
48
48 (100)
47 (97.9)
October
48
48 (100)
40 (83.3)
November
41
41 (100)
31 (75.6)
reasons for cancellations were the result of a schedule change requested by a guardian. The specific reasons that fell under scheduling change by guardian included personal reasons, unsure of undergoing the surgery, desire for a second opinion, and lack of understanding the details of the surgery.
DISCUSSION The primary goal of this QI project was to reduce the number of surgery cancellations by following an established preoperative process. Tracking the detailed reasons for cancellation was critical in identifying interventions to minimize future cancellations because all reasons are theoretically preventable. Detailed documentation that explained the reason for family cancellation can help preoperative nurses better educate future patients and their families regarding surgical procedures and arrival and departure times, which may relieve family stress and anxiety. In a study that examined the association between guardian anxiety and compliance with preoperative requirements for pediatric outpatient surgery, findings indicated that guardian anxiety could be associated with lower likelihood of guardians following preoperative requirements and could contribute to increased likelihood of surgery cancellation.10 The second most common reason for cancellations was patient health status: that is, acute illness or the patient’s status as an unfit candidate for surgery because of a medical history or
failure to meet established ASC patient criteria. Boudreau and Gibson,1 in their review of elective surgery cancellations in a pediatric institution, stated that the preoperative evaluation of patients and education of families on the prevention of illness before elective surgery can be effective in preventing pediatric surgical cancellations. In our preoperative process, nurses assessed the current health status of patients, such as any cold symptoms or recent gastrointestinal issues. However, our protocol did not require that preoperative nurses educate the guardians on potential prevention of illness before the surgery, such as avoiding international travel several days before surgery or minimizing interactions with siblings or other children with contagious illnesses. In a pediatric population, preventing illness can be a significant way of reducing same day cancellations. The most significant finding from this QI project was the 50% reduction in cancellation rates after implementing the NursePatient Preoperative Call Log. The advantages of the call log were that it helped the nurse remember to inform the patient or guardian of the surgery, provide preoperative teaching, initiate postoperative teaching, and capture necessary information from the patient or guardian to formulate an accurate clinical picture of the patient’s health before anesthesia and surgery at the ASC. All of these contributed to preventing surgery cancellations. The nurses’ active participation in the project, the use of a call log for every patient, and two preoperative phone calls made to each patient or guardian contributed to the success of this project. The second phone call was an important factor in the success of the project, because it provided information on two separate time points and gave guardians time to process the information and formulate questions for the second call. It was also helpful for RNs with preoperative clinical knowledge and assessment skills to make the phone calls, answer questions for patients or guardians, and relay information to the surgical team.
Table 4. Reasons for Cancellation of Surgery 3-Mo Preimplementation Data, n (%)
3-Mo Postimplementation Data, n (%)
Insurance issue
3 (10.3)
1 (8.3)
Patient illness
4 (13.8)
2 (16.7)
NPO violation
0
1 (8.3)
Scheduling change by family
15 (51.7)
5 (41.7)
Scheduling change by surgeon
4 (13.8)
1 (8.3)
Condition improved; no surgery needed
1 (3.4)
0
Extensive medical history, unfit for ambulatory surgery center procedure
1 (3.4)
2 (16.7)
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Anesthesia team members recognized that the clinical knowledge and assessment skills of the preoperative nurses, along with preoperative instructions to the child’s guardian, were valuable determinants of patient safety. Allison and George8 state that teaching and communicating with patients or guardians while obtaining patient information can have a profound effect on the quality of the patient’s experience; communication is key to preventing adverse events in ASCs. As a result of this QI project, ASC personnel have established the call log as a standard protocol and have modified the EMR to allow for documenting the call log. The limitations of QI this project include use of a nonvalidated tool (ie, Nurse-Patient Preoperative Call Log) and low procedure volume. Muckler et al6 used the FAIR, a nonvalidated tool, in their study to reduce adult cancellation rates and delayed first procedure starts in a community hospital setting.6 Personnel at an adult ASC used a similar nonvalidated nurse-to-patient phone call tool to reduce same day cancellations.5 As patient volume grows at our facility, the use of the call log may have an even greater effect on reducing surgical cancellations.
CONCLUSION Surgical cancellations are costly and frustrating, and lastminute surgery cancellations result in OR schedule vacancies that are difficult to fill. Although reasons for surgery cancellations related to patient illness and other uncontrollable situations are difficult to reduce, we found that overall cancellation rates improved after implementing a preoperative protocol. This QI project emphasizes the importance of preoperative screening to reduce cancellations and to help pediatric surgical patients and their guardians understand and prepare for surgery.
Editor’s notes: The focused anesthesia interview resource (FAIR) tool is a copyright of Virginia C. Muckler, Durham, NC. Epic software is a copyright of the Epic Systems Corp, Verona, WI. Excel is a registered trademark of Microsoft Corp, Redmond, WA.
References 1. Boudreau SA, Gibson MJ. Surgical cancellations: a review of elective surgery cancellations in a tertiary care pediatric institution. J Perianesth Nurs. 2011;26(5):315-322. 2. Pohlman GD, Staulcup SJ, Masterson RM, Vemulakonda VM. Contributing factors for cancellations of outpatient pediatric urology procedures: single center experience. J Urol. 2012;188(4 suppl): 1634-1638. 3. Dimitriadis PA, Iyer S, Evgeniou E. The challenge of cancellations on the day of surgery. Int J Surg. 2013;11(10):1126-1130.
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Reducing Surgery Cancellations 4. Haufler K, Harrington M. Using nurse-to-patient telephone calls to reduce day-of-surgery cancellations. AORN J. 2011;94(1):19-26. 5. Ellis S, Young D, Peters JA. Hybrid pre-op assessment model increases OR efficiency at Nebraska hospital. Anesthesiology News. http://www.anesthesiologynews.com/ViewArticle.aspx?d¼ Policy%2B%26%2BManagement& d_id¼3&i¼Marchþ2013&i_id¼ 937&a_id¼22716 [subscription required]. Published March 22, 2013. Accessed February 13, 2017. 6. Muckler VC, Vacchiano CA, Sanders EG, Wilson JP, Champagne MT. Focused anesthesia interview resource to improve efficiency and quality. J Perianesth Nurs. 2012;27(6):376-384. 7. Emanuel A, MacPherson R. The anesthetic pre-admission clinic is effective in minimising surgical cancellation rates. Anaesth Intensive Care. 2013;41(1):90-94. 8. Allison J, George M. Using preoperative assessment and patient instruction to improve patient safety. AORN J. 2014;99(3):364-375. 9. Kearney M, Jennrich MK, Lyons S, Robinson R, Berger B. Effects of preoperative education on patient outcomes after joint replacement surgery. Orthop Nurs. 2011;30(6):391-396. 10. Chahal N, Manlhiot C, Colapinto K, Van Alphen J, McCrindle BW, Rush J. Association between parental anxiety and compliance with preoperative requirements for pediatric outpatient surgery. J Pediatr Health Care. 2009;23(6):372-377.
Chelsea M. Lee, DNP, RN, is the administrator of the Pediatric Specialists of Virginia Ambulatory Surgery Center, Fairfax. Dr Lee has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Cheryl Rodgers, PhD, RN, CPNP, CPON, is an assistant professor of Nursing at Duke University, Durham, NC. Dr Rodgers has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Albert K. Oh, MD, is the director of the Fellowship for Craniofacial and Pediatric Plastic Surgery and assistant professor in the Department of Plastic and Reconstructive Surgery and Pediatrics at Children’s National Medical Center, George Washington University, Washington, DC. Dr Oh has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Virginia C. Muckler, DNP, CRNA, CHSE, is the National League for Nursing simulation leader, assistant professor, and clinical education coordinator of the Duke University Nurse Anesthesia Program, Durham, NC. Dr Muckler has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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ABSTRACT Surgery cancellations are costly and can be frustrating for patients, their families, and the surgical team. Because of the inherent nature of an ambulatory surgery center, which only performs scheduled elective procedures, surgical cancellations typically result in wasted time and resources. Pediatric surgery cancellations can be mitigated with proper preoperative screening and communication between nurses and patients’ guardians. To reduce the rate of cancellation at our pediatric ambulatory surgery center, we implemented a Nurse-Patient Preoperative Call Log. Preoperative nurses called patients or their guardians on two separate occasions during the two weeks before surgery to review health history and instructions and answer questions about the upcoming surgery. Three months after implementing the call log, surgery cancellation rates significantly decreased from 16.8% to 8.8% (P < .05). Nurses used the call log for all patients, with 85.6% of patients receiving two calls in the two weeks before their surgery. AORN J 105 (April 2017) 384-391. ª AORN, Inc, 2017. http://dx.doi.org/10.1016/j.aorn.2017.01.011 Key words: surgery cancellation, ambulatory surgery center, pediatric, outpatient surgery, preoperative communication.
S
urgery cancellations are a significant problem for many health care organizations. These events cause distress and inconvenience to patients and their families, interfere with OR use and efficiency, and add to the overall cost of care delivery by significant loss of revenue and wasted resources.1 According to Pohlman et al,2 unproductive OR time in the United States costs hospitals an estimated $1,430 to $2,025 per hour for each cancelled procedure. The estimated cost may vary depending on the type of procedure and may be lower in the ambulatory surgery center (ASC) setting because of the difference in insurance reimbursement. However, there are similar losses from costs associated with cancellation of procedures, such as the cost of supplies and labor. Although reported OR rates of cancellation in the adult population range from 5.6% to 23.8% depending on various
factors, the rate of cancellation in the pediatric population is not well known.2 A significant number of cancellations are preventable, including unreported changes in patient condition, insurance status, or misunderstanding of the preoperative NPO requirement.2 Examples of preventable reasons for procedure cancellation include the following:
lack of preoperative instructions, NPO violations, changes in insurance coverage, legal issues (eg, name change, guardianship), miscommunication regarding the date and time of surgery, lack of necessary documents, and transportation issues. http://dx.doi.org/10.1016/j.aorn.2017.01.011 ª AORN, Inc, 2017
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Nonpreventable surgery cancellations are those that are out of staff member control such as patient illness and other health conditions. Pohlman et al2 examined contributing factors for cancellations of outpatient pediatric urology procedures and found that the most common cause of surgical cancellation in the pediatric setting is patient illness.2 Examples of nonpreventable reasons for surgery cancellation include the patient being medically unfit to undergo surgery or a sudden onset or exacerbation of an illness or a health condition that affects surgery (eg, respiratory infections, flu-like symptoms, gastrointestinal symptoms). Whether cancellations are for preventable or unpreventable reasons, they affect the surgical team and may cause significant disappointment and frustration to patients and their guardians. Preparing for surgery may require special arrangements with a child’s school and the guardian’s workplace. Cancelling surgery has significant psychological, social, and financial implications. According to a study by Dimitriadis et al,3 the overall rate of same day elective surgery cancellation varied significantly, ranging from 5% to 40%. The researchers investigated the various reasons for same day surgery cancellations and proposed various examples of strategies to reduce them.3 One of the examples they emphasized was the importance of a wellestablished preassessment service and the patient’s compliance with preoperative instructions. Different strategies and changes in process can help to reduce surgery cancellations.
SETTING AND PROBLEM DESCRIPTION This quality improvement (QI) project was reviewed by the Duke University Internal Review Board, Durham, North Carolina, and was deemed exempt. A multidisciplinary team that consisted of five preoperative nurses, two surgical schedulers, an ASC administrator, and two anesthesiologists performed a pilot QI project at Pediatric Specialists of Virginia Ambulatory Surgery Center (PSV-ASC) in Fairfax. The newly accredited ASC has two ORs, and staff members perform an average of 50 elective procedures per month on patients who range from infants to 21 years of age. Emergency or urgent add-on procedures are not performed at this ASC, and most procedures are scheduled at least two weeks in advance to comply with insurance-approval procedures. Therefore, procedures that are cancelled with less than a one-week notice typically result in unproductive OR time and personnel. Despite the low volume, the ASC’s OR rate of cancellation was more than 16% during a three-month assessment period. Excessive cancellation of surgeries, resulting in unproductive OR time, was the impetus for this QI project.
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Reducing Surgery Cancellations
A well-established preoperative protocol may facilitate effective preoperative communication among nurses, patients, and patients’ families and can reduce preventable cancellations. To reduce and prevent unnecessary cancellations, it was important for the project team to establish a clear, consistent, and standardized preoperative process using an approved questionnaire and call log. The goal of this QI project was to prevent unnecessary surgical cancellations at PSV-ASC by improving communication among preoperative nurses, patients, and patients’ families using a call log. The specific aims of the project were to decrease surgical cancellations to a rate of less than 10% per month at PSV-ASC during the three-month postimplementation data-collection period, complete the call log on 100% of patients, and complete 80% of logs with 100% accuracy.
LITERATURE REVIEW Nurses have an important responsibility to communicate effectively, educate, and prepare patients and their families for surgery. Pohlman et al2 retrospectively reviewed 114 cancelled outpatient pediatric urologic procedures and found that approximately 25% of the cancellations were the result of preventable reasons, and only 22% of patients and families correctly understood the NPO instructions. The authors concluded that compliance with the preoperative instructions may be improved by adequate patient and family education.2 Haufler and Harrington4 reported that preoperative nurses at a North Carolina ASC successfully decreased the daily rate of cancellation by 53%, increased patient satisfaction scores from 89% to 94%, and increased OR use from 72.4% to 75.8% by employing a nurse-to-patient phone call protocol.5 In this protocol, the nurses used a script explaining to patients the importance of restrictions, the reasons for the guidelines, and the likelihood that a procedure would be cancelled if the instructions were not followed. The nurses subsequently communicated with the surgical team, anesthesia team, and the surgeon about any significant health history and patient needs that were identified during this call.4 A similar process was implemented successfully by a surgical team in Nebraska to reduce procedure delays and cancellations.5 Preoperative nurses used a 14-question telephone screening tool to identify high-risk patients and to collect health history from the clinical assessment. They were able to reduce first-procedureof-the-day delays from 50% to less than 20% and same day procedure cancellations from 2.6% to 1.3%.5 Several of these studies suggested that patient and guardian education and use of an effective tool in gathering important AORN Journal j 385
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health information, performance of a complete preoperative assessment, and effective communication with patients and families all contributed to positive patient outcomes and prevention of surgical cancellations. Muckler et al6 created a focused anesthesia interview resource (FAIR) tool to improve efficiency and quality in the perioperative setting. Muckler et al6 used the FAIR tool to educate nurses about how to conduct effective anesthesia preoperative interviews, which helped nurses relay important information to the anesthesia and surgical teams. By using this tool, they were able to decrease the surgical cancellation rates from 3.33% to 2.31%. Another study assessed surgery cancellations among patients scheduled for elective surgery who had visited the preadmission clinics.7 Although the researcher stated that the most common reasons for surgery cancellations were nonpreventable reasons related to patient illness (33%), preventable reasons for cancellations included nonadherence to medication guidelines (10%) and NPO violations (9%).7 The author concluded that preadmission clinics are helpful in minimizing surgical cancellations, but, overall, the cancellation rate could be improved further by clarifying NPO guidelines and providing easily understood preoperative medication instructions.7 It is not always possible to control all events that can cause cancellation of surgical procedures, but nurses can mitigate and prevent some of these events by addressing the most common causes for cancellations. The preoperative phone call made by the nurse is the best opportunity to review the preoperative instructions with the patient and his or her guardian. The nurse should allow adequate time to review preoperative instructions and to answer questions that the patient or guardian may have. This is also a good time for the nurse to initiate the discharge instructions, confirm the patient’s arrival time, and ensure that the responsible parties know the location of the ASC. The more prepared and comfortable the patient and family are before the surgery, the less likely surgery will be cancelled, and the more likely that patients will experience better postoperative outcomes.8 A study on the effect of preoperative education on patient outcomes after joint replacement surgery showed that patients who attended preoperative education classes felt more prepared for surgery than patients who did not attend.9 The knowledge gained from the preoperative education class affected patient experiences.9 The literature we reviewed shows that nursing preoperative assessments, preoperative instructions, patient education, and nurse-to-patient phone calls in preparation for surgery are
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important measures in preventing unnecessary surgical cancellations. If there are commonly known causes for surgical cancellations in pediatric surgery, the nurses can emphasize those points during preoperative assessments.
PROJECT DESIGN During two separate sessions of the monthly hour-long educational inservice meetings at PSV-ASC, the educator instructed all nurses on the purpose and process of the NursePatient Preoperative Call Log (Figure 1). The PSV-ASC administrator explained the importance of establishing a routine preoperative process and the use of call log protocol. In this preoperative protocol, preoperative nurses used the log to provide preoperative assessments, instructions, teaching, and time for questions. The preoperative process consisted of a nurse calling the patient or guardian one to two weeks before the scheduled surgery and one to two days before surgery using a 38-item call log. The call log includes a comprehensive assessment checklist that the nurse reviews with the patient or his or her guardian and a script to read during the presurgical phone call. Children’s National Health System in Washington, DC, is the parent organization of PSV-ASC and follows similar practices and processes. Therefore, the content for the preoperative assessment and information communicated during these calls was similar to that of the parent organization with minor process changes. The team believed that the use of shared and familiar resources would lead to a smooth transition. Nurses used a single call log for each patient, using the front page of the form for the first phone call and the back page of the same form for the second phone call. If a procedure was scheduled less than two weeks before the day of surgery, a nurse made a single phone call that covered both front and back pages of the call log. The educator provided the two surgery schedulers at PSV-ASC with a separate inservice session on the importance of identifying surgical cancellations and logging the cancellation reasons in the Microsoft Excel cancellation log.
Sample The team used sample data from the children who underwent surgery at PSV-ASC from June 2015 to November 2015. The preimplementation and postimplementation phases each lasted three months, June through August and September through November, respectively. The team included all procedures performed and cancelled during this six-month period, and there were no exclusions in the sample.
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Reducing Surgery Cancellations
Figure 1. Nurse-Patient Preoperative Call Log. Reproduced with permission from the Pediatric Specialists of Virginia Ambulatory Surgery Center, Fairfax. Editor’s notes: Children’s National is a trademark of Children’s National Medical Center, Washington, DC. INOVA is a registered trademark of Inova Diagnostics, Inc, San Diego, CA. Gatorade is a trademark of Stokely-Van Camp, Inc, Chicago, IL.
Data Collection Methods The team collected the necessary data from the electronic medical record (EMR), the Epic and EMR software currently used at PSV-ASC, and from a cancellation log recorded by the surgery schedulers in an Excel flow sheet. The Epic software generated a monthly report with the total number of procedures and total number of cancellations. The Epic report
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lacked detailed information that explained reasons for cancellations; therefore, the team documented all surgical cancellations and entered detailed reasons for each cancellation in the Excel cancellation log. The team kept the call logs in the designated preoperative room, where preoperative nurses make phone calls in a quiet, AORN Journal j 387
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Figure 1. (continued).
private setting. Because nurses access these call logs several times between scheduling of the procedure until the day of the surgery, they kept the documents in a locked drawer in the preoperative room until the patient underwent surgery. After the patient had undergone surgery and the preoperative call log was no longer needed, the nurse placed the log in the locked drawer in the preoperative room until the administrator 388 j AORN Journal
collected them. All completed preoperative call logs were collected at the end of the week by the administrator and scored for completeness. The call logs were scored on completeness of the 38 items. Team members discarded all project documents in the Health Insurance Portability and Accountability Actecompliant waste bin on completion of the project.
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Data Analysis The team entered all data (ie, total number of procedures, number of cancellations, reasons for cancellation) collected from the Epic EMR into an Excel spreadsheet for analysis. They grouped cancellation reasons into seven categories that were marked in percentages:
insurance issue, patient illness, NPO violation, scheduling change by guardian, scheduling change by surgeon, condition improved and surgery no longer needed, and other (eg, unfit to have surgery in the ASC setting).
The administrator counted and scored call logs for completeness on a weekly basis. The administrator used McNemar’s test to evaluate cancellation rates before and after implementation of the call log. Significance was set at P < .05.
Implementation The preoperative nurses called the patient or the designated contact guardian, as determined at the time of surgery scheduling, two weeks before the scheduled surgery date to conduct a thorough preoperative assessment following the call log protocol. During this first call, the nurse discussed preoperative policies and preparedness for the surgery with the patient or guardian(s) and completed a preoperative assessment that gathered details about the patient’s health history. After the assessment, the nurse communicated with the anesthesia team members and the surgeon about any particular needs that were identified during this call. If the nurse could not reach the guardian by phone, he or she continued to make daily phone calls until the day before the surgery; if unable to contact the guardian, the nurse left a detailed voice message or sent an e-mail to the guardian. Personnel made preoperative calls of sufficient duration one to two weeks before surgery to provide adequate time to resolve any problems, answer questions, and gather all necessary information before the day of surgery. One to two days before surgery, the preoperative nurse contacted the patient’s guardian to remind him or her of the upcoming surgery and provide detailed preoperative instructions using a script provided on the preoperative call log. If a direct conversation was not possible because the guardian was unavailable, the nurse left a detailed voice message or sent an e-mail with all necessary information to the guardian. In either situation, the communication method and message were documented on the call log.
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Reducing Surgery Cancellations
Table 1. Preimplementation Surgery Cancellation Data Total Number of Procedures
Number of Cancellations Within 2 Wk of Surgery
Cancellation (%)
June
55
9
16.4
July
64
15
23.4
August
54
5
9.3
173
29
16.8
Month
Total
Results After implementing the call log, cancellation rates decreased from a preimplementation three-month average of 16.8% to a postimplementation three-month average of 8.8%. This was a significant decrease in cancellations based on the number of procedures (P < .0001). Preimplementation data (Table 1) included 173 procedures, 29 of which were cancelled within two weeks of surgery; postimplementation data (Table 2) included 137 procedures, 12 of which were cancelled within two weeks of surgery. As shown in Table 3, the call log was used for 100% of patients. There were 137 call logs completed, and 118 of the 137 logs (85.6%) were 100% complete. Nineteen of the 137 logs (14.4%) were incomplete, missing a single item that was most commonly the “respondent” (ie, the family member who provided the information). Cancellation reasons included insurance issues, patient illness, NPO violation, schedule change by the guardian, schedule change by the surgeon, condition improved and surgery was no longer necessary, and significant medical history precluding ASC care that was discovered less than two weeks before the day of surgery. As shown in Table 4, with both preimplementation and postimplementation periods, most of the Table 2. Postimplementation Surgery Cancellation Data Month
Total Number of Procedures
Number of Cancellations Within 2 Wk of Surgery
Cancellation (%)
September
48
5
10.4
October
48
5
10.4
November
41
2
4.9
137
12
8.8
Total
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Table 3. Completion of Nurse-to-Patient Call Log Month
Number of Total Number Number of of Procedures Call Logs Call Logs with a Used, n (%) Score of 38/38, n (%)
September
48
48 (100)
47 (97.9)
October
48
48 (100)
40 (83.3)
November
41
41 (100)
31 (75.6)
reasons for cancellations were the result of a schedule change requested by a guardian. The specific reasons that fell under scheduling change by guardian included personal reasons, unsure of undergoing the surgery, desire for a second opinion, and lack of understanding the details of the surgery.
DISCUSSION The primary goal of this QI project was to reduce the number of surgery cancellations by following an established preoperative process. Tracking the detailed reasons for cancellation was critical in identifying interventions to minimize future cancellations because all reasons are theoretically preventable. Detailed documentation that explained the reason for family cancellation can help preoperative nurses better educate future patients and their families regarding surgical procedures and arrival and departure times, which may relieve family stress and anxiety. In a study that examined the association between guardian anxiety and compliance with preoperative requirements for pediatric outpatient surgery, findings indicated that guardian anxiety could be associated with lower likelihood of guardians following preoperative requirements and could contribute to increased likelihood of surgery cancellation.10 The second most common reason for cancellations was patient health status: that is, acute illness or the patient’s status as an unfit candidate for surgery because of a medical history or
failure to meet established ASC patient criteria. Boudreau and Gibson,1 in their review of elective surgery cancellations in a pediatric institution, stated that the preoperative evaluation of patients and education of families on the prevention of illness before elective surgery can be effective in preventing pediatric surgical cancellations. In our preoperative process, nurses assessed the current health status of patients, such as any cold symptoms or recent gastrointestinal issues. However, our protocol did not require that preoperative nurses educate the guardians on potential prevention of illness before the surgery, such as avoiding international travel several days before surgery or minimizing interactions with siblings or other children with contagious illnesses. In a pediatric population, preventing illness can be a significant way of reducing same day cancellations. The most significant finding from this QI project was the 50% reduction in cancellation rates after implementing the NursePatient Preoperative Call Log. The advantages of the call log were that it helped the nurse remember to inform the patient or guardian of the surgery, provide preoperative teaching, initiate postoperative teaching, and capture necessary information from the patient or guardian to formulate an accurate clinical picture of the patient’s health before anesthesia and surgery at the ASC. All of these contributed to preventing surgery cancellations. The nurses’ active participation in the project, the use of a call log for every patient, and two preoperative phone calls made to each patient or guardian contributed to the success of this project. The second phone call was an important factor in the success of the project, because it provided information on two separate time points and gave guardians time to process the information and formulate questions for the second call. It was also helpful for RNs with preoperative clinical knowledge and assessment skills to make the phone calls, answer questions for patients or guardians, and relay information to the surgical team.
Table 4. Reasons for Cancellation of Surgery 3-Mo Preimplementation Data, n (%)
3-Mo Postimplementation Data, n (%)
Insurance issue
3 (10.3)
1 (8.3)
Patient illness
4 (13.8)
2 (16.7)
NPO violation
0
1 (8.3)
Scheduling change by family
15 (51.7)
5 (41.7)
Scheduling change by surgeon
4 (13.8)
1 (8.3)
Condition improved; no surgery needed
1 (3.4)
0
Extensive medical history, unfit for ambulatory surgery center procedure
1 (3.4)
2 (16.7)
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Anesthesia team members recognized that the clinical knowledge and assessment skills of the preoperative nurses, along with preoperative instructions to the child’s guardian, were valuable determinants of patient safety. Allison and George8 state that teaching and communicating with patients or guardians while obtaining patient information can have a profound effect on the quality of the patient’s experience; communication is key to preventing adverse events in ASCs. As a result of this QI project, ASC personnel have established the call log as a standard protocol and have modified the EMR to allow for documenting the call log. The limitations of QI this project include use of a nonvalidated tool (ie, Nurse-Patient Preoperative Call Log) and low procedure volume. Muckler et al6 used the FAIR, a nonvalidated tool, in their study to reduce adult cancellation rates and delayed first procedure starts in a community hospital setting.6 Personnel at an adult ASC used a similar nonvalidated nurse-to-patient phone call tool to reduce same day cancellations.5 As patient volume grows at our facility, the use of the call log may have an even greater effect on reducing surgical cancellations.
CONCLUSION Surgical cancellations are costly and frustrating, and lastminute surgery cancellations result in OR schedule vacancies that are difficult to fill. Although reasons for surgery cancellations related to patient illness and other uncontrollable situations are difficult to reduce, we found that overall cancellation rates improved after implementing a preoperative protocol. This QI project emphasizes the importance of preoperative screening to reduce cancellations and to help pediatric surgical patients and their guardians understand and prepare for surgery.
Editor’s notes: The focused anesthesia interview resource (FAIR) tool is a copyright of Virginia C. Muckler, Durham, NC. Epic software is a copyright of the Epic Systems Corp, Verona, WI. Excel is a registered trademark of Microsoft Corp, Redmond, WA.
References 1. Boudreau SA, Gibson MJ. Surgical cancellations: a review of elective surgery cancellations in a tertiary care pediatric institution. J Perianesth Nurs. 2011;26(5):315-322. 2. Pohlman GD, Staulcup SJ, Masterson RM, Vemulakonda VM. Contributing factors for cancellations of outpatient pediatric urology procedures: single center experience. J Urol. 2012;188(4 suppl): 1634-1638. 3. Dimitriadis PA, Iyer S, Evgeniou E. The challenge of cancellations on the day of surgery. Int J Surg. 2013;11(10):1126-1130.
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Reducing Surgery Cancellations 4. Haufler K, Harrington M. Using nurse-to-patient telephone calls to reduce day-of-surgery cancellations. AORN J. 2011;94(1):19-26. 5. Ellis S, Young D, Peters JA. Hybrid pre-op assessment model increases OR efficiency at Nebraska hospital. Anesthesiology News. http://www.anesthesiologynews.com/ViewArticle.aspx?d¼ Policy%2B%26%2BManagement& d_id¼3&i¼Marchþ2013&i_id¼ 937&a_id¼22716 [subscription required]. Published March 22, 2013. Accessed February 13, 2017. 6. Muckler VC, Vacchiano CA, Sanders EG, Wilson JP, Champagne MT. Focused anesthesia interview resource to improve efficiency and quality. J Perianesth Nurs. 2012;27(6):376-384. 7. Emanuel A, MacPherson R. The anesthetic pre-admission clinic is effective in minimising surgical cancellation rates. Anaesth Intensive Care. 2013;41(1):90-94. 8. Allison J, George M. Using preoperative assessment and patient instruction to improve patient safety. AORN J. 2014;99(3):364-375. 9. Kearney M, Jennrich MK, Lyons S, Robinson R, Berger B. Effects of preoperative education on patient outcomes after joint replacement surgery. Orthop Nurs. 2011;30(6):391-396. 10. Chahal N, Manlhiot C, Colapinto K, Van Alphen J, McCrindle BW, Rush J. Association between parental anxiety and compliance with preoperative requirements for pediatric outpatient surgery. J Pediatr Health Care. 2009;23(6):372-377.
Chelsea M. Lee, DNP, RN, is the administrator of the Pediatric Specialists of Virginia Ambulatory Surgery Center, Fairfax. Dr Lee has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Cheryl Rodgers, PhD, RN, CPNP, CPON, is an assistant professor of Nursing at Duke University, Durham, NC. Dr Rodgers has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Albert K. Oh, MD, is the director of the Fellowship for Craniofacial and Pediatric Plastic Surgery and assistant professor in the Department of Plastic and Reconstructive Surgery and Pediatrics at Children’s National Medical Center, George Washington University, Washington, DC. Dr Oh has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Virginia C. Muckler, DNP, CRNA, CHSE, is the National League for Nursing simulation leader, assistant professor, and clinical education coordinator of the Duke University Nurse Anesthesia Program, Durham, NC. Dr Muckler has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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