- Email: [email protected]
Using Nurse-to-Patient Telephone Calls to Reduce Day-of-Surgery Cancellations
Using Nurse-to-Patient Telephone Calls to Reduce Day-of-Surgery Cancellations KIMBERLY HAUFLER, BS, RN; MARY HARRINGTON, BSN, RN
ABSTRACT Day-of-surgery cancellations are costly and frustrating for both the patient and the health care team. This is especially true in ambulatory surgical centers where it can be difficult to schedule a replacement procedure on short notice. Preoperative nurses at the University of North Carolina Health Care ambulatory surgical center were able to decrease the daily cancellation rate by 53%, increase patient satisfaction scores, and increase OR use by targeting three main reasons for cancellations during a preoperative telephone call. A nurse calls each patient three business days before the scheduled surgery and uses a script to communicate important preoperative information and to address any questions or concerns. The nurse then reports any new information or concerns he or she has learned from the telephone call to the scheduling clinic, anesthesia team, or the surgeon. These calls have resulted in major decreases in cancellations related to no shows, NPO requirements, and lack of a responsible adult present to drive the patient home. AORN J 94 (July 2011) 19-26. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.12.024 Key words: ambulatory surgery, day-of-surgery cancellations, preoperative telephone calls.
U
nexpected cancellations on the day of surgery are a costly frustration to both patients and medical staff members. For a stand-alone ambulatory surgical center (ASC) that is not attached to a hospital, filling an empty OR at the last minute can be impossible. Often day-of-surgery cancellations are made after the patient arrives at the ASC, thereby incurring costs to the patients and family members, including a day’s lost wages, costs of transportation, and lost productive time, and costs for the health care team, including an inability to bill for OR time, a need to resterilize equipment that is already
opened, and nonproductive hours for OR staff members, anesthesia team members, postanesthesia care unit nurses, surgical technologists, and nursing aides. Researchers have analyzed the causes of day-of-surgery cancellations and the role of nurses in their prevention, but there is a lack of studies about specific interventions to target the cause of these cancellations.1 At the University of North Carolina Health Care ASC, the preoperative charge nurse collected data about the reasons for cancellations and identified that three of the top 10 reasons were related to preoperative patient teaching: no-shows,
doi: 10.1016/j.aorn.2010.12.024
© AORN, Inc, 2011
July 2011
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No 1 ●
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noncompliance with NPO restrictions, and a lack of a responsible adult present with the patient. In an effort to reduce cancellations, the nurses initiated a project to educate patients about preoperative policies and preparedness during a preoperative telephone call. The nurses used a script when explaining to patients the importance of restrictions, the reasons for rules, and the likelihood that a procedure would need to be cancelled if the rules were not followed exactly. The nurses then followed up with the clinic, anesthesia team, or surgeon about any particular patient needs that were identified during this call. SETTING AND DATA COLLECTION The University of North Carolina ASC has four ORs, each in use for nine hours a day, five days a week. The average number of procedures performed per month is 360, with a mixture of pediatric and adult patients undergoing orthopedic, ophthalmic, plastic, general, urologic, gynecologic, dental, and otolaryngology surgeries. Staff members in the individual service clinics are responsible for adding patients to the OR schedule. At the time that the procedure is scheduled, the patient is given a date for the surgery and a pamphlet with general surgical instructions. For two years, the preoperative charge nurse recorded the patient’s medical record number, date, name of surgeon, and reason for cancellation. Cancellations also were recorded in the electronic OR schedule, and the preoperative charge nurse verified that no cancellations were missed in the preoperative log. The following categories (with accompanying log acronyms) are used to group reasons for cancellations:
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(NS) The patient was a no-show, which meant that the patient did not come for his or her surgery and provided no explanation. Most patients in this category had communicated in days prior that they intended to come, but, on the day of surgery, they could not be reached. If the patient was later contacted and gave a reason for the absence, then the cancellation AORN Journal
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was reclassified in the appropriate reason category. (NPO) The patient had solid food in the eight hours before surgery, full liquids in the six hours before surgery, or clear liquids in the two hours before surgery. (RA) The patient was not accompanied by a responsible adult who could receive the discharge instructions and drive the patient home. (SICK) The patient, the patient’s family member, or the surgeon was ill, hospitalized, or deceased. The illness was unexpected, not a known chronic condition, and was not communicated to the ASC until the day of surgery, or, in the preoperative area, the patient was found to be too sick for surgery by the examining anesthesiologist. If the condition was chronic, it would be classified in the category “needing further medical clearance/ workup” (WU), not SICK. Also included in this category were the unexpected medical conditions discovered during the preoperative assessment such as a positive pregnancy test, positive drug screen, unacceptable laboratory test values, or failure to remember to take a necessary premedication. (CL) The service clinic did not remove the patient from the OR schedule, but the patient stated that he or she had called the clinic previously to cancel or reschedule. (SNN) The surgery was not needed according to the surgeon’s preoperative assessment. Often, these are Mohs excisions performed by another physician that do not need surgical closure. Also in this category were miscarriages that were completed at home or cysts that had dissolved. (ASC) The patient had a condition, such as a body mass index higher than 35 kg/m2 without an evaluation by the precare anesthesiologist, a known difficult airway, or an American Society of Anesthesiologists physical status classification of 4, that precluded his or her procedure from being completed at the ASC.
PREOPERATIVE TELEPHONE CALLS
These situations were differentiated from SICK when the patient’s condition was chronic and had been documented one or more times in his or her record. These situations were differentiated from those in which the patient needed further workup (WU) when the conditions were not likely to change (eg, chronic obstructive pulmonary disease, obstructive sleep apnea, end-stage renal disease). (NT) There was no time left in the OR as a result of a previous procedure that lasted longer than the scheduled time. (WU) The patient needed further medical workup. Examples might include a child with von Willebrand disease who has not had a hematologist’s review of basic laboratory test results, a patient who reports chest pain with exertion without having seen a cardiologist, or a patient undergoing plastic surgery who needs a neurology consult for numbness distal to the area that needed surgery. (OR) Operating room equipment was broken, or implants or equipment were missing. (WE) Inclement weather impeded patient or staff member arrival for the procedure. ($) The patient had unresolved financial or insurance problems. (REF) The patient refused surgery. (UN) The reason was unknown. For example, a staff member may take a message that the patient called and cancelled without giving a reason, and then the patient could not be reached again. (OT) Other reasons occurred three times in two years. One was an inmate who had a court date on the day of surgery, one was a 17-year-old minor whose parents could not be reached overseas to consent, and the third occurred because the surgeon was called to a trauma in the emergency department.
During the 18 months before the project began, 6,564 procedures were audited, with 395 day-ofsurgery cancellations (6.0%).
www.aornjournal.org
INTERVENTION The preoperative charge nurse set a goal of decreasing day-of-surgery cancellations that resulted from no-shows (NS), NPO violations (NPO), and a lack of a responsible adult to accompany the patient home (RA). The nurse chose to target these three reasons because they are the factors that can be most easily affected by the low-cost intervention of teaching. Telephone interviews have been found to be effective as a hospital-based evaluation for identifying potential problems that could cause a lastminute cancellation.2 El-Dawlatly et al3 analyzed 2,480 procedures during three months and found that the most common reason for day-of-surgery cancellations was no-show and that there often was a breakdown in communication with the patients scheduled for surgery. In a hospital focus group study, 88% of patients said that the information given to them in the preoperative interview about their upcoming surgery, including what to prepare for and expect, exceeded their expectations in its usefulness to them.4 Dexter et al5 found that 80% of day-of-surgery cancellations at a university teaching hospital were from nonmedical causes. At a tertiary teaching hospital, 68% of cancellations had nonmedical causes.6 In addition, nurse researchers found that the perianesthesia nurses’ role is paramount in preventing cancellations.1 The evidence indicates that the low-cost intervention of increased communication between health care staff members and patients before surgery can eliminate some of the causes of last-minute cancellations. Before implementation of this project, a unit secretary would call the patients on the day before their surgery. Although secretaries were coached about what to say, because of their location and other tasks, they were not routinely monitored, and therefore there was not necessarily uniformity in what was said to patients. Also, comments made by patients about their health or special needs may not have been thoroughly investigated by nonclinical staff members. The AORN Journal
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clinical director and preoperative charge nurse initiated a policy that required an RN to call the patient three business days before the scheduled surgery to educate him or her, by using a script, about preoperative policies and preparedness. The RN also was responsible for following up with the clinic personnel, anesthesia team members, or surgeon about any particular needs that were identified during this call. The ASC secretary continued to contact the patients the day before surgery but started using a script and reiterating much of the same information to the patient a second time. All the nurses and secretaries attended an inservice program to learn the purpose and process for the three day calls and to become oriented to the book of scripts and the spreadsheet where numbers and notes are recorded. All scripts are kept in a logbook with patients’ telephone numbers and OR schedule. Individual staff members were instructed to initial next to the patient’s name in the log book after each contact was made with a patient or patient’s family member so that follow-up could be done in case a patient claimed that he or she had not been given the information needed. This helped in identifying the causes of cancellations that persisted as accountable to patient or nurse errors. No-Show To lower the number of no-show patients, a preoperative RN confirmed the patient’s knowledge of the date and location of the surgery during the call three days before surgery. The RN explained to the patient that the secretary would call him or her one business day before surgery to verify the exact time for his or her arrival. The patients were asked for all their contact telephone numbers, including for cell phones that they would have with them while traveling to the ASC. The RN entered all of this information in an electronic spreadsheet that he or she checked off while following the script. Many day-of-surgery cancellations were prevented at this point because the 22
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HAUFLER—HARRINGTON patient was able to tell the RN if he or she was not available on a certain date or during a specific time frame. Many patients also offered information about a change in their health status, previous problems with anesthesia, or financial concerns. Sometimes the nurse reached a patient who indicated that he or she had canceled or rescheduled the procedure by calling the specialty clinic, even though his or her procedure was still pending on the computerized OR schedule. The RN had an algorithm to follow to notify clinics, surgeons, anesthesiologists, and OR schedulers of patient’s requests and needs. It is the clinic scheduler’s responsibility to insert new procedures into slots that become available. NPO Status To address day-of-surgery cancellations as a result of inappropriate NPO status, the nurse followed a script to explain in detail what food and drink is allowed by mouth and when. The nurse stated that the reason for the restriction is that “it is not safe to have anesthesia with food or other liquids in the stomach” and the result of not following the restriction would be a delay or cancellation of the patient’s surgery. Also it was agreed by nursing staff members and anesthesiologists that the definition of clear liquids would be restricted to black coffee, water, apple juice or clear soda to simplify comprehension, and patients were encouraged to write these options down. Responsible Adult Present To decrease the number of day-of-surgery cancellations as a result of the patient not having a responsible adult present, the nurse explained, “You must have someone with you at the ASC who is over 18 years old, who is able to stay here the entire time, and who can drive you home. Is that a problem for you?” The nurse also told the patient, “If you do not have an adult with you at the ASC, we cannot start your surgery.”
PREOPERATIVE TELEPHONE CALLS RESULTS Having nurses conduct the three day calls was the only change made to decrease day-of-surgery cancellations at the ASC during the six-month period. The three day calls began in July 2009, which coincided with the peak of the H1N1 flu virus pandemic. The patient or patient’s family member being sick became the number one cause of day-of-surgery cancellations, especially in children having otolaryngology or dental surgery. Results showed a 54% decrease in the number of cancellations due to the specific causes targeted in the calls (ie, NS, NPO, RA) compared with cancellations in the previous year. The total number of cancelled procedures on the day of surgery dropped from an average of 132 in the six months before three day calls, to 94 in the six months after the three day calls began. The largest increase per category of day-ofsurgery cancellation reasons was in the “Not appropriate for ASC” category, which could be a result of decreased usage of the precare clinic. Of the 11 surgical procedures cancelled during this project for not being ASC appropriate, four of the patients had been evaluated in the precare clinic and seven had not. There is opportunity to improve communication between the ASC and those in precare and to standardize what happens in a precare evaluation. This is an area that requires further data collection, study, and intervention. Clinic communication as a reason for day-ofsurgery cancellations dropped from an average of 11 per six months, to two in the six months after the project began. Clinic communication was not one of the target reasons, but it often was discovered during the three day call that the patient had previously attempted to cancel the surgery by calling the clinic, but the clinic staff members had not followed through to remove the procedure from the OR schedule. During the previous year, the average per-day cancellation rate was 1.5 patients; however, after the three day calls, the average per-day cancellation rate decreased by 53.3% to 0.80 patients per
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day. In addition, OR use and productivity increased because discoveries that potentially led to cancellations were made in plenty of time to insert a new patient into the OR schedule. After five months, the preoperative nurses updated the scripts for the calls to suit staff members’ wording preferences. Staff members received updates via e-mail and staff meetings about the decreased day-of-surgery cancellations rates, increased patient satisfaction scores, and increased usage of ORs. Before the three day calls, NS was the most frequent cause of day-of-surgery cancellations; however, after the patient calls were initiated, NS dropped to second place (Table 1). The third most-frequent cause for cancellations were NPO violations, but, after the three day calls, these violations dropped to fifth place. Responsible adult issues dropped from the seventh to the ninth most-frequent cause. During the 18 months before the project began, 395 of the 6,564 scheduled patients cancelled on the day of surgery (6.01%); however, during the six months after the project, 94 of 2,124 patients cancelled on the day of surgery (4.43%). To consider whether this difference in proportion was significantly greater than zero, given chance, we used a 2-proportion z test. The test revealed that the ratio between the difference in proportions (1.6%) to the standard error (.006) resulted in a significant test statistic at P ⬍ .05 (z ⫽ 2.77, P ⫽ .006) (Table 2). The project resulted in a significant decrease in cancellations as a result of three target areas: NS, NPO, and RA issues. During the 18 months before the project, 155 of the 6,564 scheduled patients cancelled on the day of surgery (2.36%) for one of these reasons; however, during the six months after the project, 28 of the 2,124 scheduled patients cancelled on the day of surgery (1.32%) for one of these reasons. We used a 2-proportion z test to determine that the difference in proportions (1%) to the standard error (.006) AORN Journal
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TABLE 1. Number of Day-of-Surgery Cancellations by Reason
Reason NS: no-show NPO: NPO status RA: responsible adult present SICK: patient, patient’s family member, or physician ill, hospitalized, or deceased CL: the clinic did not remove the patient from the OR schedule SNN: surgery not needed ASC: the patient had a condition that precluded his or her procedure from being completed at the outpatient center NT: no time was left in the OR WU: the patient needed further medical workup OR: OR equipment was broken, or implants or equipment were missing WE: inclement weather $: unresolved financial or insurance problems REF: the patient refused surgery UN: reason unknown OT: other reasons Total
Jan-Jun 2008
Jul-Dec 2008
Jan-Jun 2009
Jul-Dec 2009*
18 14 11 29
27 14 11 23
37 18 5 30
17 8 3 26
6 8 15
14 13 2
12 7 3
2 12 11
7 4 0
6 3 7
11 6 2
4 7 1
0 3 4 3 1 123
1 4 0 2 1 128
6 3 2 1 1 144
0 3 0 0 0 94
* First six months into the project of nurse-to-patient three day phone calls.
resulted in a significant test statistic at P ⬍ .05 (z ⫽ 2.91, P ⫽ .004) (Table 3). Reducing our day-of-surgery cancellations to 4.43% also is significant because, according to Macario,6 a day-of-surgery cancellation rate of less than 5% is one of the eight indicators of OR efficiency. This project saved the ASC an esti-
TABLE 2. Significance of Reduction of Cancellations After the Project Began Before Project (Jan 2008 to Jun 2009) Total scheduled OR procedures ⫽ 6,564 Total day-of-surgery cancellations ⫽ 395 6.01% of cases cancelled z ⫽ 2.767
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After Project (Jul-Dec 2009) Total scheduled OR procedures ⫽ 2,124 Total day-of-surgery cancellations ⫽ 94 4.43% of cases cancelled P (2 tailed) ⫽ .006
mated $102,983 in recovered revenue because the cancellation rate was decreased by 1.6%.
DISCUSSION After implementation of patient education by a nurse through short telephone calls three days before surgery, the numbers and percentages of day-of-surgery cancellations dropped significantly, and OR use increased from 72.4% to 75.8%. Patient satisfaction survey scores increased from 89% to 94%, although there were other initiatives working simultaneously toward that goal. An unexpected drop came in the category of day-of-surgery cancellations because of lost messages from patients to clinic schedulers. The preoperative nurse making the calls is responsible for following up with patients who report that they want to reschedule or cancel a procedure. He or she does this by contacting the clinic schedulers and filling the slot in the OR schedule with an-
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TABLE 3. Significance of Reduction of Cancellations in the Three Target Areas: No-Show (NS), Not Appropriately NPO (NPO), and Responsible Adult/Ride Issues (RA) Before Project (Jan 2008 to Jun 2009) Total scheduled OR procedures ⫽ 6,564 Total day-of-surgery cancellations due to NS, NPO, RA issues ⫽ 155 2.36% of cases cancelled z ⫽ 2.910
After Project (Jul-Dec 2009) Total scheduled OR procedures ⫽ 2,124 Total day-of-surgery cancellations NS, NPO, RA issues ⫽ 28 1.32% of cases cancelled P (2 tailed) ⫽ .004
other patient, thus improving surgeon satisfaction, OR use, and revenue. In this project, the greatest increase in day-ofsurgery cancellations involved procedures that were not appropriate for the ASC satellite location. The specific reasons were known or suspected difficult airway, body mass index above the ASC limit of 35 kg/m2, the need for a specialty consult during the surgery, or chronic medical problems. In each of these situations, the preoperative nurse discovered the evidence needed to support moving the procedure to the main hospital OR previously recorded by clinic staff on the patient’s chart. “Not appropriate for ASC” cancellations have accounted for 31 instances in the past two years. This number could be decreased if the nurse making three day calls is allotted time to do a review of the patient’s chart before making the preoperative call. The nurse could discuss pertinent factors found in the chart with the ASC anesthesiologist before making the preoperative telephone call and could ask the patient specific medical questions to clarify situations that could possibly lead to a cancellation of the surgery. To have all patients seen in a precare visit is not economically or logistically feasible; however, if a nurse conducts a virtual precare visit via telephone from the ASC, with the particulars of ASC restrictions and physi-
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cian preferences known, many complications could be recognized, investigated, and referred to an inhouse anesthesiologist for evaluation, if necessary. CONCLUSION No one benefits from a procedure cancelled at the last minute, especially in an ASC where there are no other patients to fill the empty OR schedule slot. We found that most day-of-surgery cancellations were not related to a medical condition but rather to patient education issues. Scripting and advance calls by nurses are an effective way to communicate to patients the reasons for preoperative restrictions and the consequences of not following them. The calls made three days before surgery also allow enough time for the preoperative nurse to identify potential problems, reschedule patients, or rearrange schedules. By adding the three day calls, we saw a significant reduction in day-of-surgery cancellations at our facility. References 1.
2.
3.
4.
5.
6.
Gillen SMI, Catchings K, Edney L, Prescott R, Andrews SM. What’s all the fuss about? Day-of-surgery cancellations and the role of perianesthesia nurses in prevention. J Perianesth Nurs. 2009;24(6):396-398. Huang J. Comparison of the effectiveness of different preoperative screening methods: telephone interview versus hospital visit. Internet J Anesthesiol. 2003;7(2). http://www.ispub.com/journal/the_internet_journal_of_ anesthesiology/volume_7_number_2_12/article/ comparison_of_the_effectiveness_of_different_ preoperative_screening_methods_telephone_ interview_versus_hospital_visit.html. Accessed January 24, 2010. El-Dawlatly AA, Turkistani A, Aldohayan A, Zubaidi A, Ahmed A. Reasons of cancellation of elective surgery in a teaching hospital. Internet J Anesthesiol. 2008;15(2). http://www.ispub.com/ostia/index.php?xmlFilePath⫽ journals/ija/vol15n2/cancellation.xml. Accessed January 24, 2010. Hospital focus. Collaborative practice patterns cut cancellations . . . this article was adapted from one that appeared in sister-company American Health Consultant’s newsletter “Same-Day Surgery.” RN. 1997;60(5):16C, 16E. Dexter F, Marcon E, Epstein R, Ledolter J. Validation of statistical methods to compare cancellation rates on the day of surgery. Anesth Analg. 2005;101(2):465473. Macario A. Are your hospital operating rooms “efficient”? A scoring system with eight performance indicators. Anesthesiology. 2006;105(2):237-240.
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Kimberly Haufler, BS, RN, is an assistant manager, Surgical Services Department, at UNC Health Care, Ambulatory Surgical Center, Chapel Hill, NC. Ms Haufler has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Mary Harrington, BSN, RN, is clinical director at UNC Health Care, Ambulatory Surgical Center, Chapel Hill, NC. Ms Harrington 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 Day-of-surgery cancellations are costly and frustrating for both the patient and the health care team. This is especially true in ambulatory surgical centers where it can be difficult to schedule a replacement procedure on short notice. Preoperative nurses at the University of North Carolina Health Care ambulatory surgical center were able to decrease the daily cancellation rate by 53%, increase patient satisfaction scores, and increase OR use by targeting three main reasons for cancellations during a preoperative telephone call. A nurse calls each patient three business days before the scheduled surgery and uses a script to communicate important preoperative information and to address any questions or concerns. The nurse then reports any new information or concerns he or she has learned from the telephone call to the scheduling clinic, anesthesia team, or the surgeon. These calls have resulted in major decreases in cancellations related to no shows, NPO requirements, and lack of a responsible adult present to drive the patient home. AORN J 94 (July 2011) 19-26. © AORN, Inc, 2011. doi: 10.1016/j.aorn.2010.12.024 Key words: ambulatory surgery, day-of-surgery cancellations, preoperative telephone calls.
U
nexpected cancellations on the day of surgery are a costly frustration to both patients and medical staff members. For a stand-alone ambulatory surgical center (ASC) that is not attached to a hospital, filling an empty OR at the last minute can be impossible. Often day-of-surgery cancellations are made after the patient arrives at the ASC, thereby incurring costs to the patients and family members, including a day’s lost wages, costs of transportation, and lost productive time, and costs for the health care team, including an inability to bill for OR time, a need to resterilize equipment that is already
opened, and nonproductive hours for OR staff members, anesthesia team members, postanesthesia care unit nurses, surgical technologists, and nursing aides. Researchers have analyzed the causes of day-of-surgery cancellations and the role of nurses in their prevention, but there is a lack of studies about specific interventions to target the cause of these cancellations.1 At the University of North Carolina Health Care ASC, the preoperative charge nurse collected data about the reasons for cancellations and identified that three of the top 10 reasons were related to preoperative patient teaching: no-shows,
doi: 10.1016/j.aorn.2010.12.024
© AORN, Inc, 2011
July 2011
Vol 94
No 1 ●
AORN Journal
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noncompliance with NPO restrictions, and a lack of a responsible adult present with the patient. In an effort to reduce cancellations, the nurses initiated a project to educate patients about preoperative policies and preparedness during a preoperative telephone call. The nurses used a script when explaining to patients the importance of restrictions, the reasons for rules, and the likelihood that a procedure would need to be cancelled if the rules were not followed exactly. The nurses then followed up with the clinic, anesthesia team, or surgeon about any particular patient needs that were identified during this call. SETTING AND DATA COLLECTION The University of North Carolina ASC has four ORs, each in use for nine hours a day, five days a week. The average number of procedures performed per month is 360, with a mixture of pediatric and adult patients undergoing orthopedic, ophthalmic, plastic, general, urologic, gynecologic, dental, and otolaryngology surgeries. Staff members in the individual service clinics are responsible for adding patients to the OR schedule. At the time that the procedure is scheduled, the patient is given a date for the surgery and a pamphlet with general surgical instructions. For two years, the preoperative charge nurse recorded the patient’s medical record number, date, name of surgeon, and reason for cancellation. Cancellations also were recorded in the electronic OR schedule, and the preoperative charge nurse verified that no cancellations were missed in the preoperative log. The following categories (with accompanying log acronyms) are used to group reasons for cancellations:
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(NS) The patient was a no-show, which meant that the patient did not come for his or her surgery and provided no explanation. Most patients in this category had communicated in days prior that they intended to come, but, on the day of surgery, they could not be reached. If the patient was later contacted and gave a reason for the absence, then the cancellation AORN Journal
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was reclassified in the appropriate reason category. (NPO) The patient had solid food in the eight hours before surgery, full liquids in the six hours before surgery, or clear liquids in the two hours before surgery. (RA) The patient was not accompanied by a responsible adult who could receive the discharge instructions and drive the patient home. (SICK) The patient, the patient’s family member, or the surgeon was ill, hospitalized, or deceased. The illness was unexpected, not a known chronic condition, and was not communicated to the ASC until the day of surgery, or, in the preoperative area, the patient was found to be too sick for surgery by the examining anesthesiologist. If the condition was chronic, it would be classified in the category “needing further medical clearance/ workup” (WU), not SICK. Also included in this category were the unexpected medical conditions discovered during the preoperative assessment such as a positive pregnancy test, positive drug screen, unacceptable laboratory test values, or failure to remember to take a necessary premedication. (CL) The service clinic did not remove the patient from the OR schedule, but the patient stated that he or she had called the clinic previously to cancel or reschedule. (SNN) The surgery was not needed according to the surgeon’s preoperative assessment. Often, these are Mohs excisions performed by another physician that do not need surgical closure. Also in this category were miscarriages that were completed at home or cysts that had dissolved. (ASC) The patient had a condition, such as a body mass index higher than 35 kg/m2 without an evaluation by the precare anesthesiologist, a known difficult airway, or an American Society of Anesthesiologists physical status classification of 4, that precluded his or her procedure from being completed at the ASC.
PREOPERATIVE TELEPHONE CALLS
These situations were differentiated from SICK when the patient’s condition was chronic and had been documented one or more times in his or her record. These situations were differentiated from those in which the patient needed further workup (WU) when the conditions were not likely to change (eg, chronic obstructive pulmonary disease, obstructive sleep apnea, end-stage renal disease). (NT) There was no time left in the OR as a result of a previous procedure that lasted longer than the scheduled time. (WU) The patient needed further medical workup. Examples might include a child with von Willebrand disease who has not had a hematologist’s review of basic laboratory test results, a patient who reports chest pain with exertion without having seen a cardiologist, or a patient undergoing plastic surgery who needs a neurology consult for numbness distal to the area that needed surgery. (OR) Operating room equipment was broken, or implants or equipment were missing. (WE) Inclement weather impeded patient or staff member arrival for the procedure. ($) The patient had unresolved financial or insurance problems. (REF) The patient refused surgery. (UN) The reason was unknown. For example, a staff member may take a message that the patient called and cancelled without giving a reason, and then the patient could not be reached again. (OT) Other reasons occurred three times in two years. One was an inmate who had a court date on the day of surgery, one was a 17-year-old minor whose parents could not be reached overseas to consent, and the third occurred because the surgeon was called to a trauma in the emergency department.
During the 18 months before the project began, 6,564 procedures were audited, with 395 day-ofsurgery cancellations (6.0%).
www.aornjournal.org
INTERVENTION The preoperative charge nurse set a goal of decreasing day-of-surgery cancellations that resulted from no-shows (NS), NPO violations (NPO), and a lack of a responsible adult to accompany the patient home (RA). The nurse chose to target these three reasons because they are the factors that can be most easily affected by the low-cost intervention of teaching. Telephone interviews have been found to be effective as a hospital-based evaluation for identifying potential problems that could cause a lastminute cancellation.2 El-Dawlatly et al3 analyzed 2,480 procedures during three months and found that the most common reason for day-of-surgery cancellations was no-show and that there often was a breakdown in communication with the patients scheduled for surgery. In a hospital focus group study, 88% of patients said that the information given to them in the preoperative interview about their upcoming surgery, including what to prepare for and expect, exceeded their expectations in its usefulness to them.4 Dexter et al5 found that 80% of day-of-surgery cancellations at a university teaching hospital were from nonmedical causes. At a tertiary teaching hospital, 68% of cancellations had nonmedical causes.6 In addition, nurse researchers found that the perianesthesia nurses’ role is paramount in preventing cancellations.1 The evidence indicates that the low-cost intervention of increased communication between health care staff members and patients before surgery can eliminate some of the causes of last-minute cancellations. Before implementation of this project, a unit secretary would call the patients on the day before their surgery. Although secretaries were coached about what to say, because of their location and other tasks, they were not routinely monitored, and therefore there was not necessarily uniformity in what was said to patients. Also, comments made by patients about their health or special needs may not have been thoroughly investigated by nonclinical staff members. The AORN Journal
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clinical director and preoperative charge nurse initiated a policy that required an RN to call the patient three business days before the scheduled surgery to educate him or her, by using a script, about preoperative policies and preparedness. The RN also was responsible for following up with the clinic personnel, anesthesia team members, or surgeon about any particular needs that were identified during this call. The ASC secretary continued to contact the patients the day before surgery but started using a script and reiterating much of the same information to the patient a second time. All the nurses and secretaries attended an inservice program to learn the purpose and process for the three day calls and to become oriented to the book of scripts and the spreadsheet where numbers and notes are recorded. All scripts are kept in a logbook with patients’ telephone numbers and OR schedule. Individual staff members were instructed to initial next to the patient’s name in the log book after each contact was made with a patient or patient’s family member so that follow-up could be done in case a patient claimed that he or she had not been given the information needed. This helped in identifying the causes of cancellations that persisted as accountable to patient or nurse errors. No-Show To lower the number of no-show patients, a preoperative RN confirmed the patient’s knowledge of the date and location of the surgery during the call three days before surgery. The RN explained to the patient that the secretary would call him or her one business day before surgery to verify the exact time for his or her arrival. The patients were asked for all their contact telephone numbers, including for cell phones that they would have with them while traveling to the ASC. The RN entered all of this information in an electronic spreadsheet that he or she checked off while following the script. Many day-of-surgery cancellations were prevented at this point because the 22
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HAUFLER—HARRINGTON patient was able to tell the RN if he or she was not available on a certain date or during a specific time frame. Many patients also offered information about a change in their health status, previous problems with anesthesia, or financial concerns. Sometimes the nurse reached a patient who indicated that he or she had canceled or rescheduled the procedure by calling the specialty clinic, even though his or her procedure was still pending on the computerized OR schedule. The RN had an algorithm to follow to notify clinics, surgeons, anesthesiologists, and OR schedulers of patient’s requests and needs. It is the clinic scheduler’s responsibility to insert new procedures into slots that become available. NPO Status To address day-of-surgery cancellations as a result of inappropriate NPO status, the nurse followed a script to explain in detail what food and drink is allowed by mouth and when. The nurse stated that the reason for the restriction is that “it is not safe to have anesthesia with food or other liquids in the stomach” and the result of not following the restriction would be a delay or cancellation of the patient’s surgery. Also it was agreed by nursing staff members and anesthesiologists that the definition of clear liquids would be restricted to black coffee, water, apple juice or clear soda to simplify comprehension, and patients were encouraged to write these options down. Responsible Adult Present To decrease the number of day-of-surgery cancellations as a result of the patient not having a responsible adult present, the nurse explained, “You must have someone with you at the ASC who is over 18 years old, who is able to stay here the entire time, and who can drive you home. Is that a problem for you?” The nurse also told the patient, “If you do not have an adult with you at the ASC, we cannot start your surgery.”
PREOPERATIVE TELEPHONE CALLS RESULTS Having nurses conduct the three day calls was the only change made to decrease day-of-surgery cancellations at the ASC during the six-month period. The three day calls began in July 2009, which coincided with the peak of the H1N1 flu virus pandemic. The patient or patient’s family member being sick became the number one cause of day-of-surgery cancellations, especially in children having otolaryngology or dental surgery. Results showed a 54% decrease in the number of cancellations due to the specific causes targeted in the calls (ie, NS, NPO, RA) compared with cancellations in the previous year. The total number of cancelled procedures on the day of surgery dropped from an average of 132 in the six months before three day calls, to 94 in the six months after the three day calls began. The largest increase per category of day-ofsurgery cancellation reasons was in the “Not appropriate for ASC” category, which could be a result of decreased usage of the precare clinic. Of the 11 surgical procedures cancelled during this project for not being ASC appropriate, four of the patients had been evaluated in the precare clinic and seven had not. There is opportunity to improve communication between the ASC and those in precare and to standardize what happens in a precare evaluation. This is an area that requires further data collection, study, and intervention. Clinic communication as a reason for day-ofsurgery cancellations dropped from an average of 11 per six months, to two in the six months after the project began. Clinic communication was not one of the target reasons, but it often was discovered during the three day call that the patient had previously attempted to cancel the surgery by calling the clinic, but the clinic staff members had not followed through to remove the procedure from the OR schedule. During the previous year, the average per-day cancellation rate was 1.5 patients; however, after the three day calls, the average per-day cancellation rate decreased by 53.3% to 0.80 patients per
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day. In addition, OR use and productivity increased because discoveries that potentially led to cancellations were made in plenty of time to insert a new patient into the OR schedule. After five months, the preoperative nurses updated the scripts for the calls to suit staff members’ wording preferences. Staff members received updates via e-mail and staff meetings about the decreased day-of-surgery cancellations rates, increased patient satisfaction scores, and increased usage of ORs. Before the three day calls, NS was the most frequent cause of day-of-surgery cancellations; however, after the patient calls were initiated, NS dropped to second place (Table 1). The third most-frequent cause for cancellations were NPO violations, but, after the three day calls, these violations dropped to fifth place. Responsible adult issues dropped from the seventh to the ninth most-frequent cause. During the 18 months before the project began, 395 of the 6,564 scheduled patients cancelled on the day of surgery (6.01%); however, during the six months after the project, 94 of 2,124 patients cancelled on the day of surgery (4.43%). To consider whether this difference in proportion was significantly greater than zero, given chance, we used a 2-proportion z test. The test revealed that the ratio between the difference in proportions (1.6%) to the standard error (.006) resulted in a significant test statistic at P ⬍ .05 (z ⫽ 2.77, P ⫽ .006) (Table 2). The project resulted in a significant decrease in cancellations as a result of three target areas: NS, NPO, and RA issues. During the 18 months before the project, 155 of the 6,564 scheduled patients cancelled on the day of surgery (2.36%) for one of these reasons; however, during the six months after the project, 28 of the 2,124 scheduled patients cancelled on the day of surgery (1.32%) for one of these reasons. We used a 2-proportion z test to determine that the difference in proportions (1%) to the standard error (.006) AORN Journal
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TABLE 1. Number of Day-of-Surgery Cancellations by Reason
Reason NS: no-show NPO: NPO status RA: responsible adult present SICK: patient, patient’s family member, or physician ill, hospitalized, or deceased CL: the clinic did not remove the patient from the OR schedule SNN: surgery not needed ASC: the patient had a condition that precluded his or her procedure from being completed at the outpatient center NT: no time was left in the OR WU: the patient needed further medical workup OR: OR equipment was broken, or implants or equipment were missing WE: inclement weather $: unresolved financial or insurance problems REF: the patient refused surgery UN: reason unknown OT: other reasons Total
Jan-Jun 2008
Jul-Dec 2008
Jan-Jun 2009
Jul-Dec 2009*
18 14 11 29
27 14 11 23
37 18 5 30
17 8 3 26
6 8 15
14 13 2
12 7 3
2 12 11
7 4 0
6 3 7
11 6 2
4 7 1
0 3 4 3 1 123
1 4 0 2 1 128
6 3 2 1 1 144
0 3 0 0 0 94
* First six months into the project of nurse-to-patient three day phone calls.
resulted in a significant test statistic at P ⬍ .05 (z ⫽ 2.91, P ⫽ .004) (Table 3). Reducing our day-of-surgery cancellations to 4.43% also is significant because, according to Macario,6 a day-of-surgery cancellation rate of less than 5% is one of the eight indicators of OR efficiency. This project saved the ASC an esti-
TABLE 2. Significance of Reduction of Cancellations After the Project Began Before Project (Jan 2008 to Jun 2009) Total scheduled OR procedures ⫽ 6,564 Total day-of-surgery cancellations ⫽ 395 6.01% of cases cancelled z ⫽ 2.767
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After Project (Jul-Dec 2009) Total scheduled OR procedures ⫽ 2,124 Total day-of-surgery cancellations ⫽ 94 4.43% of cases cancelled P (2 tailed) ⫽ .006
mated $102,983 in recovered revenue because the cancellation rate was decreased by 1.6%.
DISCUSSION After implementation of patient education by a nurse through short telephone calls three days before surgery, the numbers and percentages of day-of-surgery cancellations dropped significantly, and OR use increased from 72.4% to 75.8%. Patient satisfaction survey scores increased from 89% to 94%, although there were other initiatives working simultaneously toward that goal. An unexpected drop came in the category of day-of-surgery cancellations because of lost messages from patients to clinic schedulers. The preoperative nurse making the calls is responsible for following up with patients who report that they want to reschedule or cancel a procedure. He or she does this by contacting the clinic schedulers and filling the slot in the OR schedule with an-
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TABLE 3. Significance of Reduction of Cancellations in the Three Target Areas: No-Show (NS), Not Appropriately NPO (NPO), and Responsible Adult/Ride Issues (RA) Before Project (Jan 2008 to Jun 2009) Total scheduled OR procedures ⫽ 6,564 Total day-of-surgery cancellations due to NS, NPO, RA issues ⫽ 155 2.36% of cases cancelled z ⫽ 2.910
After Project (Jul-Dec 2009) Total scheduled OR procedures ⫽ 2,124 Total day-of-surgery cancellations NS, NPO, RA issues ⫽ 28 1.32% of cases cancelled P (2 tailed) ⫽ .004
other patient, thus improving surgeon satisfaction, OR use, and revenue. In this project, the greatest increase in day-ofsurgery cancellations involved procedures that were not appropriate for the ASC satellite location. The specific reasons were known or suspected difficult airway, body mass index above the ASC limit of 35 kg/m2, the need for a specialty consult during the surgery, or chronic medical problems. In each of these situations, the preoperative nurse discovered the evidence needed to support moving the procedure to the main hospital OR previously recorded by clinic staff on the patient’s chart. “Not appropriate for ASC” cancellations have accounted for 31 instances in the past two years. This number could be decreased if the nurse making three day calls is allotted time to do a review of the patient’s chart before making the preoperative call. The nurse could discuss pertinent factors found in the chart with the ASC anesthesiologist before making the preoperative telephone call and could ask the patient specific medical questions to clarify situations that could possibly lead to a cancellation of the surgery. To have all patients seen in a precare visit is not economically or logistically feasible; however, if a nurse conducts a virtual precare visit via telephone from the ASC, with the particulars of ASC restrictions and physi-
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cian preferences known, many complications could be recognized, investigated, and referred to an inhouse anesthesiologist for evaluation, if necessary. CONCLUSION No one benefits from a procedure cancelled at the last minute, especially in an ASC where there are no other patients to fill the empty OR schedule slot. We found that most day-of-surgery cancellations were not related to a medical condition but rather to patient education issues. Scripting and advance calls by nurses are an effective way to communicate to patients the reasons for preoperative restrictions and the consequences of not following them. The calls made three days before surgery also allow enough time for the preoperative nurse to identify potential problems, reschedule patients, or rearrange schedules. By adding the three day calls, we saw a significant reduction in day-of-surgery cancellations at our facility. References 1.
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Gillen SMI, Catchings K, Edney L, Prescott R, Andrews SM. What’s all the fuss about? Day-of-surgery cancellations and the role of perianesthesia nurses in prevention. J Perianesth Nurs. 2009;24(6):396-398. Huang J. Comparison of the effectiveness of different preoperative screening methods: telephone interview versus hospital visit. Internet J Anesthesiol. 2003;7(2). http://www.ispub.com/journal/the_internet_journal_of_ anesthesiology/volume_7_number_2_12/article/ comparison_of_the_effectiveness_of_different_ preoperative_screening_methods_telephone_ interview_versus_hospital_visit.html. Accessed January 24, 2010. El-Dawlatly AA, Turkistani A, Aldohayan A, Zubaidi A, Ahmed A. Reasons of cancellation of elective surgery in a teaching hospital. Internet J Anesthesiol. 2008;15(2). http://www.ispub.com/ostia/index.php?xmlFilePath⫽ journals/ija/vol15n2/cancellation.xml. Accessed January 24, 2010. Hospital focus. Collaborative practice patterns cut cancellations . . . this article was adapted from one that appeared in sister-company American Health Consultant’s newsletter “Same-Day Surgery.” RN. 1997;60(5):16C, 16E. Dexter F, Marcon E, Epstein R, Ledolter J. Validation of statistical methods to compare cancellation rates on the day of surgery. Anesth Analg. 2005;101(2):465473. Macario A. Are your hospital operating rooms “efficient”? A scoring system with eight performance indicators. Anesthesiology. 2006;105(2):237-240.
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Kimberly Haufler, BS, RN, is an assistant manager, Surgical Services Department, at UNC Health Care, Ambulatory Surgical Center, Chapel Hill, NC. Ms Haufler has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Mary Harrington, BSN, RN, is clinical director at UNC Health Care, Ambulatory Surgical Center, Chapel Hill, NC. Ms Harrington 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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