Analyses of the related factors for surgery suspension at a general surgery service of medium complexity

Abstracts

OBJECTIVE: To identify the suspension rate on elective surgeries and to investigate their occurrences, and their cancelling causes. MEHTODS: This is an exploratory, descriptive and cross-sectional study with a quantitative and qualitative approach which was carried out at the Department of General Surgery in a medium complexity Hospital. All surgeries performed from January 2007 to July 2008 were analyzed. RESULTS: Seven thousand nine hundred and thirty eight surgeries were performed during the period of the research from which there were 1806 urgencies (22.75%) and 6132 (77.25%) were scheduled. There were 1018 canceled surgeries in the programmed group, corresponding to a cancellation rate of 16%. Most of the reasons concerning cancellation were related to the patients (48.23%), such as unfavorable clinical conditions (50.3%) and absences (39.9%); the reasons related to the hospital were because of human resources allocation (23.77%), the organization of the unit (22.88%) and the allocation of material and equipment (5.12%). CONLCUSION: It was found that 41% of the canceled procedures should indeed not be performed. Some corrective management measures are necessary in order to diminish the cancellation rate.

Surgical procedures; operative; Surgery; Surgicenters; Quality control

OBJETIVO: Identificar a taxa de suspensão de operações eletivas e investigar a ocorrência e as causas do seu cancelamento. MÉTODOS: Trata-se de um estudo de natureza exploratória, descritiva, transversal e com abordagem quantitativa e qualitativa realizado no Departamento de Cirurgia Geral de um hospital de média complexidade. Foram analisadas todas as operações marcadas eletivamente no período compreendido entre janeiro de 2007 a julho de 2008. RESULTADOS: No período do estudo, foram agendadas 7938 cirurgias, sendo 1806 urgências (22,75%) e 6132 cirurgias eletivas (77,25%). Do total de cirurgias eletivas, foram canceladas 1018, correspondendo a uma taxa de suspensão de 16%. Os principais fatores dos cancelamentos das cirurgias estavam relacionados ao paciente (48,23%), tais como condição clínica desfavorável (50,3%) e não comparecimento (39,9%); e ao hospital, tais como a alocação de recursos humanos (23,77%), a organização da unidade (22,88%) e a alocação de materiais e equipamentos (5,12%). CONCLUSÃO: Verificou-se que 41% dos procedimentos suspensos não deveriam ter sido marcados. Medidas gerenciais corretivas são necessárias a fim de diminuir a taxa de suspensão.

Procedimentos cirúrgicos operatórios; Cirurgia; Centros de cirurgia; Controle de qualidade

ORIGINAL ARTICLE

Analyses of the related factors for surgery suspension at a general surgery service of medium complexity

Fábio Machado Landim(in memoriam)^I; Francisco Diego Silva de Paiva^II; Maria Luciana Teles Fiuza^III; Emanoelle Pinheiro de Oliveira^IV; Jonathan Guimarães Pereira^V; Iana de Almeida Siqueira^II

^IOncological Surgeon, Hospital Geral Dr. Waldemar Alcântara (HGWA), Fortaleza, CE, Brazil

^IIMedical student, Universidade Estadual do Ceará (UECE), Fortaleza,CE, Brazil

^IIINurse, Surgical Suite Coordinator, Hospital Geral Dr. Waldemar Alcântara, Fortaleza, CE, Brazil

^IVNurse, Specialist in Surgical Ward Management, Hospital Geral Dr. Waldemar Alcântara, Fortaleza, CE, Brazil

^VResident Physician, General Surgery, Hospital Geral Dr. Waldemar Alcântara, Fortaleza, CE, Brazil

ABSTRACT

BACKGROUND: To identify the suspension rate on elective surgeries and to investigate their occurrences, and their cancelling causes.

METHODS: This is an exploratory, descriptive and cross-sectional study with a quantitative and qualitative approach which was carried out at the Department of General Surgery in a medium complexity Hospital. All surgeries performed from January 2007 to July 2008 were analyzed.

RESULTS: Seven thousand nine hundred and thirty eight surgeries were performed during the period of the research from which there were 1806 urgencies (22.75%) and 6132 (77.25%) were scheduled. There were 1018 canceled surgeries in the programmed group, corresponding to a cancellation rate of 16%. Most of the reasons concerning cancellation were related to the patients (48.23%), such as unfavorable clinical conditions (50.3%) and absences (39.9%); the reasons related to the hospital were because of human resources allocation (23.77%), the organization of the unit (22.88%) and the allocation of material and equipment (5.12%).

CONCLUSION: It was found that 41% of the canceled procedures should indeed not be performed. Some corrective management measures are necessary in order to diminish the cancellation rate.

Key words: Surgical procedures, operative. Surgery/organization & administration. Surgicenters. Quality control.

INTRODUCTION

Over the last decades, the cancellation of operations has been given attention on the part of researchers in the field of healthcare. The analysis of the cancellation rate of elective operations aims at the improvement in the quality of care and the efficiency of the service provided to the population, as well as the rationalization of financial and human resources. Such analysis should be made public on a regular basis to all those concerned¹.

The Brazilian Ministry of Health² defines surgery cancellation rate as the number of cancelled surgeries divided by the total number of surgeries scheduled over a given period of time and multiplied by 100.

The cancellation rate of operations is one of the criteria in the evaluation of the efficiency of a surgical service. Low rates reveal a good performance of the service evaluated and the surgical suite of the hospital unit. In order to construct this indicator, all reasons for surgery cancellation must be taken into account¹, such as those related to the patient (unfavorable clinical status, non-attendance, lack of fasting and others); and to the hospital, e.g. the organization of the unit (errors in surgery scheduling and priority to urgencies, for instance) and the allocation of human and material resources.

The repercussion of surgery cancellation on the patient and his or her family has also been studied. A surgical procedure disrupts a person's routine as it entails being away from his or her activities at work and home, and the need to allocate financial resources. Therefore, cancelling results in frustration and economic loss for the individual and for society¹.

From an administrative standpoint, the cancellation of a surgery affects the healthcare staff members themselves and impacts the expenditure of time and material resources. Therefore, it clashes with the concerns of the healthcare management, particularly the surgical services, with optimizing activities, cutting expenses, preventing waste and maximizing quality³.

The objective of the present study was to determine the cancellation rate of elective surgeries and to investigate the reasons for cancellations in general surgery service at a medium-complexity hospital.

METHODS

This is an exploratory, descriptive and cross-sectional study with both a quantitative and qualitative approach conducted at the Department of General Surgery of the Hospital Geral Dr. Waldemar Alcântara (HGWA) in Fortaleza, Ceará state, Brazil. The HGWA is a medium-complexity hospital within the regionalization scheme of the Sistema Único de Saúde (SUS, Unified Healthcare System), and is run by a social organization. The surgical suite of the unit comprises three operating rooms and undertakes an average of 380 to 400 surgical procedures per month. All surgeries listed on the daily surgery schedule in the period from January 1, 2007 through July 31, 2008 were analyzed. A cancellation of a scheduled operation was defined as any operation that, for any reason, was nor performed, whether elective or emergency.

In order to assess whether there were surgery cancellations, the database of the electronic medical records of the Department of General Surgery was used. The database is updated daily through surgery forms, daily surgery schedule, operating room expenses and cancellation forms. The reasons for surgery cancellation were classified by the authors in patient-related (unfavorable clinical status, non-attendance, lack of fasting and others) and hospital-related, such as the organization of the unit (e.g. errors in surgery scheduling and priority to urgent surgeries) and allocation of human and material resources.

For statistical analysis, the data were tabulated on Excel – Microsoft Office® 2003 software.

RESULTS

Of the 7938 surgeries scheduled in the period from January 2007 through July 2008, 1806 were urgencies (22.75%) and 6132 elective (77.25%).

The operations were classified according to their length as: short duration (under 30 minutes), medium (30 to 90 minutes) and long duration (over 90 minutes). Most operations were of medium duration (46.2%), followed by short (44.5%) and long duration (9.3%) (Figure 1).

Over the study period, from the 6132 surgeries scheduled, 5114 were performed and 1018, cancelled; thus, cancellation rate was 16%.

In the present study, as shown in table 1, 48.23% of the 1018 operation cancellations occurred mainly because of patient-related problems, such as unfavorable clinical status (50.3%) and non-attendance (39.9%).

The reasons for cancelled operations involving the organization of the unit (22.88%), such as priority to urgent surgeries (72.1%) and errors in surgery scheduling (12.5%) also stood out.

Problems associated with the allocation of human resources (23.77%) also accounted for a considerable proportion of cancellations. Among those, surgical procedure time overrun (64.5%), no anesthesiologist available (7.85%), no surgeon available (6.2%) and changes in medical management (14.05%) were major causes.

The causes of cancellation of elective operations associated with the allocation of materials and equipment accounted for only 5.12% of the reasons for cancellation.

DISCUSSION

One of the criteria in evaluating the efficiency of a surgical service is the low cancellation rate of operations. Low rates demonstrate a good performance of the service evaluated and the surgical suite of the hospital unit¹. For the hospital, the cancellation of an elective surgery means heavy losses due to bed allocation, booking of the operating room, waste of materials with costly sterilization, the personnel involved in the preparation of the materials and the operating room, and the missed opportunity of adding another patient to the surgical schedule^3,4.

The construction of that performance indicator should take account of all reasons for cancellation of surgeries, such as lack of clothing, surgeon delay, lack of patient preparation, no fasting, previous tests not performed, missing x-rays and non-adherence to adequate administrative planning¹.

Psychological aspects of the patients involved must be considered. These show resentment, lack of trust in the staff, insecurity, intense stress and increased distress. The notification of a surgical case cancellation has been a reason for concern on the part of the healthcare staff and the hospital administration, yet cancellations are often perceived as a trivial fact inherent to the functional structure of the institution. Increasing concern and care have been shown when communicating a cancellation. Explanations are sometimes incomplete and not always consistent between the physicians and nursing staff^{1,4, 5}.

Adequate management of elective surgeries will lessen depletion of the patient, reduce the length of hospital stay and the risks of nosocomial infection, and will also decrease treatment costs with direct benefits for users, who will be better assisted, and for the institution, which will have increased productivity and financial returns. By knowing the rate and causes of surgery cancellations, the institution can prevent them through well-planned nursing care in liaison with the other professional teams, as well as material and staff resource planning⁴.

The cancellation rate of surgeries in the present study was 16%, which is in line with the studies conducted by Paschoal and Gatto³ at a university-affiliated hospital in the city of São Paulo, where the rate was 19.91%, and by Arieta el al⁶, who found 39 cancellations in 200 ophthalmological patients, resulting in a rate of 19.50%. Other studies show higher rates of cancellation of surgeries. Gatto⁷ found a rate of 27.33% and Cavalcante et al⁴ pointed out that, after a quantitative analysis, they found 33% of surgery cancellations in a public university-affiliated hospital in the city of Fortaleza, Ceará state. According to Cavalcante et al⁴, further investigations are needed in this subject in order to know the reasons that determine cancellations. A teaching hospital in a province of Pakistan had around 25% of its scheduled surgeries called off⁸.

Other studies found a lower cancellation rate. Perroca et al¹ noted that, in the period of three months, 4870 surgeries were scheduled for the surgical suite of a teaching hospital in the interior of São Paulo state, 249 of which were cancelled – a rate of 5.1% of cancellations. A study conducted at a tertiary hospital in Australia found that 13.2% of the elective surgeries were cancelled on the day of the procedure⁹. Lacqua and Evans¹⁰, when prospectively analyzing 1063 cases of scheduled surgeries, found 184 (17%) cancellations.

The rates found in the present study conflict with the strategic planning of the HGWA, since they should not exceed 10%. Part of those cancellations was due to the priority given to urgencies (72.1% of the reasons associated with the organization of the unit ) and surgical procedure time overruns (64.5% of the reasons related to human resources); therefore, they are unpreventable service-related reasons, since the percent of urgencies was high in the period (22.75%), and 9.3% of the procedures were long-duration, outside of the profile assigned to the secondary level.

Each institution should implement specific measures to continuously reduce the cancellation rate of surgeries in its service. In our institution, there is a pre-anesthesia clinic with the aim of reducing those figures. However, as a result of socioeconomic needs, patients are admitted without the optimal clinical conditions for surgery.

Regarding the causes that contributed to the cancellation of surgeries in the present study, most were patient-related (48.23%), followed by those related to human resources (23.77%), the organization of the unit (22.88%), and equipment and materials (5.12%). In another study, the majority of reasons were also related to the patient (57%)¹. The causes associated with the organization of the unit (22.1%) predominated over the allocation of human resources (17.7%) and the reasons related to equipment and materials accounted for only 1.6% of the cancellations¹. Other studies^11,12 also show that the causes of surgery cancellation are strongly linked to factors that are inherent to the patient.

Among the patient-related factors, the lack of optimal clinical conditions (50.3%) and non-attendance (39.9%) are important. Similar results were found by Perroca et al¹; however, patient non-attendance to the scheduled surgery (56.3%) predominated, which is in agreement with a study conducted at a university-affiliated hospital in the city of São Paulo³, where the frequency of operations cancelled because of patient non-attendance represented 54.3% of the total of cancelled surgeries.

At the HGWA, operations are scheduled during the ambulatory visit, when the clinical evaluation of the patient takes place; therefore, the scheduling of a surgery is generally defined long in advance, thus the patient is more susceptible to changes in his or her clinical status, which could make the surgical procedure impracticable. There is also a policy of active search, by telephone, for patients listed in the surgical schedule to confirm attendance on the previous day. We believe that both a more effective preoperative evaluation and counseling to the surgical patient could reduce the current rates.

Among the reasons concerning human resources (23.77% of the total), surgical procedure time overrun (64.5%) and changes in medical management (14.05%) stood out. In a study conducted by Perroca et al¹, changes in medical management (43.2%) predominated over surgical procedure time overrun (25%). In the surgical suite of the HWGA, long-duration surgeries amounted to 9.3%, thus contributing to an increase in operating-room time. Shortage of anesthesiologists (7.85%) was also responsible for the cancellation of surgeries. Inadequate preoperative preparation accounted for only 1.65% of the cancellations related to human resources; however, that factor could be prevented by improved communication between the patient, doctors and nurses.

Problems related to the organization of the unit (22.88%) also accounted for a considerable proportion of the reasons for cancellation; the leading factor was priority to urgencies (72.1%). That is an unpreventable cause of cancellation and represented a major factor in the present study, given the large amount of urgency surgeries performed in the period (22.75%), even though there was no open emergency. Urgency operations reduce the number of available hospital beds and the surgery rate for elective patients, thus decreasing the efficiency of the surgery service¹³.

The results of the present study demonstrated that around 41% of the cancelled procedures should not have been scheduled. That figure is still quite high for a General Surgery Service. Measures for confirmation of the attendance of patients included in the daily surgery schedule, pre-anesthesia evaluation clinic, clinical protocols and data automation were components of the program of reduction in surgery cancellations. However, a revision of managerial processes and tools such as PDCA (Plan, Do, Check, Act) is under way to minimize that inconvenience and humanize the relations between patients and their physicians.

REFERENCES

• 1. Perroca MG, Jericó MC, Facundin SD. Monitorando o cancelamento de procedimentos cirúrgicos: indicador de desempenho organizacional. Rev Esc Enferm USP. 2007; 41(1):113-9.
• ²
  Ministério da Saúde. Secretaria Nacional de Organização e Desenvolvimento de Serviços de Saúde. Normas e padrões de construções e instalações do serviço de saúde. 2ª ed. Brasília; 1978.
• 3. Paschoal MLH, Gatto MAF. Taxa de suspensão de cirurgia em um hospital universitário e os motivos de absenteísmo do paciente à cirurgia programada. Rev Latino-am Enfermagem. 2006; 14(1):48-53.
• 4. Cavalcante JB, Pagliuca LMF, Almeida PC. Cancelamento de cirurgias programadas em um hospital-escola: um estudo exploratório. Rev Latino-am Enfermagem. 2000; 8(4):59-65.
• 5. Antonio PS, Munari DB, Costa HK. Fatores geradores de sentimentos do paciente internado frente ao cancelamento de cirurgias. Revista Eletrônica de Enfermagem (online). 2002; 4(1):33-9. Disponível em: http://www.fen.ufg.br/
• 6. Lira RPC, Nascimento MA, Temporini ER, Kara-José N, Arieta CEL. Suspensão de cirurgia de catarata e suas causas. Rev Saúde Pública. 2001; 35(5): 487-9.
• 7. Gatto MAF. Análise da utilização de salas de operações [dissertação]. São Paulo -SP: Escola de Enfermagem/USP; 1996.
• 8. Zafar A, Mufti TS, Griffin S, Ahmed A, Ansari JA. Cancelled elective general surgical operations in Ayub teaching hospital. J Ayub Med Coll Abbottabad. 2007; 19(3):64-6.
• 9. Schofield WN, Rubin GL, Piza M, Lai YY, Sindhusake D, Fearnside MR, Klineberg PL. Cancellation of operations on the day of intended surgery at a major Australian referral hospital. Med J Aust. 2005; 182(12):612-5.
• 10. Lacqua MJ, Evans JT. Cancelled elective surgery: an evaluation. Am Surg. 1994; 60(11):809-11.
• 11. Lira RPC, Nascimento MA, Temporini ER, Kara-José N, Arieta CEL. Suspensão de cirurgias de catarata e suas causas. Saúde Pública 2001;35(5):487-9.
• 12. Arieta CEL, Taiar A, Kara-José N. Utilização e causas de suspensão de intervenções cirúrgicas oculares em Centro Cirúrgico ambulatorial universitário. Rev Assoc Méd Bras. 1995; 41(3):233-5.
• 13. Wyllie JH, Kidson IG, Wyllie DH. Pursuing efficiency in surgical practice. BMJ. 1988; 297(6660):1368-71.

Publication Dates

• Publication in this collection
  09 Nov 2009
• Date of issue
  Aug 2009

History

• Received
  03 Nov 2008
• Accepted
  10 Jan 2009