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The cancellation of same-day elective and urgent cardiac surgery procedures: a single centre experience
Sara Jasionowska, Rory F L Hammond, Wael I Awad
St Bartholomews’ Hospital
Barts Health NHS Trust
Purpose
• Operation cancellation for scheduled surgery is a major cause of inefficiency and poses significant pressure on the National Health Service
• Setback for patient and families
• Risks complications for the patients
• Objectives
• Establish the frequency of same-day elective and urgent cardiac surgical cancellation at the Barts Heart Centre
• Determine the reasons for cancellations and patient outcomes
STS/EACTS Latin America Cardiovascular Surgery Conference 20182
Methods
STS/EACTS Latin America Cardiovascular Surgery Conference 20183
• Prospective review of all same-day elective and urgent inpatient cardiac surgeries
• 21st August – 30th March 2018
• Data sources: theatre register, printed theatre lists, PACS, Dendrite
• Data collected on all patients
• Patient characteristics, procedure, outcomes
• Cancelled patients:
• Reasons for, timing of cancellation, and outcomes
• Patients divided into 2 groups: Cancelled (C) and Non-Cancelled (NC)
Results • 1388 patients were scheduled for cardiac surgery
• 981 (70.7%) were elective, 407 (29.3%) urgent
• Patient characteristics
• the only significant difference between C and NC was MI status (C=82/204 (40.2%), NC = 336/1121 (30.0%)) (p =0.004)
• Overall, 16.6% were cancelled on the day of surgery
• 143 (14.6%) of the electives
• 88 (21.6%) of the urgent (p= 0.001)
• Overall in hospital mortality: 41/1388 (3.0%)
• C n = 8/231 (3.5%)
• NC n=33/1157 (2.9%) (p= 0.62)
STS/EACTS Latin America Cardiovascular Surgery Conference 20184
0 10 20 30 40 50 60 70 80 90 100
overruning case
intra-op TOE findings
death preop
electrical system failure
theatre staff shortage
transfer issue
surgeon unavailable
incomplete investigations
lack of perfusionist
procedure no longer needed
emergency intervened
patient related issues
schedulling error
medically unfit
no ITU beds/nurses
Reasons for cancellation
90 ( 39.0%)
50 (21.6%)
21 ( 9.1%)
7 (3.1%)
7 ( 3.1%)
5 ( 2.6%)
4 (1.7%)
4 (1.7%)
3 (1.3%)
3 (1.3%)
1 (0.4%)
1 (0.4%)
1 (0.4%)
18 (7.8%)
16 (6.9%)
Results
STS/EACTS Latin America Cardiovascular Surgery Conference 20185
• Timing of cancellation
• Pre-operative for 222 (96.1%)
• Intraoperative for 3 (1.3%) patients
• Anaesthetic room for 2 (0.9%)
• 61/231 (26.4%) of cancelled procedures were undertaken by a different surgeon
• 19/231 (8.23%) patients were cancelled twice
• Out of these 15/19 (78.9%) were operated on by a different surgeon
• In-hospital transfer cancellations significantly higher if
scheduled for surgery <24hrs from admission (25% vs
13.6%) p=0.00001
0 10 20 30 40 50 60 70
no data available
not performed
>28 d
4-28 d
7-14 d
3-7 d
24-72 hrs
24 hrs
Time from cancellation to operation
46 (19.9%)
53 (23.0%)
64 (27.7%)
19 (8.2%)
19 (8.2%)
2 (0.9%)
20 (8.7%)
8 (3.5%)
0 10 20 30 40 50 60 70 80 90 100
>30 d
14-30 d
7-14 d
3-7 d
48-72 hrs
24-48 hrs
<24 hrs
Hospital stay post cancellation
92 (39.8%)
6 (2.6%)
4 (1.7%)
39 (16.9%)
54 (23.4%)
23 (10.0%)
1 (0.4%)
Summary
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• Our cancellation rate of 16.6% is above average national rates of 7.5%
• Higher cancellation rates within urgent patient group compared to elective
• The most common reasons for cancellation were no ITU beds/nurses (39.0%), patient medically unfit (21.6%) and
scheduling errors (9.1%)
• 46/223 (19.9%) of patients cancelled were operated within 24 hours
• However, 40/223 (17.9%) were operated after 7 days from the cancellation
• 61/231 (26.4%) of cancelled procedures were undertaken by a different surgeon
• 20/231 (8.7%) of cancellations did not subsequently undergo surgery
• In-hospital transfer cancellations significantly higher if scheduled for surgery <24hrs from admission
• Recommendations: detailed pre-op workup, day of surgery admission, sending patient reminders, urgent referral system,
surgery for transfer patients after 24h from admission
• Target potentially preventable reasons for cancellation eg. ITU staff shortage, lack of perfusionist, inadequate workup
THANK YOU
STS/EACTS Latin America Cardiovascular Surgery Conference 20188
0
50
100
150
200
250
300
350
400
450
isolated CABG isolated valve combinedvalve and
CABG
other
Operative procedures
urgent
elective
22.4%
26.3%
15.0%
29.0%
10.4%
28.6%
11.9%
33.3%
*
**
P=0.04
STS/EACTS Latin America Cardiovascular Surgery Conference 20189
0
20
40
60
80
100
120
surgeon A surgeon B surgeon C surgeon D surgeon E surgeon F surgeon G surgeon H surgeon I surgeon J surgeon K surgeon L surgeon M surgeon N surgeon O surgeon P surgeon Q
Cancellations according to the Consutant Surgeon
n performed n cancelled
5.9%
8.0%
8.1%
13.2%
14.0% 14.3% 15.1%
14.5%
16.3%
17.0%
19.5%
19.8%
20.0%
20.7%
20.8%
22.2%
31.7%
STS/EACTS Latin America Cardiovascular Surgery Conference 201810
0
10
20
30
40
50
60
70
80
90
<24hrs 24-48 hrs >48 hrs
Cancellations within in-hospital transfers
25%
13.6%
18%
Cancellations: ITU beds/nurses - 39.0%
• 71/90 (78.9%) lack of ITU beds
• 19/90 (21.1%) lack of ITU staff
STS/EACTS Latin America Cardiovascular Surgery Conference 201811
Cancellations: Medically unfit – 21.6%
• loose stool
• gastric bleed
• Haematuria
• hyponatraemia/hypokalaemia
• new angiography findings
• Respiratory failure
• pneumonia, allergic reaction to reoperative antibiotics
• Flu
• Rash
• leg ischaemia UTI
• Pyrexia
• cellulitis
STS/EACTS Latin America Cardiovascular Surgery Conference 201812
Cancellations: ‘Scheduling error’ - 9.1%
• 13/21 (61.9%) overrunning case
• 4/21 (19.0%) operating room overbooked
• 3/21 (14.3%) late start to the operation
• 1/21 (4.8%) IT scheduling error
STS/EACTS Latin America Cardiovascular Surgery Conference 201813
Cancellations: Patient related issues –7.8%• 5/18 (27.8%) DNA
• 4/18 (22.2%) warfarin not stopped
• 3/18 (16.7%) treatment refusal
• 3/18 (16.7%) self-cancellation
• 1/18 (5.6%) late Jehovah cancellation
• 1/18 (5.6%) private treatment chosen
• 1/18 (5.6%) incorrect consent form signed
STS/EACTS Latin America Cardiovascular Surgery Conference 201814
Recommendations
• Ring – fenced beds
• Continual assessment of bed availability
• Better planning
• Detailed pre-op workup (checklist)
• Day of surgery admission
• Calling/texting patients before the surgery
• Urgent referral system (standardised referral form)• Separate coordinator to deal with urgent cases
• Try to reschedule the surgery within 24 hrs (affects patient satisfaction)
• Surgery planned for transfer patients after 24hrs from admission
STS/EACTS Latin America Cardiovascular Surgery Conference 201815
Steps towards preventing cancellations
• Unavoidable reasons for cancellation:• ITU bed numbers
• Intervening emergency case
• Patient seeking private treatment
STS/EACTS Latin America Cardiovascular Surgery Conference 201816
STS/EACTS Latin America Cardiovascular Surgery Conference 201817
27%
10%
10%
7%
7%
6%
6%
6%
6%
4%
4%
4%
1% 1% 1%
Potentially preventable reasons for cancellation 71/231 (30.7%)
ITU staff shortage
surgery no longer needed
lack of perfusionist
inadequate work up
patient DNA
transfer issues
medication not stopped
theatre overbooked
surgeon unavailable
electrical system failure
threatre staff shortage
late start
dentist appointment
late Jehovah witness declaration
scheduling error