Auditing Procedure Cancellation on the Trauma list at a London Teaching Hospital - Srdjan Saso 1/9/2008

Srdjan Saso, Zaid Shalchi, Haris Naseem, Anja Saso, Henry Dushan Edward Atkinson

Department of Trauma and Orthopaedics, Northwick Park Hospital

Background: The cancellation of patients booked on hospital trauma lists is unfortunately a common everyday phenomenon within any surgical unit. The reasons are often multifactorial, but ultimately these delays cause an increase in patient mortality and morbidity. In addition the actual act of cancelling a patient is often stressful to the hospital staff, the junior doctor who has to do the ‘cancelling’, the ward sister who is regulating necessary bed shortages and the consultant who has to then juggle their weekly operating lists (1). The doctor-patient relationship is also eroded. We audited the cancellation practise at Northwick Park Hospital to see whether things could be improved

Method: We prospectively reviewed a one month period (June 2008) and identified the cancelled trauma list operations on all 4 consultant trauma lists. The variables analysed included: patient name, hospital number, date of birth, consultant name, procedure date and description, the cancelled procedure, and reasons for cancellation.

Results: 168 procedures were scheduled during the month of June 2008. Of those 30% had been cancelled. 50% of the cancellations occurred at the beginning of the week, Monday and Tuesday. The two most common cancelled procedures were open reduction and internal fixation (ORIF) of fractures (13/50) and hemiarthroplasty for hip fractures (8/50). Other cancelled procedures (in order of frequency) were manipulation and K-wiring of wrist fractures, dynamic hip screw (DHS) for hip fractures, wound washouts and intramedullary (IM) nail insertion. The reasons for cancellation were variable, and remained unexplained in around half the cases.

Reasons for cancellations

Ran out of theatre time – 30%

Surgery not required – 10%

Patient not fit for surgery – 8%

Patient did not attend (left hospital) – 2%

No reason given – 49%

Discussion: Around a third of all procedures on the trauma list were cancelled, with the majority occurring at the beginning of the week. There was no trauma list provision on Sundays, thus all the trauma patients admitted on Saturday and Sunday were put on the Monday trauma list. This caused the deluge early in the week and resulted in many procedure cancellations. This could be improved by creating Sunday trauma lists, or by possibly creating more operating theatre capacity on Mondays and Tuesdays.

Most of the trauma lists were unrealistic in terms of productivity. It appeared that all pending patients were listed for every trauma list, and thus with limited capacity cases would always have to be cancelled. 30% of cancellations were due to difficulty in fitting all the pending trauma patients onto each working list.   Patients should have be prioritised according to diagnosis, length of waiting time since admission and co-morbidities and should not have been placed on the trauma lists unless there was a reasonable chance of the procedure taking place on that day.

Patients were also listed without regard to the skill-levels of the operating surgeon, and thus some of the more complex cases were cancelled more frequently due to the non-availability of appropriately trained staff. There were similarly some cancellations due to non-availability of appropriate anaesthetic cover. Poor planning and unnecessary cancellations thus meant that patients had to wait longer for surgery and potentially suffered increased morbidity and mortality rates (2).

Finally, poor documentation meant that no reason was given for 49% of cancellations which makes it more difficult to give proper recommendations on how to improve practise.

Recommendations: Reasons for procedure cancellations should be clearly documented as this allows for easier analysis and re-auditing. Orthopaedic teams should be less ambitious when planning trauma lists, especially early in the week when cancellations are most likely to occur. Finally, not all procedures take the same lengths of time, and extra time should be given for the anticipated more complex procedures.

References:

1. Cancelled elective operations: an observational study from a district general hospital. Sanjay P., Dodds A et al.2007. J Health Organ Management. 21(1):54-8.

2. Mortality associated with delay in operation after hip fracture: observational study. Bottle A. Aylin P. 2006 BMJ: 332(7547):947-51.