Cancellation of trauma cases in a London teaching hospital : A review of the completed audit cycle - Srdjan Saso and Zaid Shalchi

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

*Joint first authors

Department of Trauma and Orthopaedics, Northwick Park Hospital, North West London Hospitals NHS Trust, Watford Road, Harrow, Middlesex, HA1 3UJ

Introduction: Cancellation of patients on trauma lists occurs regularly in many UK hospitals, often happening with minimal warning, and is recognised as leading to significant physical and psychological morbidity. We were concerned about the cancellation rates in our own department and audited our practice.

Standards: Cancellation rates in trauma surgery should be kept at a minimum.; this will vary depending on each department’s own patient characteristics. Local standards dictate that patients who are not fit for surgery should not be routinely placed on trauma lists nor starved unnecessarily. Causes for procedure cancellations must be documented in all cases.

Methods: We retrospectively reviewed the daily operating theatre trauma lists over a one month period (1 – 30 June 2008), identifying all cancelled operations, and analyzing the case-notes of the affected patients. Information collected included the day of the week, type of procedure, and the reasons for cancellation. Following an implementation of various recommendations, a re-audit was made over a further one month period (1 – 30 September 2008).

Results of Initial Audit: There were 168 proposed procedures over the period, of which 51 (30.4%) were cancelled. Cancellations were more common on Monday (25.5%) and Tuesday (19.6%). Open reduction and internal fixation procedures were the most commonly cancelled procedures (25.5%). Not enough remaining theatre time (31.4%) and patients not being fit for surgery (9.8%) were the most common causes of cancellation, though no specific cause for cancellation was documented in 49.0% of cases.

Recommendations:

• Be less ambitious with Trauma Lists, especially early in the week
• Give sufficient time for more complex procedures
• Document all reasons for cancellations

Changes Implemented:

• The audit was widely publicised and presented to all the departmental staff.
• A “Trauma List” proforma was altered to include a ‘Reason for Cancellation’ box.

Results of Re-audit : There were 111 proposed procedures, of which 24 (21.6%) operations were cancelled. Cancellations were more common early in the week (Monday, 16.7%; Tuesday 25.0%). Open reduction and internal fixation procedures remained the most commonly-cancelled operation (37.5%). The cause of cancellation was not documented in 20.8% of cases. Lack of theatre time (45.8%) and patients being unfit for surgery (29.2%) remained the most common causes.

Conclusion: The implemented changes helped to reduce the overall trauma cancellation rate by 29.0%. The recording of information pertaining to the cancelled cases increased by 55.3%. The high relative rate of cancellations on Mondays and Tuesdays persisted. There is much scope remaining to ensure that complex procedures are allocated appropriate theatre time and with the necessary senior surgical cover. Increasing theatre capacity, especially early in the week, would also be helpful.