04/09/2015
Cancellation Audit summary
Project Title
Day of Surgery Cancellations in Elective Orthopaedic Patients at LGH in March 2015
Closing loop Audit
Project Supervisors Mr. Stuart Birtwistle and Dr. Janette Gross
Project Lead Viktoras Kubaitis MD
Terms
Theatre Cancelation is a situation in hospital service management when the operation cannot be provided for the patient. It can happen for different reason:
1. Patient is unfit clinically,
2. Administrative errors,
3. Earlier operations are over-running,
4. Emergency surgery takes priority.
The term ‘last minute cancellation’ or ‘on day cancelation’ is used by the NHS to describe cancellations on the same day the surgery is scheduled or operations axed after a patient has arrived in hospital.1
Anaesthetic risk usually is measured by ASA score2 is a subjective assessment of a patient’s overall health that is based on 5 classes:
1. Patient is a completely healthy fit patient.
2. Patient has mild systemic disease.
3. Patient has severe systemic disease that is not incapacitating.
4. Patient has incapacitating disease that is a constant threat to life.
5. A moribund patient who is not expected to live 24 hour with or without surgery.
What is a breach of the standard? If a patient has not been treated within 28 days of a last-minute cancellation then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice. If a patient is offered a reasonable date within 28 days but prefers to be treated later, this should not be recorded as a breach6.
PAC - Priorities Advisory Commitee. The committee is hosted via the NHS PrescQIPP Programme, and funded by East of England CCGs. https://www.prescqipp.info/headline-areas/priorities-advisory-committee-pac
Pt – patient
LGH - Leicester General Hospital
MSK – Musculoskeletal patients
DoS – On day Surgery
Previous Audits in Leicester NHS about theatre Cancellations
No / Name of Audit / Undertaking / To evaluate what / PresentationYear
1. / Audit of trauma list cancellations / Dr. T. Bourne / The number and reasons for Cancellations in trauma Pt / 2008
2. / Audit of Workload, teaching & Cancellations 2008 / Dr. H. James / Anaesthetic SpR training issues in elective and trauma Pt / 2009
3. / Audit of Workload, teaching & Cancellations 2009 / Dr. H. James / Anaesthetic SpR training issues in elective and trauma Pt / 2010
4. / An evaluation of patients admitted and cases cancelled for the period Nov. 2008 to October 2009 / Dr.
Usman Puar / Cancellations and overnight stay in day surgery Pt / 2011
5. / Day of Surgery Cancellations in Elective Orthopaedic Patiens at LGH / Dr. J Gross / Avoidable Cancellations cases due to clinical reason in elective Pt / 2011
6. / On day cancellations due to medical reasons in Orthopaedics elective surgery / Mr. A. Brown / Avoidable Cancellations cases due to clinical reason in elective Pt / 2012
7. / Cancellations in MSK intervention / Dr. J. Crookdake / Theatre Fluoroscopic procedures in MSK Pt / 2014
8. / Communication after cancellations in orthopaedics: The patient perspective.7 / Mr.
Jitendra Mangwani / Psychological un satisfaction after Cancellation.
Trauma Pt. / 2014
Importance of the Audit 2015
NHS forced to cancel 170 operations at the last minute every day. National Audit Office survey found that the worst performing health trusts for cancelled operations between April - September 2013 included Barts in East London, the University Hospitals of Leicester Trust, and Leeds Teaching Hospitals Trust.1 The average cost per cancelled orthopaedic operation was 750 £ in 1992.3 Today the price to cancel one operation in Leicester General Hospital is 1640 £. Total price of cancellation including expenses for surgeon and registrar service would be about 2000 £ in week day, and 3000 £ on weekend. It means that the cancelation is costly and price continuously growing up with every year.4 Communication surrounding cancellations does not meet patient expectations. Patients prefer to be notified by a doctor, illustrating the importance of communication in the doctor-patient relationship.7
Reason for Audit 2015
There are a large number of MSK patients being cancelled DoS. This is distressing for patients and adversely impacts theatre utilisation of the Trust. Several Audits were already been done about theatre cancellations previously in Leicester Trust but we suspected that there is still plenty potentially avoidable cancellations due to especially medical reasons during 2014-2015 years period. This project was to review the reasons for cancellation and identify ways of better managing avoidable causes.
Actions which were implemented by Dr. J. Gross Audit in 2011
1. Improved PAC guidance for optimisation of pre-existing co-morbidities and management of medication pre-operatively.
2. E-mail LGH MSK HoS to reinforce professional responsibility to their junior doctors to follow-up and act on results of abnormal investigations from MSK PAC.
3. Improved access to High Risk Anaesthetic Clinic to identify and optimise patients with complex co-morbidities. Significant resources required in terms of clinical space, consultant PAs and clerical support.
Project Aims & Objective
1. To close Audit loop of project which was started in 2011 year
2. To establish total number of cancelations
3. To identify medical reasons for DoS cancellation in Elective Orthopaedic Patient population at LGH.
4. To highlight features of patients who can be possibly cancelled in theatre.
5. To identify potentially avoidable causes of DoS cancellation.
6. To make recommendations as to how prevent avoidable cancellations for medical reasons
7. To check – up whether patients were pre-assessed and is anaesthetic risk was evaluated adequately.
8. Were there any medical queries were flagged – up and were they then followed – up?
9. To make improvement action plan
Project Methodology
We endeavoured to follow previous Dr. J. Gross 2011 year Audit algorithm which was described in ‘Clinical Audit Summary Form’. It was retrospective review. We collected all patients from ward journal–diary. They were sent for elective orthopaedic theatre from ward No 19 on Mach 2015. There were 572 patients in total. During the period of the Audit minority of patients were also admitted to in-patient wards 14, 16 and 19. We panned 31 patients out of 572, who were cancelled on ORMIS computer System. We collected notes of these patients and gathered all possible information about them and reason why the surgery was cancel. We collected information from High Risk Anaesthetic Clinic files as well. We discussed every case with Orthopaedic consultants responsible for particular patient. All information was displayed in Excel type table. We found Standards as national Guidelines or scientific articles in literature for comparison.
All these patients were elective patients referred by GP. We looked for letters which were written by GP. Was there trial to evaluate clinical risk or PMH? Patients were coming to orthopaedic clinic to be seen by orthopaedic doctor. We counted the period between cancelled operation and day of clinic. The attention was paid what was written in ‘Waiting List Form’ (WLF) which is filled by orthopaedics ‘Comments and Co-morbidities’ box. All patients are checked for Hb level in clinic on arrival and if haemoglobin is low they were send to be seen and treated by Haematologist. Patients have to be assessed in ‘Pre-operative Pre-assessment Clinic’ by junior doctors FY1 or SHO. The attention was paid what was written in ‘Pre-assessment Form’ and was there any trial to evaluate anaesthetic risk of patients by juniors. Doctors have possibility to trace previous information on computer, to se urine deep-stick result and ECG. Patients can be sent for heart ultrasound or to be seen by Anaesthetist High Risk Anaesthetic Clinic. Everybody goes through FBC, U&E, MRSA check. Elective patients used to arrive in morning to ward No 19. There were seen by juniors, surgeon and anaesthetist. All supporting information can be found in one volume of notes and computer systems. If operation was cancelled patients are coming back from theatre on ward. They are checked by ward nurse. Doctor has to come from theatre to talk with patient, to explain reason for unexpected cancelation. Inscription has to be done by doctor in notes: what time patient was spoken, why cancellation happened and what action has to be done. We interested was the same operation was done after the cancelation again and how long it took for a team to organise operation in case of non medical reason cancelations. Was the cancellation avoidable or not avoidable.
Main Results
All cancelled patients. Comparison a Standard with previous Audits and Audit 2015
Results / Standard 19905 / Dr. Gross Audit 2011 / Audit 2015How many Month Pt were audited / 11 / 12 / 1
Total amount of operated elective patients / 284 (100%) / 3200 (100%) / 572 (100%)
Cx patients in total / 28 (10 %) / 229 (7%) / 30 (5%)
Cx due to medical reason / 82 (36 %) / 18 (60%)
Cx due to non clinical reason* / 147 (65% ) / 12 (40%)
*Patient walked away from ward, patient did not attended ward, not enough of time for surgery - overrun, instruments issues, patient doesn’t need surgery anymore, theatre staff unable to stay past shift time – overrun.
We are doing well. Only 5 % of cases were cancelled in total on March 2015.
Patients are cancelled due clinical reason (Comparison Audit 2011 and Audit 2015)
Results / Dr. Gross Audit 2011 / Mr. A Brown Audit 2012 / Mr. BirtwistleAudit 2015
Total Cx nuber due to clinical reason / 82 (100%) / 35 (100%) / 18 (100%)
Avoidable Cx – Anaesthetic risk mist in pre-assessment / 62 (76%) / 14 (40%) / 11(61 %)
Un-avoidable Cx – due to flu / 20 (24%) / 21 (60%) / 7 (39%)
Juniors in pre-assessment clinic are doing better comparing with 2011 years.
Patients are cancelled due to non clinical reason (Comparison Standard and Audit 2015)
Total amount of cancelled on day operations due to non clinical reason on March 2015 / 8Operation was done later than 21* / 2
Operation was done later than 28 days6 / 1 (31 day)
Op. is still not done or rescheduled (already more than 4 month post cancelation) / 5
6National Step Guide to Improving Op. Theatre Perform. 2002 – Reschedule not longer than 28 days
*Leicester NHS Local Guidelines – 21 days
We are don’t recon ‘Step guide 2002’ guidelines in 75 % (6 out of 8 patients) of cases
Other Audit findings
373 operations were cancelled on day in total per March 2015 in Leicester NHS according to IT department data8. It is 12 operations per day and still 3.8 times more than is usual in UK comparing with other TRUSTs on July 20159. 45 Orthopaedic patients were cancelled in Leicester NHS on March. 30 patients were on ward No 19 and it was 67% of all cancelled orthopaedic patients on March 2015. We did not count all orthopaedic patients because we followed Dr. Gross Audit 2011 methodology.
Type of Surgery / Cases per March 2015Ophtalmology / 63
Urology / 55
O&T / 45
General surgery / 38
Gynecology / 36
Ear Nose Throat / 32
Plastic surgery / 24
Pediatric surgery / 19
Maxilofacial / 17
Chronic pain / 16
Thoracic surgery / 9
Renal access surgery / 6
Breast care / 4
Vascular surgery / 4
Obstetrics / 3
Transplantation / 1
Accident and emergency / 1
The mean age of cancelled patient is 62 years. Patients cancelled due to medical reason were older 71 years old.
4 operations were cancelled for Mr. Godsiff. 3 operations were cancelled for Mr. Ullah and Mr. Boyd. 2 operations were cancelled for Mr. Pathak, Mr. Hutchings, Mr. Chatterji and Mr. Birtwistle. 1 operation was cancelled for Prof. Dias, Mr. Kulkarni, Mr. Taylor, Mr. Mangwani, Mr. Brown, Mr. Bhatia, Miss Wildin, Mr. Modi and Mr. Spain.
Everything starts from GP letter to Orthopaedic consultant. GP is very important specialist in this sequence because potentially he knows all possible problems and PMH of the patient. It was impossible to find GP letter in the notes in 60% of cases. Only 10 % of cases GP letter was helpful: in time (less than 3 month before elective surgery), with a list of medication and PMH and with trial to evaluate anaesthetic risk.
Monday is most popular day for cancellations and only one operation was cancelled on Saturday.
Most popular theatre with cancellations due to non clinical reasons is Theatre No 9B. Couple cases were cancelled: one case was due to lack of instruments and other one was due to inability for personnel to stay after hours.
Pre-assessment Form
filled by FY1 in Pre-assessment Department in Glenfield Hospital
There is no diary in Pre-assessment office. Pre-assessment office cannot trace by whom (FY1) patients were seen on that day.
Theoretically everyone is tested by ECG and Dipstick but usually it is impossible to find confirmation in notes. There is no record in pre-assessment office and we are not able to check where really patients been tested by ECG or Dipstick.
Pre-assessment Form is un-robust. Should be boxes: ‘to print SHO name’, ‘SHO grade’, ‘fit for surgery’, blood thinning issues, ASA grade or anaesthetic risk evaluation, evaluation of ECG, date of pre-assessment and name of patient on every page of form.