A model of community based, preadmission management for elective surgical patients

Purpose

This paper outlines the process of preadmission elective surgical preparation utilised at our institution.

Methods

The process commences with a health status questionnaire sent to all patients. Based on the results of the questionnaire all elective surgical patients are then triaged: (i) to be assessed by an appropriately accredited general practitioner (45% of elective surgical patients) and subsequently attend preadmission clinic; (ii) to be seen by an anaesthetist (25%) and also be preadmitted at this visit or (iii) to go directly to preadmission clinic (30%).

Results

This has resulted in a 96% same day admission rate for all elective surgery. Cancellations due to suboptimally prepared patients are < 1%. The involvement of general practitioners in this process has reduced patient inconvenience. There has been marked improvement in the ability to admit patients on the same day of surgery for all types of surgery while minimising late cancellations. This has been achieved at a minimum real cost.

Conclusion

Preanaesthetic assessment is important for patient well-being and hospital throughput. We describe a system for utilising non-anaesthetist general practitioners in this process. Their familiarity with their own patients and appropriate training in preoperative assessment significantly contributes to the efficiency of our elective surgical throughput.     

An assessment of the effectiveness of a pre-operative dental visit: an audit of the elective orthopaedic assessment clinic in relation to dental infection and joint arthroplasty

This paper outlines the audit that was conducted to gauge the efficiency of the Elective Pre-operative Assessment Clinic in the Department of Orthopaedics, Kilcreene Orthopaedic Hospital, Kilkenny, Ireland. The study was conducted in 1999 when 380 patients were seen. Of these, 328 were on the waiting list for joint replacement and 52 for other elective procedures. We found 204 patients fit for surgery on their first pre-assessment visit. Of the 328 patients awaiting joint replacement, 48 had dental caries or infected gums, and 28 were diagnosed with minor infective foci elsewhere in the body. These 76 patients had their operations postponed until the infection resolved. One hundred and twenty-four patients had co-morbid medical conditions for which they were referred to allied medical specialities for further opinion and/or treatment. These patients had their operations after the medical conditions were stabilised or treated. The study in question has proved that the Elective Pre-operative Assessment Clinic acts as an intermediary between the outpatient department where the patient’s name is added to the waiting list and the operation theatre by determining patient’s fitness for surgery. This fact is of primary importance as it aids in preventing possible and sometimes last-minute cancellations, thereby attesting to the effectiveness and efficiency of the pre-assessment clinic. The study results have initiated a number of improvements to our Elective Pre-operative Assessment Clinic policies, such as the introduction of a checklist card for patients on the waiting list for joint replacements. This checklist includes blood and radiological investigations, medical co-morbid conditions and points to rule out infective foci in the body.     

Incidence and causes of cancellations of elective operation on the intended day of surgery at a tertiary referral academic medical center in Ethiopia

Background

Elective surgical case cancellation refers to any elective surgical case that is the list on the day prior to surgery but not operated upon as scheduled. Case cancellation has a major cause of psychological trauma to patients and their families. Despite little is known in Ethiopia. Therefore, this study aimed to assess incidence and reasons of cancellations of elective operation on the intended day of surgery at tertiary referral academic medical center in Ethiopia.

Methods

A prospective hospital-based cross-sectional study design was conducted in a tertiary referral academic medical center in Ethiopia among 146 participants. A self-administered questionnaire with an observatory checklist was used for collecting data from the anesthetist, nurse, and surgeons.

Result

In this study, 462 patients were scheduled for elective surgical operations. Among those, nearly almost one-third 146 (31.6%) of the operations were cancelled and 316 (68.4%) patients were operated on their planned date. The most common reason for cancellation were surgeon related (35.8%), patient related (28.7%), management related (21.2%) and anesthesia related factors (14. 4%). The cancellation was mainly due to improper scheduling (20.5%%), unavailability of surgeons (8.9%), unavailability of oxygen and blood (8%) and equipment (5.5%). Orthopedic (28.8%) and general surgery (17.1%) were the commonest cancelled cases.

Conclusion

The cancellation rate in our academic medical center remains high. Improper scheduling, unavailability of surgeons, medical illness, and unavailability of operating room equipment were the commonest reason for the cancellation of elective operation. Most cancellations were preventable. For this, proper preoperative assessment, proper scheduling, fulfilling necessary operating room equipment’s and cross-matched blood by the hospital and other stakeholders, early clear communication with operating room team like surgeons was recommended.

     

A 23-hour care centre model for the management of surgical patients

BACKGROUND: Much of the emphasis on gaining efficiencies in surgical care have, to date, focused on increasing day only (DO) facilities and increasing the utilization of day of surgery admissions (DOSA) for longer stay cases. However, for the majority of cases requiring surgery, both elective and acute, the episode of care can generally be delivered within an envelope of 23 h during which time patients require only pain relief and monitoring in a supervised setting until fit for discharge. The aim of the present study was to evaluate a pilot of a 23-h care centre at a principal referral hospital. METHODS: A 23-h care centre was established at a principal referral hospital in January 2003 in association with an existing DO and DOSA facility. All patients, both emergency and elective as well as surgical and medical, who fitted the following criteria were admitted as '23-h patients' to the centre: absolute expectation of discharge within 24 h; preadmission screening by a nurse screener (if elective); agreed clinical guidelines in place; agreement to protocol-based, nurse-initiated discharge. Outcomes were evaluated after 3 months. Existing admission criteria for DO and DOSA patients were maintained. RESULTS: Over 3 months, 1601 patients utilized the 23-h care centre as follows: 593 DO patients, 410 DOSA patients and 598 23-h patients. Transfers from the emergency department constituted 47% of all 23-h patients. Utilization varied with the departments of hand surgery, ear, nose and throat/head and neck surgery, and gastrointestinal surgery all managing more than 55% of their operative workload as 23-h patients (excluding DO and DOSA patients). Excluding inappropriate admissions, overall discharge compliance was 83%. Three departments achieved the compliance benchmark of 90% of admitted patients discharged within 23 h. Only 1% of patients discharged required referral back to the emergency department, with a further 2% being reviewed by their general practitioner. CONCLUSION: The 23-h care centre model, incorporating DO, DOSA and 23-h patients, offers a workable system of healthcare delivery for patients who do not require a prolonged stay in hospital including, potentially, the majority of surgical patients.     

Case cancellations on the day of surgery: an investigation in an Australian paediatric hospital

Background: This study investigates case cancellations on the intended day of surgery (DOS) at a paediatric hospital in Melbourne, Australia. The hospital in Melbourne treats over 32 000 inpatients annually and handles both elective and emergency cases. Methods: The data for this paper were collected over a period of 12 months, from June 2004 to June 2005. The data were extracted retrospectively from the theatre computer system. A nurse researcher reviewed the full written details of all cancellations to clarify their cause and confirm the reasons for cancellation; the reasons for cancellation were then sorted into one of 14 groups. Results: There were 16 559 theatre bookings, and of these, 1198 (7.2%) were cancelled on the DOS. There was a mean of 3.28 cancellations of surgery on the intended day. The hospital‐initiated postponements accounted for 18.5% of DOS cancellations. The top four reasons for cancellation accounted for 65% of all cancelled surgeries and were all patient initiated. Conclusions: There was also evidence that some specialties were more susceptible to DOS cancellation than others. The paper ends with proposals to reduce patient‐initiated cancellations and directions for future research.     

Reducing elective general surgery cancellations at a Canadian hospital

Background

In Canadian hospitals, which are typically financed by global annual budgets, overuse of operating rooms is a financial risk that is frequently managed by cancelling elective surgical procedures. It is uncertain how different scheduling rules affect the rate of elective surgery cancellations.

Methods

We used discrete event simulation modelling to represent perioperative processes at a hospital in Toronto, Canada. We tested the effects of the following 3 scenarios on the number of surgical cancellations: scheduling surgeons’ operating days based on their patients’ average length of stay in hospital, sequencing surgical procedures by average duration and variance, and increasing the number of post-surgical ward beds.

Results

The number of elective cancellations was reduced by scheduling surgeons whose patients had shorter average lengths of stay in hospital earlier in the week, sequencing shorter surgeries and those with less variance in duration earlier in the day, and by adding up to 2 additional beds to the postsurgical ward.

Conclusion

Discrete event simulation modelling can be used to develop strategies for improving efficiency in operating rooms.     

Day surgery in Finland: a prospective cohort study of 14 day-surgery units

Background: Day surgery is an established practice for elective operative care, and is considered safe and cost-effective in several procedures and for several patients. At present, day-surgery accounts for approximately 50% of elective surgery in Finland. The aim of this study was to prospectively describe the present situation at Finnish day-surgery units, focusing on the quality of care.
Methods: Fourteen large- to medium-sized day surgery and short-stay units were recruited, and all patient cases performed during a 2-month study period were registered and analyzed. Quality of care was assessed by analyzing the rates and reasons for overnight admission, readmission, reoperation, and cancellations. Satisfaction of care was inquired from day- surgery patients during a 2-week period. Head anesthesiologists were interviewed about functional policies.
Results: Of 7915 reported cases, 84% were day surgery. Typically, several specialties were represented at the units, with orthopedics accounting for nearly 30% of all day-surgery procedures. Patient selection criteria were in line with the present-day recommendations, although the proportion of older patients and the ASA physical status 3 patients were still relatively low. The rate of unplanned overnight admissions was 5.9%. Return hospital visits were reported in 3.7% and readmissions in 0.7% of patients 1–28 days post-operatively. Patient satisfaction was high.
Conclusion: Along with the growing demand for day surgery, Finnish public hospitals have succeeded in providing good-quality care, and there still seems to be potential to increase the share of day surgery. Easily accessible benchmarking tools are needed for quality control and learning from peers.     

Return hospital visits and morbidity within 60 days after day surgery: a retrospective study of 18,736 day surgical procedures

BACKGROUND: As day surgery includes more extensive procedures focus should be put on late outcome. The frequency of day surgery-related return visits and the associated morbidity were examined to identify suitable indicators of quality. METHODS: From two centres, 16,048 patients underwent 18,736 day surgery operations including 4,829 surgical abortions. Patients were retrospectively analysed for contacts to Danish hospitals within 60 post-operative days and the associated morbidity and mortality. Data were obtained from the Danish National Patient Registry and the National Causes of Death Registry. Patient records were studied to validate contacts as being definite, likely, possible or not related. RESULTS: Altogether 113 patients (not including the surgical abortions) were readmitted to hospitals with 117 complications definitely or likely related to day surgery. The most common complications were haematomas or haemorrhage (0.40%) and infections (0.29%). Morbidity after the two most common procedures, hernia repair and knee arthroscopy, was observed in 1:39 patients and 1:220 patients, respectively. More serious complications included four patients with septic arthritis of the knee and six patients with venous thromboembolism. After surgical abortion, pelvic inflammation and bleeding were observed in 3.1% and 2.2%, respectively, with centre differences. Altogether no myocardial infarctions, central nervous system deficits, pneumonias or deaths were recorded that could definitely or likely be related to day surgery. CONCLUSION: Day surgery in Denmark is a safe practice. Readmission rates, haematomas and wound infections are likely future indicators of outcome quality after day surgery.     

Dedicated operating room for emergency surgery improves access and efficiency

Background

Scheduling emergency cases among elective surgeries often results in prolonged waits for emergency surgery and delays or cancellation of elective cases. We evaluated the benefits of a dedicated operating room (OR) for emergency procedures available to all surgical services at a large children’s hospital.

Methods

We compared a 6-month period (January 2009 to June 2009) preimplementation with a 6-month period (January 2010 to June 2010) postimplementation of a dedicated OR. We evaluated OR use, wait times, percentage of cases done within and outside of access targets, off-hours surgery, cancellations, overruns and length of stay.

Results

Preimplementation, 1069 of the 5500 surgeries performed were emergency cases. Postimplementation, 1084 of the 5358 surgeries performed were emergency cases. Overall use of the dedicated OR was 53% (standard deviation 25%) postimplementation. Excluding outliers, the average wait time for priority 3 emergency patients decreased from 11 hours 8 minutes to 10 hours 5 minutes (p = 0.004). An increased proportion of priority 3 patients, from 52% to 58%, received surgery within 12 hours (p = 0.020). There was a 9% decrease in the proportion of priority 3 cases completed during the evening and night (p < 0.001). The elective surgical schedule benefited from the dedicated OR, with a significant decrease in cancellations (1.5% v. 0.7%, p < 0.001) and an accumulated decrease of 5211 minutes in overrun minutes in elective rooms. The average hospital stay after emergency surgery decreased from 16.0 days to 14.7 days (p = 0.12) following implementation of the dedicated OR.

Conclusion

A dedicated OR for emergency cases improved quality of care by decreasing cancellations and overruns in elective rooms and increasing the proportion of priority 3 patients who accessed care within the targeted time.     

Pediatric day-care surgery: a 30-year hospital experience

Over a 30-year period (may 1955 to December 1985), day care surgery was performed on 39,654 patients at the Winnipeg Children's Hospital (WCH). Up to 51% of all pediatric surgical cases and 59% of elective pediatric cases, involving more than 50 different procedures, were performed annually on a day-care basis. The overall incidence of postoperative problems and admission to hospital was 1.5% and 1.1%, respectively. A unique preoperative home visiting program by nurses was demonstrably effective in reducing late cancellations by 75%. The WCH experience adds further evidence that day-care surgery in a pediatric hospital is safe and effective for a large proportion of infants and children requiring operation.     

Preoperative assessment in patients presenting for elective surgery

Preoperative assessment of patients undergoing elective surgery is vital to ensure patients have underlying comorbidities identified, appropriate investigations performed and are optimized prior to the day of surgery. Anaesthetic pre-assessment is usually initiated at the pre-assessment clinic. A thorough assessment should include a careful history and examination as well as assessment of both the airway and functional capacity. This article provides a systematic approach to the assessment process.     

Preoperative assessment in patients presenting for elective surgery

Preoperative assessment of patients undergoing elective surgery is vital to ensure patients have underlying comorbidities identified, appropriate investigations performed and are optimized prior to the day of surgery. Anaesthetic pre-assessment is usually initiated at the pre-assessment clinic. A thorough assessment should include a careful history and examination as well as assessment of both the airway and functional capacity. This article provides a systematic approach to the assessment process.     

Early outpatient preoperative anesthesia assessment: does it help to reduce operating room cancellations?

Increased understanding of the high cost associated with operating room (OR) cancellations has led to efforts by healthcare providers to decrease case cancellations on the day of surgery. To investigate whether preoperative evaluations within 24 h of surgery were associated with more frequent OR cancellations than those completed 2-30 days before surgery, we prospectively studied OR cancellations for 3 mo. Of the 529 patients in the study, 166 were seen within 24 h of surgery (standard group), and the remaining 363 patients were seen 2-30 days before surgery (early group). There were 70 OR cancellations on the day of surgery, and the largest single group of cancellations was related to administrative problems. The standard group and the early group were similar in terms of gender, age, ASA physical status, and percentage of patients undergoing major surgery. The OR cancellation rates were also comparable between groups: 13.3% for the standard group and 13.2% for the early group. These data suggest that patients can be evaluated in an outpatient preoperative evaluation clinic in a timeframe that is convenient for the patient without adversely affecting the cancellation rate on the day of surgery. Implications: The operating room cancellation rate for outpatients evaluated 2-30 days before surgery was compared with the cancellation rate for outpatients who received their anesthesia evaluation within 24 h of surgery. Because both groups had similar rates, outpatients may be seen at a convenient time without adversely affecting operating room cancellations.     

Ambulatory surgery in Spain

In Spain, ambulatory surgery (AS) is a form of surgical care provision covered by the services delivered by the National Health System (NHS). In order to achieve an approximation of the organisation of AS, an anonymous questionnaire was sent to all Spanish hospitals (public and private) in 1995. AS surgery was carried out in 57% of the respondent hospitals (out of these, 62% were hospitals of the NHS). Of hospitals, 54% not performing day surgery were planning to set it up in the immediate future. The most common way of providing the service is by integrating the day patients with elective cases from the surgical department. Most of the ambulatory units are hospital-based; only one free-standing unit was identified. Lack of infrastructure was claimed as the main obstacle for initiating day surgery programmes. A wide expansion of AS in Spain needs more structural modifications of the traditional hospital organisation to allow the establishment of well designed units for the provision of high quality care.     

Cancellation in CMA: incidence and causes

IntroductionMajor Ambulatory Surgery (MAS) units are becoming increasingly important and require correct management. One of the principal improvement parameters in hospital management policy is the rate of cancellations of elective surgery.Material and methodWe designed a retrospective, observational study by selecting all the patients operated on in our MAS unit from 1995 to 2009: 16.934 patients. We analysed the surgical procedures cancelled the day before the operation.ResultsA total of 701 patients (4.1%) had a scheduled surgical intervention cancelled. This cancellation occurred the day before the operation in 343 patients (2%) and on the same day of the operation in 358 patients (2.1%). Reasons for the cancellation: acute intercurrent disease in 180 patients (25.7%), personal decision of the patient in 126 (18%), non-appearance of the patient in 28 (4%), incorrect preparation of the patient in 190 (27.1%), lack of resources in 177 (25.2%). Distributing the reasons for cancellation according to the possibility of preventing them; 369 cancellations (52.6%) could be avoidable, 43 (6.2%) potentially avoidable, 177 (25.2%) difficult to avoid, and 112 (16%) unavoidable.ConclusionsMore than half of the cancellations could have been avoided. We recommend improvements in the replacement of already scheduled patients. Information campaigns would be needed to increase the awareness of the population on the real cost of health services. Improvement measures would also be needed to improve the selection-evaluation of patients with pre-operative protocols/assessment units.     

Elective intrahospital admissions versus acute interhospital transfers to a surgical intensive care unit: cost and outcome prediction

After a decade of intense fiscal scrutiny, appropriate utilization of intensive care resources remains controversial. In particular, the financial impact of patients transferred to a tertiary surgical intensive care unit (SICU) from a community hospital (interhospital) is unknown, especially when compared with elective (intrahospital) SICU admissions admitted from the tertiary center itself. We prospectively studied outcome and costs in 82 consecutive tertiary SICU admissions. Half were transferred acutely from community hospitals and half were transferred from within the hospital or postoperatively. Severity of illness (APACHE II) was scored on day 1, at the same time of the day (9:00-10:00 AM) and by one attending surgeon (BCB). Acute transfer patients had a significantly elevated mortality (36%) when compared with elective admissions (12%) (p less than 0.05). When stratified by APACHE II score, acute transfers had twice the mortality for equivalent APACHE II scores (p less than 0.05). Acute transfer patients with APACHE II scores greater than 19 had an 89% mortality; those nonsurvivors cost $128,652 each. From these results we conclude the following: (1) Acute transfer patients have a significantly elevated mortality when compared with elective intrahospital admissions with equivalent APACHE II day-1 scores; (2) patients transferred acutely to tertiary SICUs are significantly more costly, irrespective of outcome; (3) admission source (elective vs. acute transfer) should be seriously considered when evaluating patient outcome and cost in a SICU.     

Performance indicators from routine hospital data: death following aortic surgery as a potential measure of quality of care.

BACKGROUND: There is increasing pressure to monitor surgical performance. In the UK, the Department of Health has produced clinical indicators based on routine data to monitor performance. This study analysed whether such data could measure performance in aortic surgery. METHODS: Routine hospital data on postoperative mortality were collected for 1995-1997 in the Trent region. Procedural and diagnostic codes, modes of admission, districts of residence, treatment and specialty data were compared with audit data and the Operating Theatre Information System. RESULTS: Inaccuracies in the Health Resource Group (HRG) codes meant that 21.4 per cent of elective aortic cases (HRG Q02) were probably emergencies and 26 per cent of probable ruptured aneurysms were not coded as a vascular emergency. Case mix and patient selection introduced a bias, apparent between tertiary and district general hospitals. For patients aged over 80 years, two district hospitals undertook no elective aortic surgery; the rate for emergency aortic surgery varied between 16 and 25 per cent in the district hospitals, and was 77 per cent in the tertiary centre. CONCLUSION: Crude mortality rates used as an indicator of performance are subject to bias and distortion owing to the collection of incorrect information, variation in patient selection between hospitals and case-mix differences. There was a considerable variation in selection and outcomes of patients undergoing aortic surgery in this study.     

The provision of a time-critical elective surgical service during the COVID-19 Crisis: a UK experience

IntroductionWith the emergence of the COVID-19 pandemic, all elective surgery was temporarily suspended in the UK, allowing for diversion of resource to manage the anticipated surge of critically unwell patients. Continuing to deliver time-critical surgical care is important to avoid excess morbidity and mortality from pathologies unrelated to COVID-19. We describe the implementation and short-term surgical outcomes from a system to deliver time-critical elective surgical care to patients during the COVID-19 pandemic.Materials and methodsA protocol for the prioritisation and safe delivery of time-critical surgery at a COVID-19 ‘clean’ site was implemented at the Nuffield Health Exeter Hospital, an independent sector hospital in the southwest of England. Outcomes to 30 days postoperatively were recorded, including unplanned admissions after daycase surgery, readmissions and complications, as well as the incidence of perioperative COVID-19 infection in patients and staff.ResultsA total of 128 surgical procedures were performed during a 31-day period by a range of specialties including breast, plastics, urology, gynaecology, vascular and cardiology. There was one unplanned admission and and two readmissions. Six complications were identified, and all were Clavien-Dindo grade 1 or 2. All 128 patients had preoperative COVID-19 swabs, one of which was positive and the patient had their surgery delayed. Ten patients were tested for COVID-19 postoperatively, with none testing positive.ConclusionThis study has demonstrated the implementation of a safe system for delivery of time-critical elective surgical care at a COVID-19 clean site. Other healthcare providers may benefit from implementation of similar methodology as hospitals plan to restart elective surgery.     

Femoral hernia: a review of 83 cases

We evaluate the factors that affect morbidity and mortality in patients who underwent surgery due to femoral hernia. The medical records of 83 patients who underwent femoral hernia repair between January 1996 and June 2004 were retrospectively analyzed. The femoral hernias were repaired either with McVay or mesh plug hernioplasty. Sex, age, surgical repair technique, presence of incarceration/strangulation, incarcerated/strangulated organs, postoperative complications, duration of hospitalization, recurrence rate, and factors that affect mortality and morbidity were studied. There were 83 patients with femoral hernia in our study. Patients’ age ranged from 10 to 75 years (mean age was 46.84) with a predominance of female (71%). Thirty-six patients (40%) underwent emergency surgery with the diagnosis of strangulation or incarceration of femoral hernia. Seventeen patients had strangulation and underwent resection; eleven of these patients had omentum in the hernial sac, whereas six patients had intestines. Four of these patients underwent laparotomy. The remaining 19 patients had incarceration and underwent simple reduction of hernial sac content without resection. Forty-seven (60%) patients underwent elective surgery. McVay technique was used for 79 patients, while the other four patients were treated with mesh-plug. Twelve patients (15%) developed a variety of complications (nine patients (25%) in emergency, three patients (6%) in elective group). There was one mortality. Recurrences occurred in two patients. Femoral hernia is an important surgical pathology with high rates of incarceration/strangulation and intestinal resection. Emergency surgery can increase morbidity and mortality especially in the elderly. Early elective surgery may reduce complication.