الفهرس 
AIM OF THE WORKOnly 14 pages are availabe for public view
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Abstract
Cost containment through effective and efficient utilization of resources has become a necessary part of healthcare delivery worldwide. This is due to rising cost of healthcare and increasing financial pressure on the healthcare system. Cancellation of scheduled elective surgeries on the day of surgery represents a source of inefficiency with consequent increase in both hospital and patient expenditure. They are not uncommon occurrences throughout the world. The reported day-of-surgery cancellation rates vary widely among healthcare institutions.
The causes of cancellation of elective surgical procedures are multi-factorial and they tend to vary from one hospital to another as every hospital is unique in terms of its service, staff pattern, demographics of the region and also work ethics and culture. Therefore, in order to minimize the rate of cancellations, it is important to have knowledge on the magnitude and causes of the problem.
The aim of the study was to survey the rate and identify causes of cancellation of planned operations on the day of surgery in three general hospitals (namely: Gamal Abdel Naser hospital, Abou Keer hospital and El Amriya hospital) implementing different strategies for reducing elective surgery cancellations in Alexandria. Financial incentives per operations are provided for surgical team in Gamal Abdel Naser hospital. While a preoperative evaluation clinic was established since 1998 in Abou Keer hospital. On the other hand, El Amriya hospital had neither financial incentives nor preoperative evaluation clinic implemented.
The study population consisted of all inpatients in all the surgical departments (general and specialties) in the three study hospitals whose elective surgical procedures were cancelled on the day of the surgery during the year 2006. The medical records of all the patients who had their operations cancelled on the day of the surgery were audited retrospectively. Data about each cancelled case was collected and recorded on a predesigned form which included information about the age of the patient, hospital identification number, date of cancellation, surgical specialty, type of operation, any associated medical problems, the presumed reasons for cancellations and resultant waste of hospital resources.
The study reveals the following findings:
A. Overall day-of-surgery cancellation rates:
• The overall day-of-surgery cancellations rate was highest in El Amriya hospital (1.96%) followed by Abou Keer hospital (1.06%) then Gamal Abdel Naser hospital (1.02%), which were below the recommended rates.
B. Characteristics of the cancelled surgeries:
• Frequency of cancellation was highest in Gamal Abdel Naser hospital as 7 cases suffered two episodes of cancellation and 3 cases were cancelled three times. Whereas, only 3 cases in Abou Keer hospital had their surgeries cancelled twice but none of cases had 3 episodes of cancellation. All cases in El Amriya hospital had cancellation only once.
• General sugery and orthopedics departments were more likely than other departments to have highest cancellation percentages. In Gamal Abdel Naser hospital, orthropedics department had the highest cancellation percentage (46.6%). However in Abou Keer and El Amriya hospitals, general surgery department showed the highest cancellation percentages (49.0% and 77.3%, respectively).
• The major operations category accounted for the highest percentages of cancellation in Gamal Abdel Naser hospital (38.7%) and El Amriya hospital (57.6%), while the moderate operations category showed the highest percentage of cancellation in Abou Keer hospital (52.9%). Moreover, the minor operations category accounted for the lowest percentages of cancellations in the three study hospitals.
• In the three study hospitals, the non-operation (NOP) group represents from about one fifth to one third of all cancelled cases compared to postponed (PO) group.
• The highest percentages of cancellation were on Sunday in Gamal Abdel Naser hospital (25.1%). While in Abou Keer and El Amriya hospitals, the highest percentages of cancellation occurred on Tuesday with 27.1% and 28.8%, respectively.
• The hospital non-clinical category had the highest cancellation percentages in Gamal Abdel Naser hospital (61.8%) and Abou Keer hospital (45.8%). While, hospital clinical category showed the highest cancellation percentage in El Amriya hospital (48.5%).
• The males reported significantly higher cancellation rates than females in Gamal Abdel Naser hospital and Abou Keer hospital (75.4% and 56.3%, respectively). On the other hand, the majority of patients who had their operation cancelled in El Amriya hospital were females (59.1%).
• The majority of the patients who had their operations cancelled in Gamal Abdel Naser hospital and Al Amriya hospital fell in the age group of 40-59 years (41.4% and 45.5%, respectively). Whereas in Abou Keer hospital the highest percentage of patients fell in the age group of less than 20 years (33.3%).
• The majority of cases in Abou Keer hospital suffered from no co-morbidity (72.9%). However in Gamal Abdel Naser and El Amriya hospitals, about half of the patients (51.3% and 50.0%, respectively) had co-morbid conditions.
C. Causes of cancellation:
• In Gamal Abdel Naser hospital, the most common reason for cancellation was unavailability/ failure of resources (48.7%), followed by surgeries cancelled by the patient (16.8%) then by inadequate patient preparation (16.2%).
• In Abou Keer hospital, the most common reason for cancellation was the inadequate patient preparation (35.4%), followed by unavailability/failure of resources (18.8%) and surgeries cancelled by the patient (18.8%), then by administrative causes (14.6%).
• In El Amriya hospital, the most common reason for cancellation was the inadequate patient preparation (31.8%), followed by surgeries cancelled by the patient (24.2%), then by administrative causes (19.7%).
• More than 80% of the reasons of day-of-surgery cancellations recorded are preventable.
D. Wasted resources due to DOS cancellations:
• The total wasted operative time resulting from day-of-surgery cancellations was 23050 minutes (=384.26 hours or 64.22 working days or 21.77% of total working days in 2006) in Gamal Abdel Naser hospital and it was 6590 minutes (=109.86 hours or 18.3 working days or 6.2% of total working days in 2006) in El Amriya hospital. While in Abou Keer hospital, it was 3460 minutes (=57.67 hours or 9.68 working days or 3.28% of total working days in 2006).
• The wasted extra bed days as a result of day-of- surgery cancellations were 81 days with an average waste of 1.69 days per a cancelled case in Abou Keer hospital compared to 552 days with an average waste of 2.89 days per a cancelled case in Gamal Abdel Naser hospital and 84 days with an average waste of 1.27 days per a cancelled case in El Amriya hospital.
• Abou Keer hospital and El Amriya hospital reported a zero percent of wasted cross-matched blood as a result of DOS cancellations compared to a 3.4% waste in Gamal Abdel Naser hospital.
• The repeated investigations resulting from day-of surgery cancellations were the least in Abou Keer hospital (21.6%) compared to Gamal Abdel Naser and El Amriya hospitals (54.9% and 36.4%, respectively).
E. Preoperative clinic and financial incentives:
• Providing financial incentives to surgical team in Gamal Abdel Naser hospital and attendance of preoperative evaluation clinic in Abou Keer hospital yielded similar results regarding the rate of overall day-of-surgery cancellations with 1.02% overall cancellations rate in Gamal Abdel Naser hospital and 1.06% in Abou Keer hospital compared to 1.96% in El Amriya hospital where neither strategies were implemented.
The study recommendations are;
I. Departmental level:
1. Implementation of a guide on time allocation for each elective operation taking into consideration factors related to surgeons, anesthesiologists and OR staff such as skills and experience to ensure that OR list are made judiciously to avoid under- or overutilization of OR facilities.
2. Strict monitoring of the elective surgeries in terms of start time, end time, causes of delay and causes of cancellation.
3. Surgical audit, a potent resource managing tool which is already being utilized in the more economically advanced countries, should be carried out on monthly basis in every hospital to evaluate the reasons for day-of-surgery cancellations and implement the appropriate corrective strategies.
4. A team approach in the presence of a good administrator can improve OR management by improved scheduling, reducing time spent preparing and cleaning OR and better handling of resources.
5. Improved communication between the surgical team members (surgeons, anesthesiologists, nurses) involved in surgeries as well as between OR, surgical wards and supportive services.
6. Patients should be adequately counseled on the diagnosis, treatment modalities and prognosis especially if the disease is advanced or untreated in order that their fears about their operations could be overcome. This will be reflected on the patient’s adherence to the scheduled date of surgery.
II. Hospital level:
1. Introduction and implementation of outpatient pre-anesthesia clinic for elective surgical procedures.
2. Implementation of financial incentives per operation for the surgical team.
3. Implementation of shared electronic medical record which allows for timely and convenient communication between all physicians including anesthesiologists as well as between OR, surgical wards and supportive services.
4. Evaluation of patients’ perception, satisfaction and their experiences regarding the utility of pre-anesthetic clinic and the patient flow in this clinic.
5. The problem of no-show of patients requires further study to explore the causes of this problem to be able to improve patients’ compliance with their scheduled procedures.
6. Orientation of healthcare providers about wasted resources resulting from day-of-surgery cancellations in order to motivate them to minimize this waste.