INTRODUCTION
The elective surgery postponement is a common problem worldwide that causes numerous detrimental effects on patients and their families, hospital finance and staff.[1 2 3 4 5 6 7 8 9 10 11 12 13 7 14
In South Africa's health institutions, few studies have been published reporting the rates and reasons for cancellation of elective surgery. Currently, there have been no investigations done on the rate and reasons for cancellation in paediatric elective surgery at Chris Hani Baragwanath Academic Hospital (CHBAH). A study to determine the rates and describe the reasons for cancellation of elective surgeries in paediatric patients at CHBAH was performed.
MATERIALS AND METHODS
A retrospective study was conducted in the theatre complex of the CHBAH affiliated to the Department of Anaesthesiology at the University of the Witwatersrand. Chris Hani Baragwanath Hospital has 29 theatres of which 17 may be used for paediatric elective procedures. The paediatric theatre records from 01 January 2019 to 31 December 2019 in the following theatres and suites: Paediatric surgery and neonates, paediatric orthopaedics (paeds ortho), ophthalmology, orthopaedic spine (ortho spine), neurosurgery, hands, burns, ear nose and throat (ENT), maxillofacial, cardiac catheterisation laboratory (cardiac cath lab), bronchoscopy, urology, plastics and audiology were reviewed. Records from magnetic resonance imaging (MRI), computed tomography (CT) scan and angiography suites were excluded because the reasons for cancellation were not documented. Elective paediatric procedures included all cases appearing on the booked list signed by the consultant anaesthesiologist and theatre matron before 14:00 the day prior to the scheduled surgery. A patient appearing on this list will be considered cancelled if the operation does not take place on the scheduled date.
The number of cases booked, done and cancelled were reviewed for each speciality. The reasons for cancellation were placed into categories (patient-related, work-up related, medical condition related, resource-related, surgery-related, anesthesia-related, facility-related and other). The above information was collected using a structured data collection sheet. Data were captured in Microsoft Excel and results were expressed as a graph and tables. Statistical Package for the Social Sciences was used to further analyse the data. The likelihood of time constraints for different surgical specialties against a reference group (paeds surgery and neonates) was estimated by odd's ratio and confidence interval using Chi-squared analysis. A P < 0.05 was statistically significant.
The categories of reasons for cancellation were described as avoidable and non-avoidable. Avoidable factors were the reasons judged as potentially avoidable because some intervention or protocol could be implemented to try decrease cancellations and these factors were resource related, patient related, surgery related, work up related and other. Non-avoidable factors were the reasons where no intervention or protocol could be implemented to try reduce cancellations and these included facility related, medical related and change of guardian's mind in patient-related factors. The study was approved by the Human Research Ethics Committee (Medical) and the Post-graduate Studies Committee of the University of Witwatersrand.
RESULTS
In the year 2019, a total of 3399 elective paediatric procedures were scheduled in 14 specialities at CHBAH. Of these, 634 (19%) were cancelled due to various reasons. The highest number of cases cancelled were from paediatric surgery and neonates (n = 204, 31%), followed by ENT (n = 99, 24%), burns (n = 80, 20%) and paediatric orthopaedics (n = 79, 16%). The lowest number of cancelled cases came from urology (n = 3, 17%) and hands (n = 3, 3%). The number of cases booked, done, cancelled and the cancellation rate by surgical speciality is described in Table 1 . The graphic form of cancellation rates by speciality is described in Figure 1 .
Figure 1: Cancellation rates in specialities. ENT: Ear nose and throat
Table 1: Number of cases booked, done and cancelled in each speciality
Reasons for cancellation placed in categories are described in Table 2 . Resource-related category had the highest cancellation rate at 34%. The reasons for cancellation by surgical speciality are presented in Table 3 . The most common reason for cancellation in each speciality is highlighted in the bold text.
Table 2: Reasons for cancellations
Table 3: Reasons for cancellation by each speciality
The most common reason for cancellation of elective surgery in paediatric patients at CHBAH was found to be time constraint. Using the paediatric surgery and neonates as a reference (it had the highest number of cases booked and cancelled), the likelihood of time constraints contributing to case cancellation by surgical speciality is described in the Table 4 . Only the surgical specialities with the cases cancelled due to time constraint are included in Table 4 .
Table 4: The likelihood of time constraints (odds ratio and 95% confidence interval) by surgical speciality
DISCUSSION
The cancellation rate at CHBAH was much higher at 19% compare to other studies (Kaddoum et al . [4.4%], Chiu et al . [7.6%], Bathla et al . [7.6%] and Okeke et al . [9.1%]) and more than three times the recommendation value of <5%.[1 2 4 5 15 16 et al .,[17 et al .,[11 et al .,[18 et al .[15
The highest number of cases cancelled were from paediatric surgery and neonates (n = 204), even though the cancellation rate was not the highest (31%). The dominant reason for cancellation in this discipline was time constraint at 38%, and this was probably due to overbooking and under estimation of duration of the surgery. The paediatric surgery and neonatal lists are one of the lists that book both inpatient and outpatients (no differentiation done during data collection). The parents or family are contacted telephonically prior to booking but there may be problems encountered such as no response, transport issues or short notice and this could have contributed to overbooking. Okeke et al .[16
Ortho spine and bronchoscopy had the highest cancellation rates (33% and 32%, respectively) even though the actual number of cases cancelled were low (n = 4 and n = 13, respectively). Therefore, the higher the number of cases booked did not correlate with the highest cancellation rate. Our study also showed the lowest cancellation rates (3% and 7%) from hands and ophthalmology specialities. This was possibly due to compliant patients, concerns about vision loss and appropriate preoperative counselling about the need and urgency for surgery. In the study by Boudreau and Gibson,[9
The main reason for cancellation was time constraint, which falls into resource-related category. Compared to paeds surgery and neonate, the odds of no available operating time were significantly less in ENT, burns, ophthalmology, plastics and the cardiac catheterisation list. The mostly likely reasons probably related to the booking of the realistic lists and in burns theatre, most booked patients are considered as emergencies and therefore every patient gets done. The long duration of operation in neurosurgery may have contributed to the increased cancellations. Chiu et al .[5
Time constraint was a problem across all specialities at 34% with different contributing factors. This was comparable to 41% and 30% reported by Asmal et al .[15 et al .,[19
Our cancellation rate due to patients not arriving for theatre was 16% and it was the second commonest reason for cancellation. Bronchoscopy, audiology, cardiac cath laboratory and ophthalmology were the main specialities where a significant number of patients did not arrive for the procedure because most patients in these specialities are outpatients. In the study by Pratap et al .,[10
Communication between the hospital and the guardian or parents seems to be a serious issue contributing to cancellation of elective surgery in paediatric patients. There is no formal communication programme or protocol in place for all elective surgeries at CHBAH that may facilitate the effective pre-operative communication amongst every part involved in planning the surgery. Multidisciplinary team meeting is the only form of communication that is available for complicated planned surgery, and most cancellations are for elective outpatients presenting for minor surgeries. According to Lee et al .,[6
In the medical condition-related category, unfit for surgery was the prominent issue which accounted for 14% of cancellations. Al Talalwah et al .[8
Bathla et al .[1 et al .,[3 et al .[1 et al .[3 20
Unavailability of post-operative placement accounted for 10.7% of the cancellation of elective paediatric surgeries at CHBAH. Desta et al .[11
The reasons for cancellation in our study were due to avoidable factors at 68% and non-avoidable at 32%. This warrants reasons to investigate intensively about cancellation of elective surgery in paediatrics and implement strategies to deal with these unnecessary cancellations due to avoidable factors. The greatest number of avoidable factors were due to time constraint, patient not arriving for surgery, surgery unnecessary and other. There is approximately 70% place for improving theatre efficiency by tackling avoidable factors. Unfit for surgery and unavailability of post-operative placement contributed the most in non-avoidable factors. In the studies by Kaddoum et al .,[4 et al .[12 et al .,[19
A new method or strategy for recording information about elective surgeries is necessary to be able to have more detailed and adequate audits. The detailed audit should include starting and finishing times, inpatient versus outpatients, any delay (from the time of initial booking by the attending physician to time of cancellation) and specific detailed reason for cancellation. The study by Asmal et al .[15 theatre efficiency may improve significantly. A pre-operative communication protocol, call log or assessment clinics would be of significant help in reducing the cancellation of elective surgery in paediatric patients, especially for patients booked as outpatients because the presence of URTI or any correctable medical condition could be identified and treated accordingly before the booking, and appropriate health education could be done.[6
Limitations
The study was done retrospectively which could have impacted on the results because information is gathered from previous records. The records could be insufficient, not detailed and scanty, this affects the audit results. Some disciplines such as MRI, angiography and CT scan were not included in the study due to unavailability of records. Thus, other factors may have been missed that contribute to the cancellation of elective surgery in paediatric patients at CHBAH.
CONCLUSION
The rate of cancellation in our study was high. Time constraint was the major reason for cancellation. Majority of the causes for cancellation were avoidable. Multiple preventable factors contributed to the high rate; therefore, a more detailed investigation and implementation of improvement strategies to tackle these factors is warranted.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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