Early Outpatient Preoperative Anesthesia Assessment

Does It Help to Reduce Operating Room Cancellations?

Abstract

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.

(Anesth Analg 1999;89:502-5)

With the current intense pressure on hospitals to be more efficient, the timing of the preanesthesia assessment may influence the cancellation rate on the day of surgery. These cancellations may lead to dissatisfied patients and can be quite costly ^[1]. Fischer ^[2] reported that almost 90% of operating room (OR) cancellations are day-of-surgery cancellations and that these cancellations add an average of 97 min to the turnover time. Because OR time costs $8.00/min, each of these potentially avoidable patient cancellations costs $776 in OR time alone ^[3].

Outpatient preoperative evaluation can decrease OR cancellations ^[2,4-7]. Although early outpatient preoperative evaluation has been advocated, in clinical practice, preoperative evaluation on the day of surgery or the day before surgery is common. In Fischer's ^[2] clinic, 70% of all outpatients are evaluated on the day before surgery. Other clinics, in which patients are routinely seen days or weeks in advance of surgery, have reported cancellation rates comparable to those of clinics that typically evaluate patients within 24 h of surgery ^[2,5,8-11]. Our outpatient preoperative evaluation clinic was designed to provide early preoperative evaluations with the expectation that this would minimize cancellations by allowing time for further testing when necessary. At our university-affiliated Department of Veterans Affairs Hospital, patients are evaluated in our clinic on the same day as their surgical clinic appointment. This allows most outpatients to receive their initial anesthesia evaluation several days to weeks before the actual date of surgery. Late cancellations have continued to occur, so it was unclear whether the timing of the preoperative assessment was optimal. To test the hypothesis that early preoperative evaluation is associated with fewer day-of-surgery cancellations, we prospectively studied all the patients seen in our outpatient preoperative evaluation clinic for a 3-mo period and compared the OR cancellation rate for patients evaluated 2-30 days before surgery with the cancellation rate for those evaluated within 24 h of surgery.

Methods

From January 1, 1997 to March 31, 1997, patients were referred to the preoperative evaluation clinic directly from outpatient surgical clinics after they had been evaluated by a surgeon and scheduled for operation. They arrived at our clinic with their medical record, which, at a minimum, included a current surgeon's history and physical examination and a signed operation consent form.

On arrival at the clinic, patients underwent a nursing assessment before being evaluated by a member of the anesthesia care team. Preanesthetic assessments were performed by a specially trained registered nurse, certified registered nurse anesthetist, resident, or staff anesthesiologist. Unusual laboratory tests or consultations were obtained only after consultation with the anesthesiologist and, whenever possible, were obtained in the clinic the same day. Written preoperative instructions were given to the patient, and the verbal teaching was completed by the nursing staff. The night before surgery, patients were called by clinic personnel with final instructions.

With institutional review board approval, all data for patients evaluated in the outpatient preoperative clinic were prospectively entered in a database during the study. The information collected included patient age, ASA physical status, date of the preoperative assessment, type of surgery, scheduled date of surgery, and the actual date of surgery. Missing data were obtained by reviewing the hospital database or the patient's chart. Each surgery was then classified as major or minor. Major surgery was defined as all upper abdominal and intrathoracic procedures or any other procedure for which a blood type and cross-match is typically obtained. All other surgeries were classified as minor surgery. The patients were separated into two groups. The patients who received their anesthesia preoperative evaluation within 24 h of surgery were classified as "standard," and those who were evaluated 2-30 days before surgery were classified as the "early" group.

Patients who did not have a scheduled date of surgery within 30 days of the preoperative evaluation were excluded. Patients who were initially cancelled on the day of surgery and then proceeded to surgery within the study period were counted as a single patient with a single cancellation.

A patient was classified as an OR cancellation if the patient's name was on the published OR schedule but did not have surgery performed on the day scheduled. These cancellations were classified as follows: insufficient OR time or staffing, acute patient illness, surgeon's discretion, patient decision, incomplete medical work-up, or miscellaneous. Acute illness was defined as a health problem that seemed to be temporary and was not an exacerbation of a chronic medical problem (e.g., an upper respiratory infection in a patient without chronic bronchitis). Cancellations attributable to surgeon's discretion included urgent or emergent surgery preempting elective surgery or illness of a member of the surgical team.

The data were analyzed using unpaired Student's t-tests or chi squared test as appropriate. A P value of <0.05 was considered statistically significant.

Results

Five hundred thirty-seven patients were examined in the preoperative evaluation clinic between January 1, 1997 and March 31, 1997. Seven patients were excluded because they did not have a scheduled date of surgery and one patient was excluded because he was evaluated more than 30 days before the scheduled date of surgery. Of the 529 patients who qualified for this study, 31% (166/529) received their preoperative evaluation within 24 h of surgery (standard group) and 69% (363/529) were evaluated 2-30 days before their scheduled surgery (early group). The standard and early groups were comparable in terms of gender, age, ASA physical status III or IV, and classification of surgery. The cancellation rates were also comparable, 13.3% for patients evaluated within 24 h of surgery and 13.2% for patients seen 2-30 days before surgery (Table 1). The four most common causes of late OR cancellations were as follows: 15 cases were attributed to insufficient OR time (21%), 13 cases were for acute patient illness (19%), 11 cases were the surgeon's decision (16%), and 10 cases were the patient's decision (14%). Nine cancellations were to allow time for further medical evaluation (13%). Other miscellaneous causes accounted for the 12 remaining cancellations (17%).

Table 1: Patient Demographics and Operating Room Cancellation Rate

The 70 patients whose surgery was cancelled were then grouped and compared with the 459 patients whose surgery was not cancelled on the day of surgery. The timing of the preoperative assessment was comparable; 31% of the patients who were cancelled had been seen within 24 h of surgery and 31% of the patients who were not cancelled on the day of surgery had also been seen within 24 h of surgery.

Discussion

The reported rates for day-of-surgery cancellation rates vary widely among institutions, depending on how OR cancellations are defined and how the data are collected. Sites that define cancellations narrowly have reported OR cancellation rates of <or=to10% ^[2,5,8-12]. In contrast, sites that include cancellations of all types, including patient no-shows and administrative reasons, have reported cancellation rates from 13% to 20% ^[13-15]. The difference between retrospective and prospective studies can also be quite large. A retrospective review of OR cancellations from our own clinic revealed a cancellation rate of 6.6% ^[4]. With this prospective review, our cancellation rate of 13% is approximately twice the rate we previously reported. These differences in reporting must be taken into consideration when comparing OR cancellation rates at different institutions.

Because this study was observational and patients were not randomized to receive standard or early evaluations, it is possible that surgeons preselected patients who were more likely to be cancelled for early evaluation. Such preselection could offset the potential benefit of early preoperative evaluations. If preselection was a factor, it was likely a minor factor, as it was not reflected in older age, ASA physical status, or surgical severity in the early group.

For a multifactorial problem such as OR cancellations, it is critical to identify and address the major factors. At our hospital, it was assumed that medical cancellations were a major source of cancellations. With this assumption in mind, one might expect patients seen early to have a lower cancellation rate than those seen within 24 hours of surgery. The expectation is that starting the evaluation several days ahead of surgery will provide enough time either to complete the medical evaluation or to reschedule more complex patients early enough to avoid most day-of-surgery cancellations. This may be true in some settings, but in this study, the patients' chronic medical problems were not the most important factor leading to OR cancellations on the day of surgery. With only one of seven cancellations attributable to the need for a more extensive medical evaluation, other causes for cancellation had a much greater impact on the cancellation rate. This finding is not unique to our setting; administrative problems have been found to be the single most important source of cancellations at a number of other hospitals. A review of OR cancellations at a community hospital revealed that 43% of their cancellations were a result of administrative reasons ^[13]. Similar results were reported in an academic setting, in which 45% of OR cancellations were attributed to a single administrative reason (shortage of OR time) ^[15].

Because cancellations on the day of surgery caused by medical problems are especially upsetting for patients, and can be more contentious for members of the medical staff, these cancellations may be more memorable than other types of cancellations ^[1]. With a complex problem as emotionally charged as OR cancellations can be, having good data is critical in devising appropriate solutions. In particular, careful analysis of cancellation data that were collected prospectively is essential for OR managers who are working to decrease OR cancellations. For hospitals like ours, with low rates of medical cancellations, addressing systems issues such as OR scheduling and staffing could result in a measurable improvement in the OR cancellation rate.

Although early preoperative assessment was not associated with a lower OR cancellation rate, there may be other benefits of early preoperative evaluation. For example, early preoperative assessments can result in a pool of patients who can be called days or weeks before their scheduled date of surgery to have their surgery at a time when OR time would otherwise be underutilized.

Patient education may also be enhanced by early assessments. It has been demonstrated that the knowledge gained by patients taught four to eight days before surgery was greater than those who were taught the day before surgery ^[16]. Although other potential benefits from early evaluations, such as lower anxiety levels, lower analgesic requirements, greater satisfaction with their surgical experience, or a decreased frequency of problems on postoperative follow-up have been suggested, none have been consistently observed with outpatients ^[17-18].

It is difficult to define the optimal timing of the outpatient preoperative assessment. Until more compelling evidence is available, it is reasonable to schedule outpatient preoperative evaluations in a timeframe that is convenient for the patient and efficient for the facility.

We acknowledge the advice and editorial assistance of Dr. Richard I. Mazze, Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine.