Late cancelations in plastic and reconstructive surgery: A departmental study

Previous results from the authors have shown that late cancelations in surgery are potentially preventable. Most of the underlying reasons can be attributed to a failure in communication, which can be improved with skilful multi-professional planning of the operating room (OR) list. Based on this, several improvements were made to the OR scheduling of the authors unit with the aim to increase efficiency. Furthermore, the hospital district underwent several fundamental changes, such as transfer of all burn and pediatric patients to other ORs.

In this prospective study, the reasons for late cancelations as recorded in the OR of the Department Plastic- and Reconstructive Surgery at Helsinki University Hospital, Finland were evaluated. All elective surgeries performed between 1 October 2017 and 30 September 2018 were included. The reasons for late cancelations recorded in operating room (CROR), with cancelations being both manually recorded by OR nurses and the information entered into the electronic Operating Room Management System OPERA® at the same time.

Altogether, 2390 operations were planned during the study period, with CROR present in 76 of 123 late cancelations (62%). Of CROR, 37 (49%) were canceled for patient-related reasons, 30 (39%) for hospital-related reasons, and 9 (12%) for staff-related reasons (Table 1).

Table 1.

Reasons for late cancelations recorded in operating room and patient demographics.

Reason for late cancelation	N = 76	Proportion in % of CROR of all late cancelations
Patient-related reasons	37	49
Change in medical conditions not noticed before	10
Acute infection	9
Operation no longer necessary	7
Other patient-related reasons	7
Operation already performed	4
Hospital-related reasons	30	39
Prioritized emergency operation	14
Previous surgery unexpectedly prolonged	13
Inadequate bed capacity	2
Required surgical equipment malfunction	1
Staff-related reasons	9	12
Lack of personnel due to another prolonged surgery	3
Personnel not available	3
Human error in entering data into OPERA®	3
Sex (male/female)	35/41	54/46
Mean age (years)	53 (18–97)
Operating room time (minutes)	151 (60–525)
Type of procedure (elective/emergency)	64/12	84/16
ASA physical status
1	6	8
2	23	32
3	22	29
4	5	7
Not identified	19	25

CROR: cancelation recorded in operating room.

Data are number of patients, means, or ranges (minimum–maximum).

ASA American Society of Anesthesiologists Physical Status Classification system

The most common hospital-related reason was prioritization of emergency surgery (n = 14, 47%), followed by a previous surgical operation running longer than expected (n = 13, 43%). Other reasons were lack of beds in the postoperative ward (n = 2, 7%) and malfunctioning surgical equipment (N = 1, 3%).

Staff-related reasons were due to a lack of personnel (n = 6, 67%), with nurses and/or doctors held back in operations running longer than planned or absent due to sick leave. In three cases (33%), the reason was human error in entering data into the OPERA®.

The main reasons for patient-related CROR were change in a patient’s medical condition (n = 10, 27%) and acute infection (n = 9, 24%). Of all patient-related CROR, 86% (n = 32) were canceled on the day of surgery, and 14% (n = 5) had been done 1–3 days earlier, but the OR list had not been adequately updated, with the oversight being noticed upon calling the patient about the appointment. Two cases were canceled after the patient had already entered the OR.

Scheduled waiting time, that is, the time interval between the date of decision for surgery and the date of CROR, was on average 70 days (range 0–405 days). Average scheduled waiting time differed greatly depending on the cancelation group, being 106 days for cancelations due to hospital-related reasons, 53 days due to staff-related reasons, and 45 days due to patient-related reasons.

In 87% (n = 66) of CROR, the surgeries were rescheduled. In 60 cases (79%), the operation was completed before 31 December 2019. Rescheduled waiting time, that is, the time between CROR cancelation date and the actual date of the operation, was on average 41 days (range 0–331 days). Average rescheduled waiting time was 30 days for the staff-related cancelation group, 31 days for the hospital-related group, and 59 days for the patient-related group. In the staff-related cancelation group, all the operations were performed later. In the hospital-related group, 95% were performed later, with two cases being rescheduled but subsequently re-canceled due to no need for the operation. On the contrary, only 27 cases (73%) of CROR due to patient-related reasons were rescheduled.

Literature recommends that late cancelation rates overall should not exceed 2%–5% for an efficiently working OR. ¹ The rate at the authors unit was 5% (123 of 2390) during the study period. Altogether, 76 late cancelations were recorded in the OR, that is, 62% of all late cancelations were CROR (76 of 123). These findings are in line, albeit at the higher end, of those previously reported, where on-the-day cancelations comprise 25%–67% of total late cancelations. Late cancelations occurring when the patient had already entered the OR constitute 0.08% of the total number of operations, which is similar to the 0.06% reported in another study ² and lower than the 0.21%–0.84% of some other studies. ³ Previous studies revealed the need for a prospective study since the reasons for cancelation remain unknown in 3%–12% of all cancelations.^4,5 In the present report, all reasons for cancelations were recorded during the study period. Of CROR, 51% were due to hospital- or staff-related reasons, and 49% due to patient-related reasons.

Earlier literature suggests that in 8.5% of late cancelations, the reason is lack of OR time and the required operation time being underestimated by the surgeon. ⁶ Other operations running over time, for example, due to complications, are difficult to predict, thus resulting in cancelations of following procedures on the list. This emphasizes the need to improve OR efficiency, as late cancelations due to hospital reasons can be seen to reflect deeper issues involving poor operational management of patient flow.