Introduction

Cancellation presents a major problem in most hospitals. The reported incidence of cancellation in different hospitals ranged from 10-40% (₁,₂,₃). There are many reasons of cancellation of elective surgical cases, however it differs from hospital to another. It was reported in one study that the most common factor which has led to cancellation was lack of theatre time (₄). In UK the Audit Commission has estimated that in 5% of hospitals, the majority of operating lists were consistently over-running (₅). There are conflicting reports on the commonest reasons of cancellation of elective surgical procedures. In one report non-availability of recovery room beds was the leading reasons of cancellation followed by patients not showing up (₆). Most of the previous studies were retrospective, therefore we conducted the present prospective study as an attempt to identify the commonest reasons of cancellation of elective surgical cases in our setting and to find the appropriate solutions for better patient management.

Methods

All patients who were scheduled to undergo elective surgical procedures were enrolled in the

study. The study period was from 1st September to 1st December 2007 at King Khalid

University Hospital (650 beds and 12 operating theatres). As this study was considered as audit

under quality assurance project, it didn't require approval of the hospital ethics committee. A

form including cancellation reasons was distributed to all operating theatres and attending

anesthesiologists were asked to fill it up (Table 1). Cancellation reasons were entered into the

database as coded variables. Statistical analysis was performed using SPSS version 15 software.

Results

A total of 2480 cases were scheduled to undergo elective surgical procedures. Of those 189 cases

were cancelled (7.6%). The highest number of cancellation occurred in the general surgical

service (28%) and the least (3.1%) occurred in neurosurgery. There were many reasons recorded

for cancellation of surgeries, the most common was the no show up reason (32.5%). The second

most common cause of cancellations was miscellaneous (19.5%). Examples of miscellaneous

reasons were: discharge of the patient, non fasting, anaphylactic shock, patient refused surgery,

patients with prolonged coagulation profile etc. The least cause of cancellations were due to

improper scheduling and acute illness (0.5%) (Figure 1). The highest cancellation among

different surgery subspecialties was for general surgery (28%), followed by orthopedic surgery

(14.8%), plastic surgery (13.7%), pediatric surgery (13%), gynecology surgery (10.5%), urology

surgery (10%). The least cancellations was found among vascular surgery and neurosurgery


sections (3.7% and 3.1% consequently) (Figure 2).

Figure 1

Table 1: Cancellation form

Figure 2

Figure 1: Reasons of cancellations in %: A. Improper preparation, B. Improper scheduling, C. Uncontrolled medical illness D. Further investigations, E. No show up, F. Acute illness, G. Insufficient OR time, H. Surgeon decision to postpone, I. Other emergency surgery, J. Unavailability of ICU or HDU bed, K. No recorded reasons, L. Miscellaneous.

Figure 3

Figure 2: Cancellations referred to surgical specialty %.

Discussion

A recent study has reported the increased morbidity in patients who wait longer duration for elective laparoscopic cholecystectomy (₇). In one study the overall incidence of cancellation including emergency cases was 24% (₆). The reported incidence of cancellation in our study was 7.6% which was less than other studies due to exclusion of emergency cases. In our study the most common reasons of cancellation was no show up of patients and miscellaneous reasons like, discharge of the patient, non fasting, anaphylactic shock, patient refused surgery, patients with prolonged coagulation profile etc. While in another studies it was due to lack of theatre time, lack of postoperative bed, patient cancellation, and incomplete investigations (₂). Our results revealed that we might be able to reduce the rate of cancellations with improving the booking process and improving the function of pre-anesthesia clinic. As in other studies we don't have problem with theatre time. In other studies lack of theatre time was dominant caused by surgeons underestimating the time needed for the operation (₂). In our study we found that most cancellations were in the general surgery section followed by orthopedic , plastic, pediatric surgery and the least cancellation was in the neurosurgery section. General surgical patients presents in our hospital the main bulk of patients who will undergo surgery. During working days we have daily two theatres reserved for general surgery. Also orthopedic section presents a major part of cancellations due to large number of patients, besides two theatres/working day reserved for orthopedic procedures. Neurosurgery presents the least number of cancellations due to less number of neurosurgical patients besides three theatres/week reserved for neurosurgery section. In contrary to our results three reports have indicated higher cancellation rate among the urology, orthopedics and gynecology than in general surgery (₁,₆,₈).

In conclusion, this audit highlights the most common reasons of cancellations in a teaching

hospital. It has demonstrated that no show up of patients was the leading cause of cancellations

in elective surgery. It is obvious from this audit that there is problem in communication with

patients scheduled for surgery beside scheduling problem. Therefore improving the scheduling

and admission procedure is required for better use of hospital resources. Also we believe that

the issue of no show up of patients can be minimized by improving communication between

surgeon and anesthetist beside improving the function of the pre-anesthetic clinic.

Acknowledgement

Correspondence to

A. El-Dawlatly Riyadh 11461 P.O.Box 2925 dawlatly@ksu.edu.sa http://faculty.ksu.edu.sa/dawlatly http://www.saudija.org