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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 7  |  Page : 965-969

Cancellation of elective surgical cases in a nigerian teaching hospital: Frequency and reasons


1 Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State; Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Surulere, Lagos, Nigeria
2 Department of Surgery, Alex-Ekwueme Federal University Teaching Hospital; Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
3 Department of Surgery, Lagos University Teaching Hospital; Department of Surgery, College of Medicine, University of Lagos, Idi-Araba, Surulere, Lagos, Nigeria

Date of Submission02-Dec-2019
Date of Acceptance17-Apr-2020
Date of Web Publication3-Jul-2020

Correspondence Address:
Dr. C J Okeke
Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_650_19

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   Abstract 


Background: Dwindling economic resources and reduced manpower in the health sector require efficient use of the available resources. Day of surgery cancellation has far reaching consequences on the patients and the theatre staff involved. Full use of the theatre space should be pursued by every theatre user. Objective: The study aimed to report on the rates and causes of day of surgery cancellation of elective surgical cases in our hospital as a means towards proffering solutions. Materials and Methods: It was a retrospective study of all elective cases that were booked over a 15-month period from January 2016 to March 2017. Cancellation was said to have occurred when the planned surgery did not take place on the proposed day of surgery. Cancellations were categorized into patient-related, surgeon-related, hospital-related and anesthetist-related. Reasons for the cancellations were documented. Data were analyzed using Statistical Package for the Social Sciences (SPSS) software program, version 22. Variables were compared using Chi-square tests. A value of P < 0.05 was considered statistically significant. Results: During the 15-month period, a total of 1296 elective surgeries were booked. Of this, 118 (9.1%) cases were cancelled. Patient-related factor was the most common reason (47.5%) followed by surgeon-related factor (28%). Lack of funds was the most common patient related-reason for cancellation. Majority of the cancelled cases were general surgical cases (36.4%) followed by orthopedics (25.4%) and urology (11%). Seventy percent of the cancelled cases were first and second on the elective list. Conclusion: The cancellation rate in this study is high. The reasons for these cancellations are preventable. To ensure effective use of the theatre, efforts should be made to tackle these reasons.

Keywords: Cancellation, elective surgery, operating theatre


How to cite this article:
Okeke C J, Obi A O, Tijani K H, Eni U E, Okorie C O. Cancellation of elective surgical cases in a nigerian teaching hospital: Frequency and reasons. Niger J Clin Pract 2020;23:965-9

How to cite this URL:
Okeke C J, Obi A O, Tijani K H, Eni U E, Okorie C O. Cancellation of elective surgical cases in a nigerian teaching hospital: Frequency and reasons. Niger J Clin Pract [serial online] 2020 [cited 2020 Aug 15];23:965-9. Available from: http://www.njcponline.com/text.asp?2020/23/7/965/288886




   Introduction Top


Cancellation of elective surgical cases refers to surgical procedures not being done on the intended day of surgery.[1] It is a common problem worldwide.[2],[3],[4],[5],[6],[7],[8] In Nigeria, the rising cost of health care is unmatched by the dwindling economy and brain drain in the health sector; hence, the need for effective use of every available resource.[9]

Day of surgery cancellation results in ineffective use of scarce resources.[10] It has far-reaching consequences. To the patient, it results in prolonged hospital stay and repetition of preoperative investigations, thereby increasing cost.[11] It prolongs the waiting list, causes upward stage migration of previously booked cancer cases and results in poor patient turnover which is also detrimental to residency training in teaching hospitals. It is a waste of time for the surgeons and other staff involved.[8] Cancellation rate is an indicator of quality of patient care.[12]

The study aimed to report on the rates and causes of day of elective surgery cancellation in our hospital as a means towards proffering solutions.


   Materials and Methods Top


Approval for the study was obtained from the hospital ethical committee.

It was a retrospective study of all consecutive elective cases which were done from January 2016 through March 2017 in Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi State. The institution is the only referral center in the state. It receives referrals from neighboring states of Enugu, Benue, Cross River, and Imo. The patients for surgery were seen in the surgical outpatient department and were clinically worked up. The patients were admitted when considered fit for surgery, usually about two (2) days prior to surgery date. Day cases were admitted on the morning of surgery. They were all reviewed by the anesthetists while on the ward. Emergency cases were excluded from the study. Data collected included number on the elective surgical list, specialty involved with reasons for the cancellation. A member of the surgical team completed a questionnaire to fill in these data and what caused the cancellation. Causes were grouped into: Patient-related which included lack of funds, failure to procure materials for surgery, refusal of consent, inability to provide blood for surgery and failure to show up for surgery; surgeon-related factor which included, late arrival of surgeon, failure to identify/control co-morbidities, cancellation by surgeon when surgery was deemed not necessary; hospital/system related factors which included lack of drapes, gowns, boots, non-functional equipment, lack of theatre space, unavailability of light, oxygen and water and anesthesia-related factors which included difficult intubation and unavailability of anesthetists.

Data collected on a proforma were analyzed using Statistical Package for the Social Sciences (SPSS) software program, version 22.0. Variables were stated as frequencies. Chi-square test was used to compare categorical variables.


   Results Top


A total of 1409 elective surgical cases were booked during the 15-month study period (January 2016 to March 2017). Of these, 113 cases were excluded because of incomplete data. A total of 1296 cases were subsequently analyzed. General surgery and orthopedic surgery accounted for 754 (58.2%) of cases done during the period as shown in [Table 1].
Table 1: Specialty distribution of booked cases

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One hundred and eighteen cases 118 (9.1%) were cancelled. [Table 2] shows the distribution of cancelled cases per specialty. Eighty-three (70.4%) of cancelled cases were first and second on the list as shown in [Table 3].
Table 2: Total day of surgery cancellation per specialty

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Table 3: Distribution of cases cancelled by number on the list

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Patient-related cancellation was the most common cause of cancellation (47.5%), followed in decreasing frequency by surgeon-related factor (28%), hospital-related factor (13.6%), and anesthesia-related factor (3.4%) as shown in [Table 4].
Table 4: Reasons for cancellation

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Across all specialties, patient-related factor was the most common cause of cancellation followed by surgeon, hospital and anesthetic factors as shown in [Table 5].
Table 5: Reasons for cancellation by specialty

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Irrespective of the number on the list for elective surgery, patient-related factor accounted for most of the reasons for cancellation followed by surgeon factor. [Table 6] shows the distribution of reasons for cancellation by numbering on the elective surgical list.
Table 6: Reasons for cancellation by number on the list

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For patient-related reasons, 26 (46.4%) of surgeries were cancelled due to financial constraints, another 15 (26.8%) were cancelled due to failure of patients to turn up for surgery. Twenty eight (84.8%) of the surgeon- related reasons for cancellation were due to improper work up of patients. [Table 7] shows the distribution of these reasons.
Table 7: Causes of cancellation

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   Discussion Top


Use of theatre to full capacity should be sought after by all concerned. Cancellation of surgeries leads to underutilization of the theatre space, increased waiting list and reduced internally-generated revenue for the hospital.[13] Cancellation has far reaching effects on the patients and their relatives.[13]

The prevalence of cancellation in our study was 9.1%. This is similar to a study in Jordan (9.31%) but much higher than the 5% cancellation rate reported in a study in the United Kingdom.[3],[4] Our cancellation rate is however lower than previous studies carried out in Nigeria with cancellation rates ranging from 15.6% to 48.5%.[6],[7],[14]

Close to half (47.5%) of all cancellations were patient- related in this study. This is slightly lower than what was reported by Kolawole and Bolaji in Ilorin, Nigeria where they noted that 52.2% of cancellations were patient-related.[11] However, studies done in Jos, Kano and Lagos reported patient–factors to have accounted for as high as 62.7%, 60.8%, and 62%, respectively.[6],[15],[16] Majority of the patient-related cancellations were due to financial challenges faced by the patient. This has also been the experience of other authors.[6],[7],[15] This is particularly important in our environment where poverty is endemic and majority of the populace fund their health care out-of-pocket.[17] Therefore, the implementation of universal health coverage with adequate funding of health care will certainly help reduce the cancellation rate in our setting. The National Health Insurance Scheme of Nigeria currently covers only federal civil servants that constitute a small percentage of the populace. The scheme needs to be expanded to include state and local government workers. Special funds can be set up for the treatment of indigent patients.

Another factor related to this is failure of patients to turn up on the day of surgery for no apparent reason. One can only speculate on the reasons. Financial challenges, inadequate communication, decision by patients to seek alternative care (including unorthodox medicare due to fear of surgery) could be contributory. This incidence can be reduced by seeing patients at the outpatient clinics close to the day of planned surgery to ascertain their readiness for surgery and replacing them with financially and psychologically-ready patients.[8] Communication with the patients should be unambiguous as some of the defaulting patients had later claimed not to have understood the instructions. Communication channel with booked patients should also be maintained via GSM and their readiness for surgery ascertained before the day of surgery.

Surgeon-related factor was the second most common reason for cancellation (28%). Majority of the reasons in this group were due to poor patient preparation with patients having abnormal laboratory results that were detected after admission. This factor can be mitigated by reviewing the laboratory results closely before booking patients. This would enable other patients to have their surgeries done pending when the abnormal laboratory results are corrected. Another solution is having a pre-anesthetic clinic for evaluation by the anesthetist. Pre-operative ward round specifically done a day before surgery to check for fitness of the patients and their readiness with funds, adequate investigation results, as well as other necessary resources remain a good practice.

Hospital related factors ranked third accounting for 13.6% of cancellations. This is less than the rate that was found in Jos, Lagos, and Burkina Faso.[2],[8],[16] Most cases were associated with non-availability of functional equipment to perform the surgery. Very high rates were reported in Ido Ekiti by Olajide et al. where hospital-related cancellations accounted for 76.3%. In their study, top of the reasons in the hospital factors include, lack of gowns, linen, water and oxygen supply.[14] These reasons were corroborated by other studies highlighting the extent of this menace nationwide.[6],[7],[8],[11],[15] This can be tackled by confirming that there are materials for surgery in the theatre before booking. Having a dedicated theatre manager who oversees the stores and cooperates with various units to monitor the supplies and equipment will go a long way in curbing this menace. Power outage is a chronic recurrent decimal in interrupting surgery in our setting. Setting up a dedicated electricity supply to tertiary health institution like ours will go a long way to reduce logistic problems of unsterilized drapes or instruments, shortage of water supply and lighting for operations. That will in turn reduce surgery cancellation rate in our setting. Government on its part needs to tackle infrastructural decay, which hinders efficient services and productivity with appropriate budgeting.

Anesthetic factor due to failed intubation accounted for 3.4% of all cancellations. Such patients often wake up from induction anesthesia thinking their surgery had been done; only to be disappointed. This can be overcome by thorough improved pre-anesthetic assessment of patients. Where failed intubation is anticipated, arrangement with otolaryngologist for an accessory tracheotomy should be made in advance, to avert cancellation of planned surgery.

Nine (7.6%) cancellations were due to interplay between some of the factors. In one of the cancellations with mixed etiology, operating table could not be adjusted and the prosthesis to be used was not the appropriate size.

Cases booked as first or second on the list ranked significantly high among those cancelled. This is apparently because most surgeons book the major cases early on the list. It is of course the major cases that indeed need more meticulous workup and preparations, including arrangement for blood and intubation for general anesthesia. The operation cost for major cases are usually also higher and constitutes a risk factor for cancellation of the case on the desired day of surgery.


   Conclusion Top


Cancellation rate in this study is far lower than studies in other places in our environment. However this rate can be further reduced if the preventable causes of cancellation are tackled. Use of theatre to full capacity should be the objective. Cancellation of surgeries leads to underutilization of the theatre space, increased waiting list and waste of scarce resources.

Acknowledgement


Special thanks to my teachers for their unwavering support towards seeing this article published and to Dr. Chidimma Ogechukwu Ezeilo for her technical input.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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2.
Lankoande M, Bonkoungou P, Traore S, Kabore R, Ouangre E, Pendeville P. Cancellation of elective surgical procedures in the university teaching hospital center Yalgado Ouedraogo in Burkina Faso: Incidence, reasons and proposals for improvement. South African J Anaesth Analg 2016;22:140-4.  Back to cited text no. 2
    
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Abeeleh MA, Tareef TM, Hani AB, Albsoul N, Samarah OQ, ElMohtaseb MS, et al. Reasons for operation cancellations at a teaching hospital: Prioritizing areas of improvement. Ann Surg Treat Res 2017;93:65-9.  Back to cited text no. 3
    
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Dakum N, Ramyil V, Misauno M, Ojo E, Ogwuche E, Sani A. Reasons for cancellations of urologic day care surgery. Niger J Surg Res 2010;8:30-3.  Back to cited text no. 7
    
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Kolawole I, Bolaji B. Reasons for cancellation of elective surgery in Ilorin. Niger J Surg Res 2002;4:28-33.  Back to cited text no. 11
    
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Kumar R, Gandhi R. Reasons for cancellation of operation on the day of intended surgery in a multidisciplinary 500 bedded hospital. J Anaesthesiol Clin Pharmacol 2012;28:66-9.  Back to cited text no. 12
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Zafar A, Mufti TS, Griffin S, Ahmed S, Ansari JA. Cancelled elective general surgical operations in Ayub teaching hospital. J Ayub Med Coll Abbottabad 19:64-6.  Back to cited text no. 13
    
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Olajide GT, Aremu SK, Olajide TA, Adegbiji WA, Raji MM, Ali A. Reasons for cancellation of surgeries in a Nigerian tertiary hospital. Paripex- Indian J Res 2018;7:551-4.  Back to cited text no. 14
    
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Ramyil VM, Dakum NK, Kidmas AT, Opaluwa AS, Songden ZD, Azer T. Reasons for day case surgery cancellation in Jos. Niger J Surg 2004;10:17-9.  Back to cited text no. 15
    
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Bode CO, Adeyemi SD. Reasons for day surgery cancellation in paediatric surgical practice at the Lagos university teaching hospital. Niger J Surg 1996;3:41-4.  Back to cited text no. 16
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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