Wong DJN, Harris SK and Moonesinghe R on behalf of the SNAP-2: EPICCS collaborators
British Journal of Anaesthesia 2018: 121 (4); 730–738
Aim of Study
To explore the incidence of surgery cancellations and risk factors for cancellation at patient and hospital level. Focus on cancellations of planned surgery due to insufficient bed capacity.
Background
Cancellation of planned surgery impacts substantially on patients and health systems. Elective surgical cancellation rates appear to be rising, even after accounting for seasonal fluctuations.
The rates of surgical cancellations attributable to different risk factors are not known: current collated reports of cancellations at a national level do not record causes, and studies that have looked at this issue have predominantly small samples or are single-centre evaluations
Design and Location
National (NHS wide) prospective observational data collection as part of bigger study-Second Sprint National Anaesthesia Project: EPIdemiology of Critical Care provision after Surgery (SNAP-2: EPICCS) study. Local clinicians involved in clinical care of patients collected data on patients undergoing surgery in 2 week period in March 2017.
Inclusion criteria: Adult patients undergoing inpatient elective or expedited surgery (NECEPOD category)
Exclusion criteria: Planned day case procedures, emergency or urgent surgeries, paediatric surgery.
Primary Outcome
Previous cancellation of the same operation due to inadequate bed capacity (‘historical cancellations’).
Secondary Outcomes
Number and reasons for day-of-surgery cancellations for each day of the recruitment period (‘contemporaneous cancellations’), and structural characteristics collected in an organisational survey.
Statistics
Incidence of historical cancellations and reasons for these, normally distributed data compared with means and non normally distributed with median. Comparisons made with multilevel logistic regression models, p <0.05 considered significant.
Results
245 hospitals (90% of NHS services offering inpatient adult surgery) responded – data collected for 14796 patients.
3724 cases were cancelled on the day of surgery (13.9%).
There were 1499 (10%) historical cancellations. 31% were due to lack of post operative beds and 33% for clinical reasons. Associated factors were categorised as patient level and hospital level. The only patient level predictor that increased likelihood of cancellation was requirement for post operative critical care. Surgery for treatment of cancer, obstetric procedures and expedited surgery was associated with reduced odds of previous cancellation. Hospital level predictors associated with cancellation were the presence of an emergency department and presence of enhanced care wards.
Conclusions/Discussions
* Clinicians prioritise appropriately
* Hospitals with enhanced care wards are more likely to cancel surgery-is this because they were introduced due to a lack of beds in the first place
* Options
- Ring fenced elective surgical beds
- Dedicated theatres/wards
- Seasonal planning
- Increasing dedicated emergency surgery beds/operating theatre capacity
* UK has fewer critical care beds than many other high and middle income countries
* Decision to admit is based on consensus opinion and not evidenced e.g. Decision to admit is based on consensus opinion and not evidence for example patients undergoing cardiac vs major bowel surgery are more likely to be admitted to intensive care despite the fact that major bowel surgery has both a higher morbidity and mortality associated with i
* It is not clear which patients would benefit from post op critical care- the larger study for which this data was collected is looking into this (SNAP-2:EPICCS)
* This study received a lot of national attention by the press
Strengths
* Largest study of its kind
* Useful for policymakers
* First time to look at causes and associations with cancellations
* Topical
Limitations
* Does it add anything – working in these environments we know that bed pressures lead to cancelled elective cases.
* Study period was in March- is this relevant to the rest of the year?
* Reasons for clinical cancellation were not elaborated upon
* If they were preventable eg poor pre op assessment, this could be improved on a local level
* If for acute clinical deterioration then not preventable
* No reason for cancellation given in 14% historical and 57% contemporaneous cancellations
* The NHS is a unique health system – are these results applicable internationally?
Discussion from Journal Club Meeting
Although findings were obvious, this is still a useful study as evidence base is required before policymakers can enact change. Good patient numbers.
There are no easy solutions to this problem.
Including obstetric cases is not relevant because they are a unique subset.
Summary by Dr S Sethi. Journal Club Meeting 04 October 2018.
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