INTRODUCTION

One of the key performance indicator of any healthcare facility is optimal utilization of resources which not only reduces operational costs but also improves patient satisfaction. Operation theatres and intensive care units are the largest revenue generators for the hospital. There are various factors which can prevent optimal utilization of operating room resources and cancellation of scheduled surgeries is one of them. Cancellation of elective surgery especially within 24 hrs of scheduling not only results in wastage of resources, but also has a significant psychosocial impact on the patients.

Cancer surgeries are considered as semi-emergencies. Any delay in scheduling or cancellation of scheduled cases can cause significant distress to the patients and their family. We already have very long waiting lists and any delay in rescheduling cancelled cases can lead to disease progression.Cancellation of surgery leads unnecessary expenditure and wastage of hospital resources.it also increases the psychological trauma and financial burden on the patient and their family.

Studies have shown that cancellation rates vary between different hospitals and ranges from 5-40% depending on the type of hospital (private/teaching institute/ charitable institutes) and size of the hospital (number of hospital beds). We would like to do this quality improvement audit to see the cancellation rates in our institute which is an academic institute and a tertiary cancer referral centre.

PRIMARY OBJECTIVE: To see the incidence and reasons for cancellation within 24 h of scheduled surgery in a tertiary cancer centre.

SECONDARY OBJECTIVE: Identifying areas for intervention to reduce avoidable surgery cancellations and reduce waste of resources.

INCLUSION CRITERIA: All adult and pediatric patients scheduled for elective surgery in major OT complex including operation theatres in TMC will be enrolled in study.

EXCLUSION CRITERIA: Patients posted for minor OT procedures in TMC, emergency procedures and day care procedures and procedures in radiology suite.

STUDY METHODOLOGY: This is a prospective observational study to see the incidence and reasons for cancellation of scheduled elective surgical procedures in major operation theatres in Tata Memorial Centre. This study is a part of MD dissertation at Tata Memorial Centre and will be conducted after approval from institutional ethics committee and CTRI registration.

The study group will include all patients scheduled for elective surgical procedures and patients who are kept as standby for scheduled cases. A list of scheduled cases is made a day prior to surgery. This list is shared with all the OT staff (Surgeons, Anaesthetists and nursing staff). Patients who are scheduled for surgery are admitted a day prior to the scheduled date of surgery. There would be a few cases kept as standby in case an OT slot is available. A list of standby cases will be obtained from the surgical registrar of the units which are operating on the scheduled date. At the end of the day, Co-investigator and research nurse will interview the OT anaesthetist and primary surgeons to find out if any of scheduled case has been cancelled. The reasons for cancellation will be obtained from the surgical registrar, respective OT anaesthetist, OT staff or from electronic medical records.All this information will be obtained within 24 hrs of scheduling and cancellation.

The following data will be recorded.

•        Demographic data: Age, gender, height, weight.

•        Surgical unit

•        Diagnosis

•        Date of hospital admission and discharge

•        Plan of surgery

•        ASA status

•        Details of comorbidities

•        Pre operative medication details

•        Details of preoperative chemotherapy

•        Preoperative investigation details

•        Whether PAC was done or not?

•        Was review PAC asked for?

•        Any advice given in PAC?

•        Was final fitness given in PAC?

•        Vital parameters recorded in PAC (Heart rate, blood pressure, saturation in PAC)

•        Was case informed to OT anaesthtist a day prior to surgery

•        IF Patient was seen on EMR the previous day, any advice was given, if any reason it could not be followed.

•        If patient was seen clinically the previous day, any advice was given, if any reason it could not be followed

•        Scheduled or standby case

•        Timing of cancellation- day prior to surgery, before taking to OT, on table before induction of anaesthesia or after induction of anaesthesia.

•        Reason for cancellation of surgery (cancelled by surgeon, anathesiologist, patient refusal)

This is a quality improvement audit. All patients will receive treatment according to current standards of care. No additional interventions or change in management will be done for the purpose of the study. Data will be collected from the electronic medical records, surgeons and anaethetist who are involved in the care of the patient. At no point in the study will there be any patient contact. No biological samples will be taken from the patient. There are no stop points or withdrawal criteria.

STATISTICAL ANALYSIS:

Descriptive analysis will be used to summarize patient characteristics at baseline. Continuous variables will be presented as the mean ± standard deviation (SD) or Median (IQR) based on normality of the data. Categorical data will be presented as numbers (percentages). Normality of data will be assessed using Shapiro Wilk test.

For objectives, Univariate and multivariable logistic regression will be conducted for comparisons between surgery cancellation and predictors of interest (patient, surgeon and system factors) in tertiary academic hospital.

A stepwise backward LR selection method will be used for the multivariable logistic regression model. P value < 0.05 will be considered statistically significant.

Software: All analysis will be two sided, and significance will set at a p-value of 0.05. Statistical analyses will be performed using R v3.4.3 software and SPSS (the statistical package for social sciences) IBM Corp. Released 2017.IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.