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Anesthesia and Operating Room Efficiency

Joe Cantlupe, for HealthLeaders Media, December 13, 2012
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Success key No. 1:  Avoiding cancellations

Patients forget they have a surgery appointment. They get lost going to the hospital. For whatever reason—or excuse—they may fail to show up for a scheduled operation.

Sometimes hospitals themselves mess up the OR schedules because of lack of bed space or equipment. 

The missed appointments and scheduling miscues can have a huge dollar impact on hospitals, with surgeries canceled on short notice. But meticulous preoperative coordination can improve care and reduce the possibility of cancellations, ensuring that patients are medically ready for surgery and have received the proper preoperative instructions for the day of the procedure, says Bent.

In a 2009 study at Tulane University Medical Center, Bent and her colleagues found that cancellations occurred in 487, or 6.7%, of scheduled surgeries at the hospital. That amounted to a $1 million financial loss in one year, she says. The losses showed that there was a need for preoperative clinic visits by patients, which are now mandatory, she says.

Last-minute cancellations may stem from various reasons. More than 30% of patients in Bent's study failed to show up at the time of surgery because of transportation problems, confusion over the date of the procedure, forgetting about the appointment, or for other reasons, she said. Another one-third of the procedures were canceled because of issues at the hospital itself, such as a lack of beds or equipment. "There are multifactorial reasons for cancellations," says Bent.

Scheduling errors also can occur when one piece of expensive equipment is needed in two ORs at once, other equipment fails, or the intensive care units happen to be full, leaving no place for patients to recover following procedures.

The cancellations were more likely among patients who did not have a preoperative clinic visit with the anesthesiologist; nearly 11% of the surgeries were ultimately canceled compared with less than 4% of those that were preceded by a clinic visit.

The canceled cases show the need for preoperative evaluation. Of the canceled cases, 19% had undergone preoperative evaluation and 76% had no preoperative assessment at all, says Bent.

A new scheduling paradigm was established, with a focus on mandatory preoperative clinic visits and stopping cancellations, she says. There was a "concerted effort" among administrators, providers, and fiscal analysts at the hospital to carry out the program, she says.

The hospital initiated a mandatory preoperative clinic visit by patients to ensure proper fasting prior to surgery, for instance, and having their blood pressure monitored or EKG performed. Online educational programs are also available for patients, who are considered otherwise healthy without comorbidities.

While many hospitals and surgery centers have some form of preoperative clinic or evaluation, many aren't mandatory and the compliance of patients being evaluated "is not 100% and frequently a lot less," Bent says. "Surgical referral to an anesthesiologist for a preoperative clinic or to a preoperative online is not consistent." Since Tulane adopted the mandatory program, compliance has been estimated at near 100% among patients and staff, and follow-up studies are continuing, Bent says.

Hospitals also have been historically at fault for needless surgery cancellations and failure to adhere to preoperative clinic programs, Bent says. Surgeons, for instance, have been reluctant to tell patients they should attend such programs. "The whole point is to be able to recognize and treat or otherwise optimize the patient for surgery before the day of surgery," she says.

One of the most important elements in dealing with postoperative care is the variability among specialties.  Some surgeries simply have more cancellations or delays, depending on the patients and kinds of care.

"The cost of cancellation varies by specialty, so you might concentrate on the cost of canceled cases," Bent adds. "For those implementing processes, specialties stand to be the greatest in lost revenue."

According to Bent's 2009 study on revenue loss by specialty, general surgery had an average loss per case of $2,000 and a total revenue loss of $200,478; neurosurgery had an average loss per case of $5,962 and a total revenue loss of $41,735; ophthalmology, $2,927 per case and a total of $46,828 lost; and orthopedics, $2,779 and a total of $71,807 lost.

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