Effects on Efficiency

Why we should plan for high-risk.

Weiser TG, Haynes AB, Molina G, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015;385 Suppl 2:S11. doi:10.1016/S0140-6736(15)60806-6

Bottom Line:​  This abstract provides an estimate that surgical volumes have increased from 234.2 million in 2004 to 312.9 million in 2012. In low-resource countries, almost a third of a surgical procedures are C-sections. Since access to surgical services is associated with positive long-term health outcomes, improvements in capacity and delivery of surgical services must be a major component of health system strengthening. 

Wong DJN, Harris SK, Moonesinghe SR, et al. Cancelled operations: a 7-day cohort study of planned adult inpatient surgery in 245 UK National Health Service hospitals. Br J Anaesth. 2018;121(4):730-738. doi:10.1016/j.bja.2018.07.002

Bottom line: This 7-day observational study of inpatient elective surgeries demonstrates a large number of surgical cancellations. A large proportion of these cancellations are due to either insufficient bed capacity  (~10%) or for clinical reasons (~28%). Restructuring surgical services (e.g. separation of elective and emergency services), seasonal planning to respond to surges in emergency surgeries and ring-fencing beds for elective surgeries are possible strategies to reduce the amount of surgical cancellations. 

Major points:

1. On retrospective survey, approximately ~10% of patients had previously experienced at least 1 cancellation for the same procedure. Similarly, during the present 7-day study, about 10% of patients presenting for surgery had the procedure cancelled that day. 

2. Requirement for a post-operative critical care bed increased odds of having prior surgery cancelled while factors such as undergoing obstetrical procedure, cancer surgery and urgent/expedited surgery decreased the risk. 

3. Presenting for surgery in a hospital with an emergency department or in a hospital with enhanced ward facilities also increased the risk of having a prior surgery cancelled. 

4. Approximately 30% of prior cancellations were for clinical reasons. Unfortunately, the study could not discriminate between a cancellation for inappropriate pre-operative preparation (e.g. failure to stop an anti-coagulant) or a cancellation because of an acute illness (e.g. URTI). 

5. Planning ahead can help reduce the amount of cancellations and simultaneously improve patient outcomes, and satisfaction while providing multiple benefits to the healthcare system. Strategies include: (a) ring-fencing funding for elective surgery beds, (b) scheduling less elective surgical procedures during the winter months when more emergency surgeries occur, and (c) creating dedicated emergency surgical services that do not encroach on elective surgeries.