53% cancellation rate cut to less than 20%

Preadmission visits before day of surgery pay off

A day-of-surgery cancellation rate of 53% was higher than the same-day surgery staff at North General Hospital in New York City was willing to accept, so a task force was put into place to identify reasons for cancellations and recommend solutions. Two years later, the rate never jumps above about 20%, and the reasons for these cancellations are usually out of the control of same-day surgery staff, such as the patient becoming ill the night before or morning of surgery.

The hospital’s cancellation rate was significantly higher than the rate of other participants in the Maryland Quality Indicator Project, a benchmarking service offered by the Elkridge-based Maryland Hospitals and Health Systems. "After we saw our higher rate, we took a look at why procedures were cancelled on the day of surgery," says Rosalie E. Vilar, MA, RN, CPHQ, vice president of quality management at North General Hospital.

"We found that patients weren’t prepped properly, had eaten just before arriving, had a medical condition that required a consult with another physician, or had gotten lost on the way to the hospital and arrived very late." (See Same-Day Surgery, February 2002, p. 23.)

The solution to these day-of-surgery cancellations was to create a preadmission area and have the patients come for their preadmission visit one week before their scheduled surgery, Vilar says. Within the preadmission area, patients receive education about their procedure, are seen by the anesthesiologist, have any diagnostic tests such as blood work and EKGs performed, and are seen by a internal medicine physician if a consult is needed due to another medical condition such as hypertension, she adds.

Because the consultation for other medical conditions was a frequent reason for same-day cancellations, the department of medicine developed a schedule that designates a block of time for each physician to cover the preadmission area, Vilar says. "Having the physician available to check the patient immediately enables us to address medical problems that might interfere with surgery," she says.

These medical problems can require adjusting medications such as blood thinners, addressing low potassium levels, or treating rashes that cover the site of the incision, says Barbara Ann Harmer, RN, BSN, MHA, director of surgical services at Florida Hospital in Kissimmee. "If you wait until the day of surgery to see the patient, you don’t have time to make changes that are needed," she says. For example, Harmer’s facility has had a young patient show up for a dilation and curettage with her leg in a cast. "If we had seen her a few days early, we would have known to have a different action plan in place to address her lack of mobility," she explains.

Saying that her day-of-surgery cancellation rate is always near zero when the pre-op visit is made several days before surgery, Harmer is an advocate of preadmission visits for several reasons in addition to medical issues that may be identified. "If our anesthesiologist has a question for the physician of the patient who is being seen prior to a 7:30 a.m. surgery, how are we going to find that physician?" Harmer asks. Also, there is time to perform extra blood work or diagnostic tests that the anesthesiologist may order, she adds.

Having the patient visit you for preadmission prior to the day of surgery also prevents any delays or cancellations on the day of surgery because the patient can’t find the facility or doesn’t know where to park, says Harmer. "I would much rather have the patient be late to the pre-op visit and on time for the surgery," she says.

To make the preadmission visit easy for patients who might be traveling long distances to see their surgeons and have their surgery, Harmer’s facility is flexible with the preadmission visit schedule and leaves gaps that can be used for patients who are in the surgeon’s office and want to come over for the preadmission visit immediately after the surgeon schedules the surgery. "We also use this time to talk about not eating before surgery, what to expect on the day of surgery, and answer general educational questions," Harmer says.

Moving away from the widely accepted pre-op visit that occurs on the morning of surgery may be hard for some same-day surgery programs because society encourages convenience, quick access, and as little disruption to the patient’s life as possible, Harmer says. She does point out that this is surgery, and it needs to be taken seriously.

"We make too little of minimally invasive surgery, but we have to remember that it is major to the patient, so we need to take the appropriate amount of time to prepare the patient and ourselves for the procedure," Harmer says. "This is best done with a preadmission visit before the day of surgery."

Sources

For information on preadmission departments to reduce cancellations, contact:

Barbara Ann Harmer, RN, BSN, MHA, Director of Surgical Services, Florida Hospital. E-mail: barbara.harmer@flhosp.org.

Rosalie E. Vilar, MA, RN, CPHQ, Vice President of Quality Management, North General Hospital, 1879 Madison Ave., New York, NY 10035. Telephone: (212) 423-4164. E-mail: rosalie.vilar@ngsc.org.