Use of Preoperative Checklist in Reducing Inpatient Neurosurgical Procedure Cancellations: A Quality Assurance Initiative

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Abstract

BACKGROUND: Preoperative checklists are a potential way of reducing unanticipated inpatient surgical cancellations.

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OBJECTIVE: To determine if preoperative checklists are effective in reducing surgical cancellations and thus, improving operating room efficiency.

METHODS: A retrospective study was conducted that compared cancellations of inpatient general neurosurgery procedures (cranial or spinal) before (2012) and after (2013) the implementation of a preoperative checklist. These inpatient cancellations were then stratified according to the reasons for cancellation, which were preventable, surgeon preference and unforeseeable.

RESULTS: A total of 602 inpatient procedures were performed in 2012, and 642 inpatient procedures were performed in 2013. The cancellation rates were similar in both years: 18.0 percent (110 of 602) in 2012 and 20 percent (126 of 642) in 2013 (p >0.563). However, preventable cancellations decreased from 29 of 110 (26 percent) to 16 of 126 (13 percent) over the course of the two years (p=0.012). Use of the preoperative checklist was associated with decreased cancellations with an odds ratio of 2.461 (95 percent confidence interval, 1.263–4.796). Infectious and cardiac causes accounted for the majority of preventable cancellations.

CONCLUSIONS: Our results suggest for the first time, to our knowledge, that the use of a checklist decreases the rate of inpatient neurosurgical cancellations.

Keywords: efficiency, hospital, operating room, neurosurgical procedures, preoperative checklist

Introduction

Approximately 4 to 26 percent of scheduled operative procedures are cancelled on the day of surgery (1,2,3). Much of the current data on this subject centers around ambulatory or elective procedures in which preoperative evaluations are performed at outpatient clinics. However, for procedures in patients who are already hospitalized, the unavailability of or limited access to such clinics generally leads to higher rates of surgical case cancellations (3). Approximately 17 to 60 percent of all cancellations are potentially avoidable (2,3,4). These cancellations can have a tremendous negative impact on the efficiency of hospital operations and can account for a significant amount of revenue lost. For example, in the public sector at a Veterans Hospital, cancellations during a one-year period led to an estimated $32 million loss or approximately $850 per case; and the loss can be even higher in the private sector, costing $1,700-$2,025 per case (1).

Preoperative checklists are a potential way of reducing unanticipated surgical cancellations. At our hospital, the department of neurosurgery has devised a preoperative checklist with blanks for risk:benefit assessment and diagnostic data to provide the anesthesiologist, nursing staff and surgeon the information needed to carry out a successful and safe surgery (Figure 1). By having the necessary tests and risks listed, efficiency is maximized and errors or omissions are diminished, which potentially reduces the number of unprepared patients, thus, decreasing the potential for surgical cancellation. We hypothesized that the implementation of a preoperative checklist, compared to standard handwritten preoperative notes, would lead to a reduction in cancellations of inpatient neurosurgical cases.

Methods

The preoperative checklist was implemented at the beginning of January 2013. Prior to this date, preoperative notes were handwritten in the hospital charts in no standard format. In developing a comprehensive checklist, we included sources of cancellations based on our previous experience, including cardiovascular, renal/electrolytes, antiplatelet/anticoagulation, pulmonary, infections and endocrinologic and hematologic abnormalities.

The present study consisted of two arms: prior to (2012) and after (2013) the implementation of the preoperative checklist. After receiving institutional review board (IRB) approval, all ambulatory and inpatient neurosurgical procedures for 2012 and 2013 were queried using the hospital’s surgical scheduling program, and the results were cross-referenced with the neurosurgery department’s electronic medical record system. Only operative cranial and spinal procedures were included in the search. Elective outpatient (ambulatory) surgical procedures were subsequently excluded because outpatient procedures had a preoperative workup that did not incorporate the inpatient checklist. Angiographic cases, epidural steroid injections, lumbar punctures and other smaller, non-operative procedures were also excluded from analysis as the checklist was only utilized for the general neurosurgery service and not the endovascular and outpatient neurosurgery services.

Inpatient, general neurosurgery procedure cancellations were then identified, and cancelled cases were reviewed in detail using the electronic medical record (EMR) system to determine precise reasons for cancellation. All these cancellations were then stratified into preventable cases, surgeon preference and unforeseeable, depending on the reason for cancellation. Preventable cases included cancellations that could have been discovered and prevented prior to surgery with the use of the preoperative checklist. Examples of preventable cancellations included cases involving patients who were not medically stable or optimized for surgery, such as those with urinary tract infections (UTIs), heart failure, deep venous thrombosis and skin infections.

Surgeon preference cancellations included cases that were cancelled due to time constraints at the surgeon’s request or because the treatment decision was changed by the surgeon. For instance, cases may get cancelled due to delays from other emergent cases or cases that are longer than expected from any surgical service as the surgeon would not be available at a later time. In addition, some patients are added to the operating room schedule for anticipated surgery with an appropriate workup, but the surgeon ultimately does not recommend surgery in light of new imaging findings or clinical examination changes. Neither of these events could be accounted for on a preoperative checklist and thus were not considered preventable. Unforeseeable cancellations included cases in which the patient ultimately declined to undergo the surgical procedure or cases where there was a catastrophic medical event unrelated to the planned surgery. Unforeseeable cancellations also included difficult intubation prior to surgery, patient reporting of new or improved symptoms, failure to adhere to the nothing-by-mouth requirement and recent use of recreational drugs by the patient.

Data analysis and graphical representation of the results were subsequently generated using Excel software (Microsoft Corporation, Redmond, Wash.), and statistical analysis was performed with XLSTAT software (Addinsoft, N.Y.). Beta was set at 0.80, alpha was set at 0.05 and p-values were calculated using the Fisher exact test of independence.

Results

A total of 1,911 neurosurgical procedures were identified in 2012, and a total of 2,026 neurosurgical procedures were identified in 2013 at our institution (Table 1). These surgeries were performed by 10 neurosurgeons. In 2012, 1,309 of the 1,911 surgeries (68 percent) were elective outpatient procedures. In 2013, 1,384 of the 2,026 surgeries (68 percent) were elective outpatient procedures, for which the implemented preoperative checklist was not employed. All these cases were therefore excluded from the current study. The preoperative checklist was utilized for the remaining 642 inpatient cases (32 percent) in 2013. Therefore, our study included 602 cases for the year 2012 and 642 cases for the year 2013.

Table 1 peer reviewed

Inpatient cancellation rates were similar during both years: 110 of 602 (18 percent) cases were cancelled in 2012, and 126 of 642 (20 percent) cases were cancelled in 2013 (p >0.563). In the year 2012, 29 cancelled cases (26 percent) were considered preventable, 72 cases (65 percent) were cancelled due to surgeon preference and nine cases (8 percent) were unforeseeable cancellations. In the year 2013, 16 cancelled cases (13 percent) were considered preventable, 95 cases (75 percent) were cancelled due to surgeon preference and 15 cases (12 percent) were unforeseeable cancellations. The decrease in the number of preventable cancellations between 2012 and 2013 was statistically significant (p=0.012). Use of the preoperative checklist was associated with decreased cancellations with an odds ratio of 2.461 (95 percent confidence interval, 1.263–4.796). Conversely, the change in cancellations due to surgeon preference and unforeseeable events did reach statistical significance (p=0.115, and p=0.393, respectively). Most surgeon preference cancellations were due to time constraints on the surgeon because of emergent cases that took priority and intraoperative delays of other cases. The remainder were due to clinical status changes.

Preventable cancellations were subsequently substratified into seven categories based on our preoperative checklist including cardiac, pulmonary, infectious, clearance, hematologic, endocrine and renal (Table 2). Infectious and cardiac causes accounted for the majority of preventable cancellations in both years. UTIs, skin infections and pneumonia accounted for all infectious causes of cancellations. Myocardial infarctions, congestive heart failure and hypertensive emergencies represented all cardiac causes. Deep venous thrombosis and pulmonary emboli comprised the pulmonary cancellations. One endocrinologic cancellation occurred due to a hyperglycemic episode in a diabetic patient. There were two cases of elevated partial thromboplastin time, one case of thrombocytopenia of unknown etiology occurring in 2012 and one case of anemia in 2013 accounting for the hematologic causes of cancellation. There were no renal cancellations in either year. Clearance issues accounted for the remainder of the cancellations.

Table 2 peer reviewed

Microsoft Word - Revised%20Preop%20Note%20Final.docx
Figure 1. Preoperative checklist for our neurosurgical service. Beta human chorionic gonadotropin, (?-hCG); basic metabolic panel (BMP); complete blood count (CBC); Coags, prothrombin time, activated partial thromboplastin time; international normalized ratio; electrocardiogram (EKG); urinalysis (UA); portable chest x-ray (pCXR).

 

Discussion

Operating rooms play a key role in hospital operations as a major source of resource utilization and financial expenditure. Considerable resources are used on a daily basis to prepare patients for surgery. Operating rooms must be cleaned and prepared with operation-specific autoclaved instrument sets, utilizing several staff members for each room. Several medical services and diagnostic investigations are undertaken before each patient reaches the operating room. Although difficult to measure, some estimate operating room cost as $10–20 per minute or $600 per hour (5). Although costly, surgical procedures are a major contributor to a hospital’s profit margin, accounting for a significant amount of revenue (6). Neurosurgery in particular was found in one analysis to be the most profitable specialty to a hospital’s margin when compared to all other surgical specialties (6). In that analysis, relative value units in 2004 were 41.26 per case and 9.93 per operating room hour compared to averages of 24.49 and 7.10, respectively. Therefore, it becomes imperative to maximize operating room efficiency to decrease cost and improve revenue.

Unanticipated preoperative surgical cancellations are costly and pose a significant threat to both efficiency and patient safety. One study found that unprepared patients account for 2.1 to 5.3 percent of surgical cancellations and are potentially avoidable scenarios (4,7). It is estimated that an unprepared patient accounts for 12.1 percent of wasted operating room time, equating to an average of 9.48 hours per week, or $5,688 per week, of lost revenue (5). In addition to the obvious tangible losses, there are significant opportunity costs. When procedures are scheduled in advance with the hospital, that block time is no longer available for other potential scheduled and same-day “add-on” operations from across all subspecialties. With unforeseen cancellations, the opportunity to utilize that operating room time for these procedures is lost, and although same-day, add-on cases may quickly fill those lost spots, the overall number of operations per year may be decreased.

Currently, a paucity of published data is available to help identify ways in which to reduce preoperative cancellations. Some institutions have introduced preoperative anesthesia clinic evaluations, but these are primarily for ambulatory outpatient surgery; and no study has effectively studied patients who are scheduled and evaluated preoperatively while in the hospital. Preoperative checklists are a potential way of reducing unanticipated surgical cancellations. The use of checklists in the surgical field has been recognized for many years. For instance, in 2007, the World Health Organization (WHO) established a surgical checklist, with the goal of reducing the number of surgical deaths across the world (8). Implementation of this list was shown to significantly decrease the rate of surgical complications in multiple settings (9,10,11). Other studies have shown that the use of preoperative checklists can also reduce the risk of post-procedural infections (12). The universal time out performed in operating rooms across the world is another successful example of how checklists can improve patient care.

The aim of this study was to determine if a preoperative checklist was effective in reducing surgical cancellations and thus improving operating room efficiency. Prior to January 2013, neurosurgical preoperative notes at our hospital were handwritten in the charts, and some of the required information – such as that the patient had received medical clearance for the procedure – was handed down from one team member to another by word of mouth. For obvious reasons, this system had many gaps and left much room for error, resulting in a considerable number of case cancellations.

These cancellations not only wasted the resources of the hospital and affected its revenue but also posed a considerable risk to the health and safety of the patients for multiple reasons. First, certain patients who urgently or emergently required surgery had to have their operations postponed, which could potentially result in a detrimental outcome to their health. Second, critical information pertinent to certain patients, such as the use of antiplatelet drugs or anticoagulation, was occasionally missing from the handwritten notes, which resulted in increased risk of intraoperative hemorrhage, occasional return to the operating room and overall worse outcomes. These problems elucidated the need for a preoperative checklist. Thus, given the lack of data on ways to improve the inpatient preoperative evaluation, we set out to create and successfully implement a preoperative checklist to reduce unnecessary inpatient cancellations as a quality assurance inititative at our institution.

Our study demonstrates that implementation of the preoperative checklist resulted in a 13 percent absolute decrease in preventable inpatient cancellations. The data indicate that most were due to surgeon preference or unforeseen issues, although neither reached statistical significance. Changes to surgeon schedules and delays caused by emergencies in a specialty like neurosurgery are difficult to anticipate, and therefore, the number of such cancellations is difficult to reduce with any type of preoperative checklist. Likewise, cancellations due to patient preference cannot be controlled for through a preoperative evaluation.

There are known limitations to our study. The retrospective design limits our ability to infer causality with respect to the reduction in inpatient cancellations, and the need for a prospective design is certainly warranted. Furthermore, the stratification of cancelled cases employed in this study (preventable, surgeon preference, unforeseeable) and the definition of what would constitute preventable versus non-preventable cancellations were not agreed upon before the study was conducted. Thus, bias may have arisen from subjectively stratifying cancellations into these different categories.

In the future, there are several ways to increase the effectiveness of our preoperative checklist. On the basis of our data, cardiac causes and failure to obtain proper medical clearance represent major sources of cancellations. Therefore, implementing cardiac clearance for every patient admitted to the hospital may be a potential solution. In addition, anesthesia consultations could help identify potential sources of medical contraindications to surgery. To reduce infectious disease cancellations (another major source of cancellations), the checklist could include simple screening for potential skin infections.

Conclusion

Our study has demonstrated for the first time (to our knowledge) that the use of a preoperative checklist decreases the rate of inpatient surgical cancellations. Furthermore, our currently implemented preoperative checklist provides the anesthesiologist, nursing staff and neurosurgeon with the information needed to safely proceed with the surgical procedure. By addressing deficiencies in preoperative evaluation, hospitals can improve daily operations, resulting in improvement in the quality of surgical care, decreased costs, and increased revenue.

Conflict of Interest/Investment/Financial Disclosure
None of the authors has any conflict of interest that may affect the subject matter of this manuscript.

References
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