Nothing can put a hole in your schedule and a kink in your day like a cancelled case, especially when the patient who bailed on you doesn't give you enough notice to prevent your OR from sitting cold and empty.

No-shows are no joke, finds an Outpatient Surgery survey of 62 readers. Nearly half (47%) of our respondents classify cancellations as a "problem" and 16% consider them a "serious problem."

"It wreaks havoc on my staffing — paying for a full day of anesthesia and only having 1 or 2 cases or sometimes none," says Kim Merrill, RN, BSN, nurse administrator at Harford County Ambulatory Surgery Center in Edgewood, Md. Others report having to cancel a per-diem they brought in to assist on a busy day because of patient cancellations.

Our panel says patients usually give precious little notice when they cancel a case — 15.6% call out on the day of surgery and 46.9% cancel the day before surgery. A last-minute cancellation is a dagger to the schedule, an almost certain guarantee that the OR will sit empty because it doesn't give you enough time to ask another patient to come in early or to offer the slot to another surgeon.

More than one-third of our panel (34.4%) say patients are courteous enough to cancel a few days before surgery. "If we can get a cancellation as far out as 3 days, then we can fill it with someone else that is on a waiting list," says Polly Ladd, RN, CGRN, BSN, clinical nurse manager at Crowne Point Endoscopy & Surgery Center in Flint, Mich.

Why patients cancel

From missing lab results and missing rides to inadequate preps and inordinate copayments, patients cancel for many reasons. The most popular, according to our survey, have nothing to do with medicine — patients don't have a ride home (46.9%) or they can't afford their out-of-pocket responsibility (43.8%). Then there are clinical reasons patients cancel. The patient isn't suitable for same-day surgery (25%), the patient didn't complete pre-surgical testing (21.9%), the patient isn't NPO (18.8%) or the anesthesia risk is too high (18.8%). Whatever the reason, it's never a good thing to waste the OR minute — the most expensive in healthcare. Just ask Joy Schwartz, RN, administrator at Atlantic Surgical Group in Oakhurst, N.J. One of her ORs sat empty for 3 hours last month because the results of a last-minute blood sugar test on a diabetic patient were too high. Just like that, the case was cancelled and, with no remaining patients to move up, the room sat empty for the rest of the day, says Ms. Schwartz.

A last-minute cancellation usually results in frayed nerves and an empty operating room.

Here are 4 tips to prevent cancelled cases.

1. Engage with patients

Whether you rely on the time-honored pre-op phone call or automated text messaging reminders, the more you communicate with patients, the fewer cancellations you'll have. In addition to improving patient engagement, patients are more likely to arrive on time, be NPO compliant and be fully prepared for surgery when you call and text them before surgery.

Don't assume patients know the time and date of their surgery. Or that they're not to eat or drink after midnight. Or that they can't take a taxi, Uber or bus home. "Sometimes they say, 'No, I'm going to take a taxi,'" says Ms. Schwartz. "(I say) not in our state."

Ms. Schwartz recommends calling a few days before surgery so that you give yourself enough time to adjust the schedule if a patient cancels.

2. Send automated texts

As more and more facilities turn to technology for improved communication and patient engagement, many are choosing the most affordable, accessible and simplest tool available today: texting. Automated texts can instruct patients when to discontinue eating and drinking, how to apply cleansers and what medication regimen to follow. They also remind patients to provide required medical history or forms and reiterate logistics like arrival time and directions.

Does texting work? In a study of 170 patients undergoing thoracic surgery at Toronto East General Hospital, 98% of patients reported satisfaction with text messaging, and researchers found those receiving texts were at a reduced risk of procedure delays and cancellations. Plus, consider the time your staff will save without having to make phone calls, leave voicemails and send emails.

3. Take a detailed medical history

Don't you just love it when patients show up on the day of surgery all set to go, but they forgot to get a needed medical test or follow up on a health condition? To avoid such same-day cancellations, it's critical to get a detailed and complete health history well ahead of the procedure so you can identify any red flags or potential medical risks during their operation, says Susan Struck, RN, health history nurse at Casper (Wyo.) Surgical Center.

Give patients the option to mail in a filled-out form, to use an online health history portal or to give their medical history to a nurse over the phone. As a health history nurse at her ASC, Ms. Struck reaches out to patients 1-2 weeks before their surgery to go over their medical history.

The health history call should be separate from the pre-op call, she notes, because it needs to be done well before surgery in order to gauge and try to fix any health risks or medication complications a patient might have. It's intended primarily to identify red flags that could cause complications when your patient is put under anesthesia.

During the health history call, the nurse should ask about any prior medical conditions involving the patient's heart and lungs, infections, diabetes, cancer, neurological history and what medications they're taking, says Ms. Struck. Be sure to ask about body mass index — a BMI over 60 is a red flag — and about sleep apnea. Can their snoring be heard through a closed door? Do they use a CPAP machine? Has a family member complained about their snoring? If a patient answers yes to 1 or more of the sleep apnea questions, that's a red flag, says Ms. Struck, who adds that if you have multiple concerns about a patient's risk of having sleep apnea, it's a good idea to fill out a STOP-Bang questionnaire.

Once the health history nurse has identified the red flags in your patient's medical history, she can bring that information to the anesthesia provider, who can make the final determination on whether that history precludes the patient from being put under general anesthesia, whether they need to reschedule the procedure or whether special arrangements need to be made for the surgery. "If they're just getting propofol, the anesthetist is a little more lenient because they're not put under as deeply," says Ms. Struck.

4. Collect ahead of time

For many patients, out-of-pocket payments pose an issue and a concern — one that can make them frightened enough to stay home the day of surgery. A study on the causes of same-day cancellations at a teaching hospital found that patients cancelled 71.6% of the time due to financial issues.

Collecting deductibles, coinsurance and copays ahead of the scheduled procedure is a way to help combat finance-related cancelled cases, says Kelly Crumbo, an administrator at the Florida Endoscopy Center in Brooksville, Fla., who adds that patients who have skin in the game are less likely to cancel. Collect the patient's responsibility during a pretest that's scheduled anywhere from 1 week to 3 days before your patient's surgery. "They've already paid, so they go through with it," says Ms. Crumbo.

Some patients might be able to pay their copay but have difficulty paying for their deductible, says Ms. Crumbo. Consider implementing a payment plan for patients to ease their financial burden, she says. Her facility spread a patient's payment out over 3 months, with minimum payments of $50 a month. OSM