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A single pre-op phone call will help to keep your surgical schedule on track.
FULL STORY It's not enough to keep a tally of last-minute case cancellations. You also need to keep track of why they happened.
Last-minute cancellations of elective surgeries send negative ripples outward from empty ORs. Surgeons without patients to operate on and facilities with unexpected holes in their schedules lose time and money. Frustrated patients who were physically and mentally primed for surgery lose faith in the providers they trusted with their lives.
Those are avoidable outcomes because most case cancellations are entirely preventable and often unnecessary. They should be considered never events, just like a medication error or a wrong-site procedure. You need to identify their causes and determine how to solve them. Your ultimate goal is to make sure every surgery goes
off as planned.
A call for change
AORN advises surgical facilities to keep their same-day case cancellation rate under 2%. Ours was as high as 4% when we decided to take a critical look at the problem. The rate is now down to 1% thanks to over-the-phone assessments of patients conducted by one of our CRNAs during calls made the day before scheduled cases.
When we began investigating why our same-day cancellation rate was too high, we zeroed in on a frequent factor — patients would arrive for their scheduled surgeries, but then be disqualified after the anesthesiologist's pre-op examination. On the day of surgery, your anesthesia providers might be looking at labs that are a week old. In the meantime, they learn the patient's been bleeding, so their hemoglobin level might be very different. It's determined that the patient needs blood before surgery. That's another two or three hours of time your surgeon or your schedule might not have.
When we decided to test the effectiveness of day-before-surgery patient assessment phone calls, we took 120 cases and split them evenly into two groups: patients assessed over the phone by a CRNA and patients who were contacted by a peri-op nurse. Our facility usually performs 40 to 60 procedures per day, so this was a good sample size. There were 10 cancellations, a rate of 8.3%, but only two of those cancellations occurred among patients the CRNA called.
PROACTIVE APPROACH
6 Common Causes for Case Cancellations
PAYMENT PLAN Inform patients of exactly how much they will owe out of pocket so there are no surprises on the day of surgery.
Implementing an anesthesia assessment pre-op phone call will help you address most issues that can cause case cancellations. It's still important to stay on top of potential day-of-surgery problems, according to Natalya E. Nelson, DNP, RN, CNOR, unit director of UCLA Santa Monica Ambulatory Surgery Center and the Medical Procedure Unit ?at UCLA Medical Center, Santa Monica.
1. No NPO. Patients who eat just before they arrive for surgery usually didn't get a clear explanation of your NPO requirements. Be specific and precise with your language. A patient might hear, "Have a light breakfast," by which you meant a piece of dry toast and clear fluids. Maybe that patient usually eats several pancakes in the morning and might consider a short stack a "light breakfast." Remove all ambiguity.
2. Logistical miscommunication. The patient arrives at the wrong campus, or at the wrong time. The patient arrives late for surgery, but the surgeon is already gone for the day, so the surgery is cancelled. You had the wrong phone number for the patient and couldn't get in touch. The list goes on and on. Make sure patients receive detailed information about their day-of-surgery experience. If there are any schedule changes in the days leading up to the surgery, confirm that the patient is aware of the new time. Don't let it fall through the cracks between the surgeon's office and your facility.
3. Medication mix-ups. The patient didn't understand which medications to stop taking and which to continue and is on a therapy —blood thinners, for example — ?that necessitates cancelling the case. Be sure patients provide an accurate and current list of all the medications they're taking. Ask probing questions about specific medications instead of open-ended questions that force patients to recall or fail to mention on purpose or by accident.
4. No ride home. The patient doesn't have a way to get home, even though you told them to have a responsible adult on hand to give them a ride and stay with them during the initial 24 hours of recovery. The patient insists they're strong enough to take care of themselves. They're not. Clearly state your facility's discharge policy as it relates to rides home and post-op home monitoring.
5. Insurance issues. This becomes an especially big problem toward the end of the year, when patients might think they've met their deductible, but actually haven't. Make sure patients clearly understand how much they'll owe out-of-pocket well before they arrive for surgery.
6. Unforeseen delays. Cancellations can occur when schedule delays begin to stack up and windows of opportunity are missed. Perhaps a surgeon can't operate late into the afternoon and doesn't have time to perform a case that was delayed from the late morning. Keep surgeons constantly updated about the progress of the day's schedule and try to accommodate their needs whenever possible.
"Achieving a low same-day cancellation rate doesn't mean it will stay that way," warns Ms. Nelson. "Keep tracking cancellations, identifying their causes and constantly addressing the issues that arise."
— Joe Paone
The results prompted us to revamp our system for contacting patients before they arrive at our facility for surgery.
Anesthesia involvement. You can review all the charts you want the day before a patient's surgery, but it's nothing like talking to the patient. Who talks to the patient is also important. A perioperative nurse will read a chart differently than an anesthesia provider will. A CRNA will notice, for example, that the patient doesn't have cardiac clearance, and had a cardiac event six months ago. The scheduling surgeon or the perioperative nurse might not have picked up on that important cause for concern. Using a CRNA to make the call as opposed to an anesthesiologist is a more efficient use of resources.
Tag team calls. Perioperative nurses still contacts patients the day before their scheduled procedures and go through the usual script — when and where to show up, which medications to take and which not to take, when and what to eat and drink, what to wear, what to bring and so on. Once nurses are finished, they hand the phone to CRNAs (both are on the same call, so we don't bother the patient twice), who perform pre-op assessments and, if there are any red flags, immediately consult with the anesthesiologist.
Scripted questions. In order to give CRNAs as many tools as possible to discern disqualifying issues during conversations with patients, we developed a protocol in close cooperation with our department of anesthesia. This assessment form, based on a validated and reliable anesthesia script, helps CRNAs examine and evaluate surgical patients over the phone.
They can uncover things like a questionable medication regimen, outdated lab results, a need for an in-person consultation, the lack of a specialist's clearance, new symptoms, new diagnoses and much more. During our study, for example, a CRNA noticed a patient's breathing pattern was peculiar over the phone and brought it up with the anesthesiologist, as nothing about the issue was noted in the patient's chart. You might also learn of red flags the patient wouldn't think to tell you about: They have a cold, or their 3-year-old son has strep.
Time to adapt. CRNA calls provide an effective layer of fact-checking that avoids disqualifying surprises on the day of surgery. The goal is to act upon the information the CRNA gathers in order to reschedule cases to another day in advance of the patient's arrival, clarify an issue so the surgery can take place as planned or buy some time to clear the patient for surgery later in the day on which the case was originally scheduled.
We're not changing our day-of-surgery process in light of the new CRNA calls. Our patients still need to arrive an hour before their scheduled surgeries. To ensure patient safety, we go over everything the CRNA covered during the phone call assessment the day before. If any problems or needs emerged from the phone call, we've likely already addressed them.
Restoring trust
Robert Hernandez A STEP AHEAD ?Day-before anesthesia assessment phone calls from clinicians like ?Debbie Paris Teho, CRNA, principal nurse-anesthetist at UCLA Medical Center, Santa Monica, enable the facility to eliminate same-day cancellations due to unexpected disqualifiers.
Imagine what a cancelled case feels like from the patient's perspective. A patient has seen a surgeon several times over numerous months to diagnose a health issue and eventually decides surgery is the best treatment option. The patient built a relationship with the surgeon, trusting her opinion and in her ability to perform a successful surgery.
The patient reads about your facility, checks online reviews and speaks to people who've had surgeries in your ORs. She expects your staff to provide excellent surgical care.
Now the patient is speaking to the physician's office about the particulars of the procedure. Her loved ones need to make accommodations at home. She must make difficult financial decisions in order to cover her significant co-pay. She needs to know how long to take off from work, and must arrange for at-home help during her recovery.
The week before surgery, the surgeon's office sends the patient a stack of paperwork, and she fills out every last form. One of your nurses calls the day before surgery to provide needed information about the big day. The patient is fully onboard and feels like she's doing everything right to prepare for the procedure. She's fully entrusting her care to her surgeon and your surgery center. She's ready to face one the most important and scariest days of her life, and arrives at your facility calm and confident.
And the case is cancelled. Just like that.
She feels as if her trust in you has been violated. Not only are you losing money, but an unhappy patient is telling anyone who will listen about how she feels and posting a not-so-positive online review about your facility.
And to think, this could all have been avoided. OSM
Restoring trust
A STEP AHEAD ?Day-before anesthesia assessment phone calls from clinicians like ?Debbie Paris Teho, CRNA, principal nurse-anesthetist at UCLA Medical Center, Santa Monica, enable the facility to eliminate same-day cancellations due to unexpected disqualifiers.
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