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Prevalence of Elective Surgery Cancellations in the Operating Room of

East Avenue Medical Center (September 2019 – February 2020):
A Hospital-Based Retrospective Study

Sheila Perez1, Donn Rhoederick C. Abuan 1, Fritz Gerald V. Jabonete2*

East Avenue Medical Center, Quezon City, Philippines1
College of Allied Health, National University2
*Corresponding Author: [email protected]

Abstract: Elective surgical cancellations pose threats to quality care. It is a significant

source of psychological distress for patients and their families. This study aimed to
determine the prevalence of elective surgery cancellations on the scheduled day of surgery at
a tertiary DOH hospital in Metro Manila. A retrospective, hospital-based cross-sectional
study design was conducted among nurses (n=259). Document review was employed using
the client’s hospital record for collecting data. The number of cases of elective surgeries
ranges from 437 to 558 every month from September 2019 to February 2020. The average
cases of surgical cancellation are around 25-29% from September 2019 to February 2020.
The medical and paramedical staff-related recorded the most causes of surgical
cancellations. September 2019 had the most prevalent cases of surgical cancellations. The
surgical cancellation rate remains high. Most causes of cancellations are avoidable. Medical
and paramedical-related causes such `as improper scheduling, unavailability of surgeons and
operating room equipment, and medical illness were the most prevalent reasons for the
elective surgery cancellation. It is recommended that a root cause analysis should be done to
identify the precedents for surgical cancellation. It is also advised to revisit the guidelines of
the OR operations. This way, interventions to mitigate surgical cancellations will be
evaluated and may initiate adopting best-fit interventions to solve the problem.

Keywords: cancellation; elective surgery; operating room

1. INTRODUCTION
1.1 Background
Cancellation of scheduled surgeries is a persistent issue confronting the
operating room department staff and its management daily because this problem
affects health care performance and patient outcomes.
The East Avenue Medical Center (EAMC) is a tertiary government training
hospital under the Department of Health. It caters to patients from all over the
country - pay and service cases. In 2018 alone, it catered to 7,189 pay and service
elective and emergency operations. Service cases are performed by resident surgical
and anesthesia doctors under the different residency training programs on
collaboration and interface with resident medical doctors of the hospital. These
resident doctors are under the guidance and mentorship of their respective
consultants. Consultant surgeons pay cases, and anesthesiologists are duly
acknowledged and accredited by EAMC.
The EAMC Main Operating Room has 11 rooms divided into seven major
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operating rooms, one emergency operating room, two urology rooms, and one
minor operating room. This theatre is manned by 32 Operating Room nurses and 16
nursing attendants. Elective procedures are scheduled on Mondays to Saturdays
with a cut-off time for service cases but unlimited time for pay cases. The Operating
Room has its Operating Room Management Committee (ORMAC) with rules and
guidelines agreed upon by all the concerned Department Chairman, Nursing
Supervisors of the Operating Room, Delivery Room, Post Anesthesia Care Unit,
and Surgical Intensive Care Unit.
Like most government hospitals, EAMC experiences capacity constraints
due to the growing number of patients, limited staffing, inadequate resources, and
fixed limited space. Cancellation of elective surgical procedures causes a significant
emotional toll on the patient and his relatives. It could lead to extended hospital
stays, complications, and increased financial incapacity. Furthermore, case
cancellations disrupt other scheduled surgeries, interfere with the other departments'
plans and objectives, waste scarce resources, increase healthcare costs and cause
emotional stress to all concerned; this also significantly affects the institution and its
employee’s image. Recognizing the causes of these cancellations will lead to
finding solutions to provide better services. In so doing, this will help increase
productivity and boost the morale of the entire operating team and may further the
institution’s respectability. Furthermore, the findings of this study will provide a
basis for improvement of the quality management tools to attain minimal
cancellation and prompt accomplishment of elective surgeries.

1.2 Statement of the Problem

The Operating Room Management recognizes this problem as an urgent and
exceedingly important issue that needs to be addressed. Cancellation of cases
indicates inefficient management of resources – men, machines, and materials – and
hinders our service to patients.
Hence, this study aims to establish the prevalence of elective surgical case
cancellations as scheduled and the reasons for these cancellations stratified
according to their causes in a tertiary DOH hospital in Quezon City.

1.3 General Objective

To identify the factors in canceling elective surgeries in the operating room
of East Avenue Medical Center from September 2019 to February 2020.

Specific Objectives
1. To determine the number of elective cases done as scheduled
2. To determine the number of cancellations of elective cases
3. To determine the prevalence of cancellations of elective cases as to:
3.1 Patient-related
3.2 Nursing staff related (ward and operating room nursing staff)
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3.3 Medical and paramedical staff related (doctors, laboratory, pharmacy,

and radiology personnel)
3.4 Hospital management- related
1.4 Scope and Limitation
The study was conducted only in the main operating room (4th floor),
which covers all surgical patients of all ages, gender, pay, service patients, and
admitted patients. Outpatient cases are scheduled for elective surgical procedures
from Mondays to Saturdays, excluding holidays, but elective surgeries have been
canceled during the study period from September 2019 to February 2020.

1.5 Review of Related Literature

East Avenue Medical Center is a Department of Health tertiary training
hospital (DOH). In compliance with the no-refusal policy of (DOH) and looking at
the incontestable knowledge, abilities, and competence of doctors and nurses, the
institution has a steadily increasing influx of patients from all over the country with
medical and surgical issues ranging from the simplest to the most complex. Resident
physicians schedule and nurses assist as many patients as possible per day to reduce
the number of patients in the wards and make room for patients on the waiting list
who urgently need their services.
Due to different factors, reasons, and circumstances, most elective cases
cannot be accommodated. Canceled surgeries increase costs, decrease efficiency,
and waste time and resources. It affects the institution, the medical staff, and the
patient. Mutwali et al., (2016) revealed that the termination of elective surgical
operations is not unusual, but these terminations can be avoided so as not to cause
considerable anguish to the patient. Each hospital should formulate careful planning
to deal with this effectively and efficiently.
The occurrence of canceled elective surgical operations can be attributed
either to the hospital, patient, or physicians. In the Ogwal et al. (2020) study, the
dominant reason for the cancellation was facility-related, which could have been
counteracted. Non-availability of certain medical team members due to their
limited staffing, the prioritization of emergency over elective cases, and the lack of
time to complete an operation in the crucial period also contributed to these
cancellations.
According to Cho, H., Lee, Y., Lee, S., Kim, J. et al. (2019), the leading
causes of surgical cancellations were because of surgery schedule-related, surgery-
related, and patient-related. These findings were also supported by the study of
Nigatu and Aytolign (2019) with the addition of hospital administration-related
factors. Moreover, Desta M, et al. (2018) reaffirmed that improper scheduling,
unavailability of surgeons, medical illnesses, and unavailability of operating room
equipment were the most prevalent causes for the cancellation of elective
operations. These avoidable cancellations were due to financial constraints,
deficient pre-operative assessment, patients not showing up for surgery, and lack of
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time (Kaddoum, R et al. (2016).

A 15-month study in a Nigerian Hospital revealed that the top reasons for
canceling elective cases were patient-related factors followed by surgeon-related
factors (Okeke, CJ, Obi, AO et al (2020). Non-availability of funds was the most
common reason for patient-related factors. Most canceled surgical operations were
from the General Surgery, Orthopedics, and Urology Departments. According to
National Health Service England, some canceled operations due to non-clinical
reasons are to be rescheduled within twenty-eight (28) days, or the patient’s
treatment will be funded by the hospital of the patient’s choice and at the time
convenient to the patient. Some of the non-clinical reasons that were found include
the unavailable beds, surgeons, theater staff, equipment failure, and emergency
cases overtaking elective cases. To lessen the cancellations of elective surgeries, the
National Heart Center Singapore (NHCS) established its Pre-Operative Evaluation
clinic managed by a cardiothoracic surgery unit composed of doctors, nurses, and
physiotherapists. The team conducts a comprehensive pre-admission check on
patients to prevent surgeries from cancellation. These steps include a review of
their pre-operative diagnostics, laboratories, and medication history; financial
counseling and a pre-operation video is shown to the patient and his family for them
to have an idea and understanding of the whole hospitalization process.
Cancellations of elective cases are primarily preventable and avoidable.
The table below shows the common causes of surgical cancellations found in
studies according to Desta (2018).
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1.6 Conceptual Framework

Figure 1. Factors affecting the cancellation of elective surgeries

The figure above shows the interplay of variables that will be entertained in
the study. Previous literature indicates that several factors were found to have
caused the cancellation of elective surgeries. These factors could be patient-related,
nursing staff-related, medical and non-paramedical, and hospital management-
related. These factors are the independent variables. Moreover, the cancellation of
elective surgeries is the dependent variable. The study findings will be the basis for
recommendations to identify strategies to minimize further cancellation of elective
surgeries.

2. METHODOLOGY
2.1 Research Design
A hospital-based, retrospective evaluation of cancellations of surgical operations
was conducted. Document review was employed using the client’s hospital record.
Review references will include logbooks such as the Operating room schedule and
Operating room record

2.2 Sample/ Sampling Design

A cross-sectional design will be utilized in the sampling selection.
Approximately 500 surgeries performed in the operating room are scheduled
monthly. For this study, data that will be gathered for the study will follow the
following criteria:

2.3 Inclusion Criteria

Minor and major elective surgical procedures from September 2019 to
February 2020 (6-month period only).
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2.4 Exclusion Criteria

All emergency surgical cases

2.5 Data Gathering Procedure

This study sought approval to conduct the study first at the Nursing
Services Office. When the approval was secured, the researcher prepared the
manuscript together with study tools that were utilized. Then, the research proposal
will be forwarded to Professional Education, Training, and Research Office
(PETRO) for technical review. Then, ethics approval from East Avenue Hospital
Ethics Review Board has sought after. Furthermore, when permission was secured,
actual data collection commenced. The researcher utilized a self-made tool to gather
data from hospital reference reviews using OR records. After data were collected,
data analysis and interpretation followed.

2.6 Ethical Considerations

The study secured ethics approval from East Avenue Medical Center Review
Ethics Board with approval code EAMC IERB 2021 – 69. Furthermore, the
researchers secured consent from the administration regarding using the patient
records for the study. Each data collection tool was coded with numbers to ensure
the anonymity of the respondents. Only the researchers had access to the
documents. The researchers declared no conflict of interest in completing the study.

3. RESULTS AND DISCUSSION

Figure 1 shows the number of elective cases done as scheduled from September
2019 to February 2020. It can be seen that elective cases range from almost 320 to
400 cases each month. Figure 2, however, shows the total number of canceled
elective cases. October 2019 had the highest number of canceled elective cases. It
can be observed in the two figures that October 2019 had the highest number of
elective cases and the number of cancellations, while December had the least
recorded cases. The prevalence rate of canceled elective surgical procedures ranges
from 24% to 29%, which is considered high. September and October 2019 are the
months with the most prevalent elective surgical cancellations. Figure 4 shows
elective surgical cancellations are more common in in-service wards than in pay
wards. Figures 5 to 8 show that medical & paramedical staff-related factors are the
leading causes of elective surgical cancellations.
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Fig. 1. Total Number of Elective Cases Done

Fig. 2. Total Number of Cancelled Elective Cases

Fig. 3 Prevalence Rate of Elective Surgical Procedures Cancellation

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Fig. 4 Number of Cancelled Surgical Elective cases by Case Type

Causes of Elective Surgical Cancellations

Fig. 5 Number of Patient-Related Cancellations

Fig. 6 Number of Nursing Staff-Related Cancellations

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Fig. 7 Number of Medical & Paramedical staff- related Cancellation

Fig. 8 Number of Hospital management- related Cancellations

Elective surgical cancellations pose threats to quality care services. It is

identified as a significant burden owing to limited health resources, increased
operating room costs, threats to patient satisfaction, wasted operating room time,
and decreased efficiency. An efficient surgical service should have a low
cancellation rate (Chalya PL et al., 2011; Leslie RJ et al., 2013; Perroca MG et al.,
2007). However, there are known reasons that caused the surgical cancellations.
This study shows that 24-29% of the elective surgical cases were canceled, which
may be analyzed as preoperative system inefficiency. The result of the current
research is supported by the studies conducted in India (Garg R et al., 2009), in
Burkina Faso (Lankoandea M et al., 2016), and in Nigeria (Ebirim LM et al., 2012).
Still, the current cancellation prevalence rate is higher when compared to studies
done in America (Kaddoum et al., 2016), Brazil (Santos, 2017), and Germany,
12.7% (Schuster et al., 2011). This discrepancy might be due to the lack of
operating room equipment and bed and the unavailability of a surgeon in public
hospitals in the Philippines. Thus, this reduces the operating room time and gives
priority to emergency referral cases, which subsequently end up canceling the
elective surgical cases.
This study shows that patient-related factors accounted for the second
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cause of canceled cases. This study is similar to other studies done in Brazil (Santos,
2017), India (Garg R et al., 2009), and Burkina Faso (Lankoandea M et al. 20016)
patient-related factors were the common cause for cancellation. The leading causes
of patient-related cancellations are acute and chronic medical conditions and
medication use. This may be explained by the fact that patients who continue taking
medications on the day of surgery due to illness may affect the surgical procedure
and the efficacy of the anesthetic agent. Another identified cause of surgical
cancellation is hospital administration-related accounts. Observed in China (Chiu
CH, Lee A, Chui PT, 2012) and Sudan (Chiu CH, Lee A, Chui PT, 2012) was a
failure to prepare cross-matched blood, an OR material shortage, and a lack of bed
availability (Mutwali et al., 2016). It is noteworthy that nurse-related factors
accounted for minor causes of elective surgical cancellation. The results suggest that
nurses prepare to ensure their readiness before the surgery, thus preventing
unnecessary circumstances that may inhibit the conduct of the procedure. Surgical
cancellations are more common in service (charity) wards than pay wards, which
are more prevalent in public hospitals because patients in charity care have less
access to resources than those in pay wards. This study cannot establish a causal
relationship, for it is difficult to know which factors preceded the exposure or
outcome. Furthermore, it is less likely to generalize the result to the general
population because it is a health facility-based study.

4. CONCLUSIONS
The surgical cancellation rate in EAMC remains high and most medical and
paramedical-related. Most cancellations were preventable.

5. RECOMMENDATIONS
This study recommends revisiting the guidelines of the OR operations. Hospital
resources need to be used more efficiently. Apply scheduling rules to weekly
schedules for surgeons, anesthesiologists, and surgical team members. Add beds to
the postoperative unit depending on the number of surgical cancellations. Prior
clinical screening of patients and patient involvement in this manner may increase
patient satisfaction with treatment decisions made during the initial consultation, a
strong predictor of surgical participation. When patients are actively involved, they
are more likely to support the treatment plan and participate adequately, reducing
the likelihood of delay or abandonment. Further research is needed to determine
which patient conditions are most associated with delays and cancellations so that
resources and interventions can be focused on these areas.

6. ACKNOWLEDGMENTS
The researchers would like to acknowledge the Nursing Service Office of
East Avenue Medical Center through the former chief nurse, Dr. Teresita A.
Santiago, current chief nurse, Mrs. Filomena I. Juguilon, and ACNET Ritchel S.
Acuna. The active participation of the whole nursing community made this research
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project feasible and successful.

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