الفهرس 
DESIGN AND LAYOUT OF OPERATING THEATERSOnly 14 pages are availabe for public view
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Abstract
Cancellation of elective surgery is considered when an elective case is booked into the operation list but is not operated on the supposed day (Dawlatly et al., 2008). Surgery cancellations on the scheduled day of the procedure has a negative impact on the operating room efficiency, it reduce utilization of OR time and waste resources, all of which result in a big financial loss for the patient, hospital and health care cost of a country at large, (Lankoandé et al., 2017). Aside from its economic impact, it is also associated with considerable psychological and social impact on patients and their families, (Chalya et al., 2011; Chang et al., 2014).
Operation cancellation rates show high variation in literatures. A study that was conducted in Brazil reported that the cancellation rate in developed countries ranges between 0.37–28% (Santos & Bocchi, 2017). Other studies reported higher rates in developed countries ranging from 2 to 40% (Morris et al., 2017; Yu et al., 2017; Sung et al., 2010; Chiu et al., 2012). In low and middle-income countries, this rate may reach as high as 73% (Chalya et al., 2011; Carvalho et al., 2016; Botazini et al., 2017; Okonu, 2012). In Egypt, a cross-sectional study conducted by El Bokl and colleagues in 2021 at Cardiothoracic Ain-Shams University Hospital showed that the overall cancellation rate in the hospital was 21.7% (El Bokl et al., 2021). These variations depend on the hospital setting, culture, and socioeconomic status of the nation (Zafar et al., 2007; Basson et al., 2006).
To our knowledge, there is scarcity of published data on causes of operation cancellation in Egypt. El-Demerdash University Hospital is a major tertiary hospital for surgery. Identification of the magnitude and causes of elective surgery cancellation can motivate the managerial bodies to make appropriate strategies for better utilization of the operating rooms.
This study was conducted to:
1- Measure the prevalence of cancellation of elective surgeries at El-Demerdash Hospital.
2- Identify causes of cancellation of elective surgeries at El-Demerdash Hospital.
3- Explore the perception of operating room staff on causes of cancellation of elective surgeries.
A Mixed method study was conducted in the form of Quantitative and Qualitative study:
• For the quantitative study, a cross-sectional study was conducted that included 993 elective surgical procedures at El-Demerdash Ain Shams University Hospital. A cancelled case was defined as a scheduled elective surgery that was cancelled on the same day of surgery after operating list submission to operating department secretary at 7:00AM, same day of surgery. The operating department was visited three times per week on alternate days to collect data on all surgical list and cancelled operations of the previous day.
Of the 993 scheduled cases during the study period, 125 were cancelled on the same day of surgery. Thus, the prevalence of same day elective surgical cancellation was 12.59%. The mean age of the study participants was 40.5 ± 19.49 years old; the majority were adults ranging from 25-64 years old (66.26%). Gender distribution, as well as distribution of residence (inside Cairo/outside Cairo), are almost equal. 29.81% of the studied operations were booked for General surgeries, while the rest were distributed between different special surgeries.
Regarding cancellation rates, seniors ≥ 65 years old show the highest cancellation rates (22.4%) followed by children ≤ 14 years (14%) with age being the only demographic factor showing statistically significant difference.
The highest cancellation rate among specialties was in vascular surgery (25.40%), followed by plastic surgery (16.0%) and uro-surgery (14.53%) with statistically significant differences between surgical departments regarding cancellation and general surgery/vascular surgery, uro-surgery/ENT and plastic surgery /neurosurgery departments were the pairs that responsible for the difference.
Regarding cancelled cases, age distribution among cancelled cases showed that Mean ± SD = (43.42 ± 22). Most of cancelled cases fall within age group 55-60 followed by 65-70, 40-45, and 0-5 while cases aged between 80-85 were the least frequent among cancelled cases. Also, 22.40% of cancellation were on Tuesday followed by Monday that account for (21.60%) of cancelled cases, while Saturday and Wednesday had the same cancellation percentage in the study sample (19.20%).
Many causes of elective surgical cancellation were reported at El-Demerdash Hospital. The majority of causes of cancellation were Hospital-related factors which were responsible for more than two-thirds of the cancellation.
According to Pareto chart, insufficient operating room time, Unavailable ICU bed, prolonged previous operation, change in patient’s medical condition, and Unavailable/failed equipment were the vital few causes that were responsible for 80% of cancellation.
Regarding vital few causes of cancellation in relation to different variables, 92.5% of cancelled cases due to unavailable ICU bed were classified according to the American Society of Anesthesiologists as ASA 2 & 3 and more, while 85.8% of cancelled cases due to prolonged previous operation were ASA 1 & 2. On the other hand, 63.2% of cases cancelled because of changes in their medical condition were ASA 3 or more. Also, these differences were statistically significant with p-value < 0.05
• A qualitative study was carried out including 25 operating room staff in the form of 2 focus group discussions for operating room nurses, and 15 in-depth interviews for surgeons representing different specialties, anesthesiologists, and operating room secretary.
The qualitative study showed that most of the study participants ”operating room staff” expected that the rate of elective surgical cancellation at El-Demerdash Hospital was between 10-20%. Also, half of the operating room staff reported unavailable ICU bed as the main cause of elective surgical cancellation, followed by cancellation due to changes in patient medical condition that reported by some of them, while few of them reported that type of patient and illiteracy was the main cause.
Regarding the operating staff response on the real most common cause of cancellation (unavailable OR time), most surgeons and anesthesiologists agreed with that result, while most nurses expressed their surprise with that finding. More than half of the operating room staff, mainly surgeons and nurses, attributed this result to intraoperative unexpected events which resulted in prolonging the previous operation. In addition, some of them reported that prolonged previous operation is related to the nature of the hospital where the junior and trainee staff may take more time than expected in teaching hospitals. On the other hand, few of them, mainly surgeons, pointed to time management issues as prolonged turnover time as an underlying cause. Also, nearly half of the operating room staff attributed unavailable OR time to scheduling errors in the form of over-scheduling, and logistical issues, such as the anesthesia induction deadline set at 3 pm for major surgeries.
Regarding the operating staff’s response on unavailable ICU bed, most of them (surgeons, anesthesiologists, and nurses) agreed with that finding. Nearly half of operating room staff justified this result by the shortage of ICU beds as they are usually occupied by surgical emergency cases as well as post-operative cases requiring ICU stay. This leads to uncertainty of ICU bed availability before scheduling the list. Also, some of surgeons reported that scheduling several complicated cases requiring post-operative ICU bed in the same list may increase the chance of surgical cancellation. In addition, one surgeon reported that this problem arises from poor communication between anesthesiologists and ICU staff on the availability and priority of ICU bed allocation.
Regarding the operating room staff response on changing in patient medical condition as a common cause of cancellation, many of them agreed with that result while few of them disagreed. Nearly half of operating room staff explained that preoperative surgical stress may lead to unexpected disturbance in patients’ vital data even in previously vitally stable cases.
Regarding the operating staff response on unavailability/equipment failure as a common cause of cancellation, nearly half of operating room staff, mostly surgeons and nurses, agreed with that result. However, most anesthesiologists disagreed. The majority of nurses indicated that this cause could stem from errors linked to the company responsible for supplying specialized equipment for certain types of surgeries.
So, same-day elective surgery cancellation at El-Demerdash University Hospital is mainly due to hospital-related causes. Managerial strategies and efforts towards vital few causes of cancellation for better utilization of the operating rooms are highly recommended through the application of scheduling and time management strategies, creating a channel for better communication between surgeons, anesthesiologists, and ICU staff for ICU bed allocation and requesting post-operative ICU bed based on defined criteria, proper preoperative patient preparation. and contracting with companies that committed on availability of equipment as requested and fund raising to manage the problem of old equipment and limited resources at the operating department.