Managing Same-day Cancellations

Missed appointments can disrupt patient care and undermine a surgery center’s efficiency. Here’s how some OASCs handle this often unavoidable problem.

By Virginia Pickles, Contributing Editor

In the 2012 Outpatient Ophthalmic Surgery Society (OOSS) benchmarking survey of 2011 data, 159 responding centers reported that nearly 4% of cases were cancelled by the patient or the surgery center. This measure reflected a substantial uptick when compared with 2010 at 1.3% and 2009 at slightly less than 1%. In response to this trend, OOSS conducted a topical survey of 82 facilities in fall 2012. Of those centers, 40% say cancellations are a concern — 6% of facilities consider cancellations a “major problem,” while 34% consider them “somewhat” of a problem.” (For more details on the fall survey, see “Breaking It Down.”)

We spoke with representatives from several surgery centers to find out why procedures are cancelled on the day of surgery and how they minimize the impact of these cancellations.

Why Patients Cancel

Albert Castillo, administrator at San Antonio Eye Center in Texas, serves on the OOSS education committee and helped design the same-day cancellation study. “I raised the question because we’ve had the problem of cancellations in our surgery center, and I wanted to see if others in the industry were experiencing the same thing,” he says. “After reviewing the data, I suspect our location and demographics — we’re in a lower-income area with a largely managed care population — may affect our cancellation rate, especially cancellations by patients.”

Mr. Castillo notes that patients often cancel their surgeries at his center because they failed to obtain clearance from their primary care physicians. “Either they couldn’t schedule a physical examination or their physician felt they weren’t healthy enough for surgery and needed further testing,” he says.

According to Lawrence Lohman, MD, medical director and part owner of St. Clare Eye Surgery & Laser Center in Cuyahoga Falls, Ohio, when a patient cancels his procedure on the day of surgery, it’s usually because of a sudden illness. “A patient may have the flu or be hospitalized for some reason,” he says. “Depending on how the schedule is running, we may be able to get another patient in if he’s nearby and has the flexibility. Most often, however, it’s a lost spot in the surgery schedule that you can’t recoup.”

When patients cancel their surgeries before they arrive at the surgery center, there’s little more you can do than reschedule their procedures. When problems are discovered at the facility on the day of surgery, then the center’s guidelines and the doctor’s discretion come into play.

Why the OASC Cancels

Anticipating some of the reasons why a surgeon might cancel a procedure on the day of surgery, the OOSS survey included questions about blood pressure, blood glucose levels and preoperative antibiotics.

According to Karen Chiles, RN, BSN, administrative director at Commonwealth Eye Surgicenter in Lexington, Ky., her center’s guidelines call for diastolic blood pressure to be less than 100 mmHg and for blood glucose to be between 60 mg/dL and 200 mg/dL. She emphasizes that these are guidelines, and the final decision on proceeding with surgery rests with the surgeon and the anesthesiologist. “We take into account the patient’s baseline and history,” she says. “Sometimes what’s considered normal is not normal for a particular patient.”

Ms. Chiles says the center has protocols to manage elevated blood pressure if the physicians approve. “If a patient’s blood pressure is elevated and we know it’s usually controlled, we may use palliative measures to lower it,” she says. “Nine times out of 10, the patient is experiencing anxiety, or he didn’t take his blood pressure medications that morning, in which case, we administer them. We may observe that patient for an hour or two and possibly move his surgery to the end of the day rather than cancel it.”

Dr. Lohman also will try to lower a patient’s blood pressure if his history shows it’s usually within normal limits. “We may administer mild sedation and observe the patient,” he said. “We may have to revise our schedule to do that, but if we can lower the pressure, we may be able to get back on track and avoid canceling the surgery. We might give a patient intravenous blood pressure medication, but we don’t want to be overly aggressive because it’s not our job to manage a patient’s hypertension. If we think it’s just a temporary situation, we’ll try to treat it and provide some reassurance.”

Each case is unique, Dr. Lohman notes, but he says, “In general, if systolic pressure is above 200 and diastolic is above 100 with sedation on board, we would consider canceling. In particular, if I’m performing a corneal transplant and will have an open globe for an extended period, I want a patient’s blood pressure very well controlled.”

Ms. Chiles says Commonwealth Eye Surgicenter also has protocols for patients who present with high blood glucose levels — they may administer fluids, for example — but if the level doesn’t decrease, the procedure is cancelled, and the patient is referred to his primary care physician for follow-up.

Dr. Lohman notes, “We have a somewhat high tolerance for blood glucose levels, because we know people with diabetes can have significant fluctuations. As a general guideline, if blood glucose is above 300 mg/dL, we consider cancelling a procedure, but we don’t have a hard-and-fast rule. We may cancel one person at a lower level and someone else at a higher level. We have to consider the patient’s normal status and his history, as well as the type of procedure we’re scheduled to perform.”

Same-day cancellations are inevitable, but their frequency and impact can be minimized by establishing parameters for guidance while giving physicians the flexibility to address each patient’s unique situation.

Most OASCs require patients to use preoperative antibiotics, but few will cancel surgery if a patient doesn’t use them. Many physicians administer a loading dose prior to surgery. This, too, is on a case-by-case basis and at the discretion of the surgeon. Dr. Lohman is in the majority. “Our preference is that patients start topical antibiotics at home prior to surgery, but if they haven’t done that, we administer the drops at the surgery center,” he says. “Fortunately, that doesn’t happen often, because we spend a great deal of time educating patients prior to surgery.”

Ms. Chiles also emphasizes the importance of presurgical education for patients. “Our schedulers work one-on-one with patients to review all aspects of surgery,” she says. “In addition, we make sure patients have written explanations of everything we’re going to do and everything they need to do prior to coming to the surgery center.”

Dr. Lohman mentions two other red flags that may prompt a cancellation at St. Clare Eye Surgery & Laser Center. “We ask patients not to eat solid food 6 hours prior to surgery, but many people eat anyway,” he says. Depending on the type of surgery and the anesthesia planned, Dr. Lohman may proceed, or if the patient’s surgery was scheduled for early in the day, the surgery may be rescheduled for later that day. The second red flag is bleeding time, which is measured only for patients undergoing more complicated surgeries. “If a patient is scheduled for oculoplastic or corneal surgery, for example, and his international normalized ratio is above 2, then we might cancel the surgery,” Dr. Lohman explains.

Cost of Same-Day Cancellations

Estimating the cost of a cancelled procedure in an OASC is difficult because of the variables involved, including the type of surgery, the time of day when the cancellation occurs, how surgery time is blocked for the day, staff allocation and so on. As Dr. Lohman explains, “If we cancel a cataract surgery, a relatively short procedure, and we have a full schedule for the day, it may not cost the center too much — other than the income from that procedure — because we may be able to move up the other surgeries in the schedule and send everyone home a little earlier. On the other hand, if we learn we can’t get tissue from the eye bank for a corneal surgery, the procedure must be cancelled. That’s a longer procedure and cancelling it creates a larger hole in our schedule, which affects our productivity. We’re paying to staff and keep the center open, so it’s a much more costly process.”

Minimize the Impact

Same-day cancellations are inevitable, but their frequency and impact can be minimized by establishing parameters for guidance while giving physicians the flexibility to address each patient’s unique situation. Thorough patient education is also an important factor.

According to Ms. Chiles, same-day cancellations are not a serious problem at Commonwealth Eye Surgicenter. “We perform really good workups in our clinic prior to surgery,” she says. “Then we follow our guidelines and the discretion of the surgeon and the anesthesiologist. We do everything we can to avoid cancelling procedures. It’s troublesome for us, and it takes away a slot from someone who’s on a waiting list, but it’s also hard on patients. They’re here. They’re ready. They don’t want to cancel, but we have to look at the whole picture and make sure the surgery will be safe for them.” ◊