As demonstrated during the COVID-19 pandemic, administrative matters such as the efficiency and capacity of a hospital can notably influence mortality and patient outcomes.1 Healthcare facilities must address this issue systematically, identifying where waste and delays occur and how they might be remedied by changing how a facility operates.2 One factor affecting efficiency is delays in elective surgery.
Depending on the nature of the operation, delaying an elective surgery can negatively impact both the health of a patient and their satisfaction.3 Furthermore, a delay has ramifications beyond an individual patient. According to surgeons writing to the Annals of Surgery in April 2020, the postponement of non-emergency elective surgeries due to the pandemic’s strain on hospitals had created a backlog of nearly 5 million surgical cases. Surgeons across the country, Fu et al. wrote, would soon be facing the ethical dilemma of allocating limited surgical resources among an influx of patients whose conditions had worsened as a result of the delay. Even when patients are not significantly harmed by delays, delaying elective surgery can complicate the hospital’s schedule, potentially causing delays for other cases, strains on the hospital’s resources, and reductions in morale among hospital and surgical staff.4
Understanding the common reasons behind delays in elective surgery can help facilities predict when and how delays may occur and can enable them to enact policies and safeguards to mitigate their effects. A cohort study by Tan et al. that analyzed all elective surgeries on patients 18 years and above between June 2015 and December 2016 in one healthcare system found that surgical procedures cancelled within 24 hours of the scheduled start time of the surgery were associated with a history of heart failure, advanced chronic kidney disease, or a history of hip fracture.5 Additionally, a prospective observational study by Becker et al. analyzing 2519 patients undergoing elective surgery from October 2018 to May 2019 found that elderly patients and patients colonized by multidrug-resistant pathogens were significantly more likely to have their elective surgery rescheduled.6 Knowledge of such patterns of increased risk provides an opportunity for both the hospital and the patient to be adequately prepared for a possible postponed procedure. Additionally, patients may decrease the risk of postponement through some methods, such as attending a preoperative anesthesia assessment clinic.5
Importantly, many factors that researchers have identified as increasing a patient’s risk for a delay in elective surgery are non-medical. In addition to the aforementioned medical factors, the Tan et al. cohort study found that low socio-economic status (measured in their study by whether or not a patient was on Medifund financing) had a strong association to cancellation of a surgery within 24 hours of the scheduled start time.5 The Becker et al. study found that the probability of a surgery being postponed was significantly lower when the patient had private health insurance or a personal relationship with hospital staff.6 Thus, providing additional education and resources to lower-income patients and eliminating bias among hospital staff would likely help create a more efficient and equitable system. Addressing the medical and non-medical conditions that can increase the risk of a delay in elective surgery will create healthcare systems better equipped to serve their patient populations, even in times of crisis.
References
(1) French, G.; Hulse, M.; Nguyen, D.; Sobotka, K.; Webster, K.; Corman, J.; Aboagye-Nyame, B.; Dion, M.; Johnson, M.; Zalinger, B.; Ewing, M. Impact of Hospital Strain on Excess Deaths during the COVID-19 Pandemic-United States, July 2020-July 2021. Am J Transplant 2022, 22 (2), 654–657. https://doi.org/10.1111/ajt.16645.
(2) Clarkson, J.; Dean, J.; Ward, J.; Komashie, A.; Bashford, T. A Systems Approach to Healthcare: From Thinking to -Practice. Future Healthc J 2018, 5 (3), 151–155. https://doi.org/10.7861/futurehosp.5-3-151.
(3) Koh, W. X.; Phelan, R.; Hopman, W. M.; Engen, D. Cancellation of Elective Surgery: Rates, Reasons and Effect on Patient Satisfaction. cjs 2021, 64 (2), E155–E161. https://doi.org/10.1503/cjs.008119.
(4) Fu, S. J.; George, E. L.; Maggio, P. M.; Hawn, M.; Nazerali, R. The Consequences of Delaying Elective Surgery: Surgical Perspective. Annals of Surgery 2020, 272 (2), e79–e80. https://doi.org/10.1097/SLA.0000000000003998.
(5) Tan, A. L.; Chiew, C. J.; Wang, S.; Abdullah, H. R.; Lam, S. Sw.; Ong, M. Eh.; Tan, H. K.; Wong, T. H. Risk Factors and Reasons for Cancellation within 24 h of Scheduled Elective Surgery in an Academic Medical Centre: A Cohort Study. International Journal of Surgery 2019, 66, 72–78. https://doi.org/10.1016/j.ijsu.2019.04.009.
(6) Becker, J.; Huschak, G.; Petzold, H.-C.; Thieme, V.; Stehr, S.; Bercker, S. Non-Medical Risk Factors Associated with Postponing Elective Surgery: A Prospective Observational Study. BMC Med Ethics 2021, 22 (1), 90. https://doi.org/10.1186/s12910-021-00660-0.
