Cataract surgery cancellations

EFTHYMIOS CHALKIASClinical Fellow in Medical Retina/Vitreoretinal SurgeryZUWASE MWALEMedical studentAMMAR MIRIOphthalmology Consultant

Cataract surgery on-the-day cancellations and optimization of preoperative assessment

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HEALTHpresentation

Cancellations cost approx £911 per patient (Yip, Aly, Raj, 2018)

INTRODUCTION

0.7-1.8% of scheduled elective operations are cancelled in the UK within 24h (NHS, 2017) Surgical cancellations cause psychological pressure on patients & relatives as well as reduce operating theatre efficiency (Arshad et al., 2018) Common causes of cancellations are INR, BP, BM

Retrospective study of cataract surgery cancellations during a 1 year period Data collected from electronic patient database Sample size = 78 Reasons for cancellation reviewed then categorised as avoidable / unavoidable

METHODS AND MATERIALS

Review on-the-day cancellation reasons alongside current pre-op assessment practiceIdentify potentially avoidable cataract surgery cancellations in hopes to reduce these Suggest guideline to reduce cancellation in a specified group

Improve patient outcomes and hospital costs as a result

AIM

High INRHigh BP

Unfit

Not enough beds Not enough staff IOL not available

Equipment/staff issue

LA but patient needed GA Patient wanted LA Further investigation required Missing anaesthetic assessment Cancelled by consultant due to risk Lid repair required

Pre-op assessment issues

Not enough time Overbooked list Operation no longer needed Interpreter needed Patient double booked for another hospital appointment

Admin error

Avoidable reasons

RESULTS

48 patients out of 78 were avoidable causes

All were 1st cancellation 31 were non-avoidable

Pre-hospital Standardized referrals from optometry to surgery, with feedback for better referralsHospital Clinic -Risk-based list planning, defining case complexity, and adequate resources needed for different scenarios -Different list types based on complexity and anesthetist involvement-Identify reliable patients to start lists promptly -Consider specific lists tailored to varied patient needsHospital Pre-Surgery Preparation -Confirm patient attendance, transport, and COVID-19 testing 5 days pre-operation to ensure readiness and avoid last-minute disruptions-Review lists, lens choices, and patient records before surgery to address any issuesHospital Theatre Essentials On-the-day assessments focused on patient health changes, avoiding repetitive checks unless necessary

RCOphth High Flow Cataract Surgery guidelines – relevant highlights

Assessment of whether the health, medications, and allergies of the patient have changed since their pre-assessment.Specific local anaesthetic cataract proforma which is brief and focused only on the required checks for these patients, not determined by the extensive set of “standard” checks required by other operations or those done under GA.

On-the-day nursing assessment

INR

does NOT need to be checked on the day, as long as there is evidence that their anticoagulation is likely to be within its normal therapeutic range.

Blood sugar measurement (BM)

testing NOT needed on the day of surgery unless patient is feeling unwell. This should trigger BM measurement that would guide further management aimed at preventing cancellation wherever possible. Low BM: if <72mg/dl or 4mmol/l: patient should be offered something sweet with the aim to proceed with surgery when BM is normal. High BM: should not result in the cancellation of surgery unless there are concerns about hyperosmolar hyperglycaemic state (levels often over 600mg/dl or 33mmol/l) or ketoacidosis (BM greater than 250mg/dl or 13.9mmol/l with elevated ketones in blood or urine).

Blood pressure

On-the-day measurements often a reflection of patient anxiety. As long as patient has a blood pressure recorded at pre-assessment and/or confirmed by GP to be within the safe level, this does NOT need repeating on the day of surgery.

complications requiring VR surgery are assessed within 24 hours

Handling of complications

There should be a clear understanding of how to manage the flow of the list in the event of a complication or delay: a written process should be in place detailing a locally agreed protocol i.e. use of second theatre, limitations on how much vitrectomy is done, and when and how to cancel other patients. Providers must have internal vitreoretinal surgeons available or a formal agreement and excellent communication channels with nearby vitreoretinal providers to ensure that

-Emphasis on anaesthetic preference in patients -No bed/staff was highest cause of cancellation (17 cases)! -BM second highest and BP 3rd highest -Discuss with consultants before listing certain high-risk patients (i.e. need to book in VR list?) -Make sure IOL is available or ordered for extremes (high or low dioptric power) - alert consultant -Consider RCOphth guidelines

Discussion

Nair et al., 2008 Gave oral nifedipine to patients that presented with systolic BP >200 or diastolic >100 on day of surgery 5mg given regardless of current mx 16/17 patients showed decrease in BP after 30' Surgery was uneventful in all 17 cases Saved over £10,000 for 17 patients

High BP - recommendation

Bamashmus, M., Haider, T. and Al-Kershy, R. (2010) ‘Why is cataract surgery canceled? A retrospective evaluation’, European Journal of Ophthalmology, 20(1), pp. 101–105. doi:10.1177/112067211002000113. Bheemidi, A.R. et al. (2023) Baseline factors and reason for cancellation of elective ophthalmic surgery, Nature News. Available at: https://www.nature.com/articles/s41433-023-02421-2 (Accessed: 12 December 2023). Cochrane Database of Systematic Reviews: All Issues: Cochrane Library (no date) Cochrane Database of Systematic Reviews: all issues | Cochrane Library. Available at: https://www.cochranelibrary.com/cdsr/table-of-contents?volume=2021&issue=5 (Accessed: 12 December 2023). Koushan, M., Wood, L.C. and Greatbanks, R. (2021) ‘Evaluating factors associated with the cancellation and delay of Elective Surgical Procedures: A systematic review’, International Journal for Quality in Health Care, 33(2). doi:10.1093/intqhc/mzab092. Nair, J. et al. (2008) ‘Using low dose oral nifedipine to prevent cancellation of cataract surgery for patients with preoperative hypertension’, Eye, 23(4), pp. 989–990. doi:10.1038/eye.2008.72. Taylor-Rowan, M. et al. (no date) Cochrane Reviews: Cochrane Library, Cochrane Reviews | Cochrane Library. Available at: https://www.cochranelibrary.com/?contentLanguage=eng (Accessed: 12 December 2023). Yıldız Altun, A. et al. (2020) ‘Evaluation of the reasons for the cancellation of elective procedures at Level 3 University Hospital on the day of surgery’, Journal of PeriAnesthesia Nursing, 35(5), pp. 514–517. doi:10.1016/j.jopan.2019.12.008. Yip, I.Y., Samia-Aly, E. and Raj, A. (2018) ‘Current trends of peri-operative Cataract Cancellations Among Consultant Ophthalmologists in the United Kingdom’, Eye, 32(6), pp. 1147–1148. doi:10.1038/s41433-017-0007-x. RCOphth and GIRFT joint guidance on high flow cataract surgery (2021)

REFERENCES

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