Delayed and cancelled orthopaedic surgery; Causes and consequences

Abstract

Extended waiting time, over-booked waiting lists and cancelled and delayed surgical procedures are realities for some patients treated at orthopaedic clinics in Sweden. This situation affects the prioritisation procedures for both emergency and elective surgery and results in even longer waiting lists, not only for planned patients, but for emergencies as well. Methods: Studies I and III were retrospective, observational, single-centre studies with data collected from the hospital’s registers. The aim was to evaluate and describe the number and reasons of delays and cancellations, as well as the waiting times. Study I included 17,625 elective patients over a period of five years and Study III, of 36,017 emergency patients over seven years. The design in Study II was qualitative, aimed to elucidate lived experiences of patients being cancelled of replacement surgery. The 10 interviews were analysed by phenomenological hermeneutic method. Study IV was a systematic review of literature in evidence of factors used to reduce cancellations and delays of orthopaedic procedures. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and the Cochrane Handbook were used as guidelines. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence in the included studies. Results: In Study I, 39% of all patients received at least one, some several cancellations. The most common reasons were various patient-related factors 33%. The median waiting time for those cancelled once was 54 days. In Study III, 24% of all patients scheduled for emergency surgeries were delayed, 80% of these were organisational reasons; 21% of all delays were rescheduled within 24 hours, whilst 41% waited more than 24 hours up to three days. In Study II the comprehensive analyses revealed that the participants described their feelings as not being the chosen one and thereby feeling rejected. And described the cancellation using words with connotations to physical pain, like feeling hurt. The relationship between the participant and the health-care provider appeared to be damaged by the cancellation. Study IV included eight articles. The analysis indicated that the evidence was ranked from low to very low across the different studies. The main limiting factor, also the reason for a decrease in quality, was the designs. Conclusion: In Study I more than a third of the patients had their surgery cancelled and in Study III almost one-fourth had their emergency surgery re-scheduled. One possible way of influencing the high rate of the elective patients’ cancellations, might be to involve them more in the overall planning of the care process. In Study III the results can be interpreted in two ways; first, organisational reasons are avoidable and the potential for improvement is great and, secondly and most importantly, the delays negatively affect patient outcomes. The result in Study II is promising first step towards building a better understanding on patients experiences of having a surgical procedure cancelled. These new evidence gives possibilities to reflect, develop and improve care. Study IV revealed items that might be useful to help reduce the risk of cancelled and delayed orthopaedic procedures.