Better evaluation of patients before operations has reduced last-minute cancellations.

By Sol E Solomon, Singapore Health

An improvement project by nurses has more than halved the last-minute cancellations of elective surgeries at National Heart Centre Singapore (NHCS).

Previously, around 11 per cent of operations at the Cardiothoracic Surgery Unit were unavoidably cancelled. After some changes, cancellations dropped to 5 per cent.

The main change was the setting up of a Pre-Operative Evaluation Clinic run by the cardiothoracic surgery unit. It is staffed by a doctor and a nurse from the unit, two clinic nurses and a physiotherapist.

Together, they do comprehensive pre-admission checks on patients to avoid, as far as possible, any reason to cancel surgeries.

These include the following steps:

  • Blood tests are reviewed a week or two before surgery.
  • A pharmacist will go through patients' medication to ensure they do not self-medicate (for example, use traditional herbal medicine).
  • Patients with loose teeth or poor oral hygiene will be referred to a dentist before surgery.
  • Patients will also be referred for financial counselling to medical social workers if needed.
  • Patients and their families will be shown a pre-operation Intensive Care Unit orientation video so that they better understand the hospitalisation process.

Ms Huang Na, Senior Staff Nurse, NHCS said these checks and the video will help allay patients' anxieties, and ensure they are better prepared for their operations mentally, physically, psychologically and even financially.

"We ensure all pre-op tests are done and results are within the acceptable range. If there are abnormalities, the surgeon will be alerted. The aim of proper and early assessment is to reduce avoidable cancellations. In addition, these patients risk a heart attack while waiting for a new operation date," she said.

In their review of previous cancellations, the team nurses found that a common reason was the inadequate stopping of patients' antiplatelet (blood thinning) medication. Patients scheduled for a heart bypass operation need to stop taking these drugs five to seven days before surgery. This is to clear the drug from the body, or there may be excessive bleeding during or after surgery.

Another reason was patients not having dental clearance for the operation. Oral bacteria is the most common cause of prosthetic valve infections, so patients going for heart valve surgery need a dentist's confirmation that oral infections are not present.

Yet another reason was the need to further investigate patients for whom general anaesthesia could pose a risk.

It was obvious that they had to reduce last-minute cancellations. Booked operating theatres could not be used at short notice, wasting the time of surgeons and others, and frustrating patients and their families, who arrive mentally and psychologically prepared for the operation.

This story was first published in Singapore Health, May-Jun 2018 issue.