Lea Anne Gardner, PhD, RN
Senior Patient Safety Analyst

Jeff Bomboy, RN, BS
Patient Safety Liaison

Pennsylvania Patient Safety Authority

Corresponding Author
Lea Anne Gardner

Abstract

* Correction (Pa Patient Saf Advis 2016 Jun;13[2]:80.)

Ambulatory surgical facilities (ASFs) in the northeast region of Pennsylvania and the Pennsylvania Patient Safety Authority worked in collaboration to reduce day-of-surgery (DOS) cancellations and transfers to a hospital through the implementation of a nurse-driven preoperative screening and assessment. Implementation of a standardized checklist, initiation of a second preoperative patient phone call, and evaluation of preoperative patient oral and written instructions were interventions implemented in the 18-month collaboration. No-show cancellation rates were 120% higher in patients lacking a preoperative screening and assessment compared with patients screened preoperatively during the postintervention period. Transportation-related and protocol-related DOS cancellations decreased by 28.5% and 22.4%, respectively, in patients receiving a preoperative screening and assessment using a standardized checklist. ASF transfer rates decreased during the postintervention period by 14.7%.

Introduction

A nurse-driven preoperative screening and assessment is a separate clinical evaluation for patients undergoing same-day surgery. This evaluation of the patient’s history and physical, diagnostic tests, and psychosocial information is used to identify the patient’s medical, physical, and psychosocial needs and risks for developing complications or requiring cancellation of same-day surgery.^1-3 Federal, state, and certification regulations for ambulatory surgical facilities (ASFs)^4,5 do not require nurse-driven preoperative screening and assessment, which can lead to variations in who (i.e., clinical versus nonclinical staff) performs the screening, the scope of information ascertained, and the timing of preoperative screening and assessment.⁶ Improving nurse-driven preoperative screening and assessment processes has the potential to increase patient safety and efficiency by identifying appropriate surgical candidates, increasing compliance with preoperative instructions, maximizing revenues, and avoiding surgery delays, cancellations, and transfers.^7-10 Cancellations and transfers represent opportunities to address patient safety concerns (e.g., patients not meeting screening criteria). The ASF transfer rate to an acute care hospital is a patient safety measure that the Centers for Medicare and Medicaid Services will use for public reporting and payment determination for 2014.^11,12

From January 2012 through June 2013, the Pennsylvania Patient Safety Authority conducted an 18-month collaborative improvement project with 11 ASFs in the northeast region of Pennsylvania. All 11 ASFs were actively engaged throughout the collaboration; there was no facility attrition during this 18-month time period. The collaboration focused on improving the preoperative screening and assessment process to reduce cancellations and avoid medical problems requiring transfer to a hospital. The project focused on day-of-surgery (DOS) cancellations for two reasons: (1) preoperative screening on the DOS is the last opportunity to catch medical conditions that would place patients at risk for a complication, and (2) rearranging schedules due to last-minute cancellations creates opportunities for mix-ups with patient names, procedures, or medications.   

The goal of this collaboration was to reduce patient DOS cancellations by 30% and transfers to acute care hospitals by 25% through the implementation of a standardized checklist, evaluation of patient-related preoperative oral and written medical instructions and forms (e.g., preoperative instructions, history forms) using health literacy principles, and institution of a second preoperative phone call to patients. The primary intervention, implementation of a standardized checklist, evaluated clinical and nonclinical aspects of care for every scheduled patient to identify preexisting comorbidities, psychosocial issues (e.g., financial constraints), and screening criteria (e.g., medical clearance not obtained) that place patients at risk for surgical delays due to cancellations or at risk for medical complications leading to transfers.¹³  

The ASF collaboration had three phases: (1) planning, (2) preintervention, and (3) postintervention.

Methods

Planning Phase

The planning phase, January 6, 2012, through June 30, 2012, focused on standardizing definitions for cancellations and transfers, including defining cancellation time periods (e.g., DOS, 24 hours prior to surgery); mapping preoperative screening and assessment processes, including patient scheduling and registration; identifying cancellation and transfer outcome data; and developing event investigation forms to gather detailed information on cancellations and transfers. A focus group of three participating ASFs helped to develop the cancellation and transfer event investigation forms.

Preintervention Phase

Facilities implemented the cancellation and transfer event investigation forms in the preintervention phase, July 1, 2012, through November 30, 2012. Both forms contained questions about the scheduled procedure, the type of and reason for a cancellation or transfer, and contributing factors. The cancellation event form included questions addressing the primary person who cancelled the procedure and time of cancellation (i.e., prior to admission, after admission, or after anesthesia). The transfer event form included questions concerning the time of transfer (i.e., preoperative or postoperative), patient characteristics (i.e., patient’s age, physical status according to the American Society of Anesthesiologists’ classification system,¹⁴ and body mass index¹⁵), and the presence of certain preexisting medical conditions (e.g., cardiovascular disease, neurologic disease, peripheral vascular disease).

The event forms were streamlined two months after implementation by standardizing the list of procedural choices, consolidating the contributing factors, and adding two data fields: (1) event date (i.e., date the cancellation or transfer occurred) and (2) time preoperative screening occurred (e.g., 24 hours prior to surgery, 48 hours prior to surgery). The ASFs received quarterly reports containing deidentified cancellation and transfer rates with benchmarking data, an aggregated list of cancellation event types and occurrence percentages, and an aggregated summary of deidentified transfer event information.   

Postintervention Phase

In December 2012, the postintervention phase began with implementation of the standardized preoperative screening checklist, which is available on the Authority's website. The checklist was developed using evidence-based guidelines,16-18 medical literature,19-29 and questions from the Institute  for Clinical Systems Improvement preoperative evaluation checklist.30 In addition, psychosocial questions regarding the patient’s ambulatory status, mental status (e.g., depression, dementia), and transportation and financial barriers^1,31 were incorporated into the checklist. Each ASF compared the questions from the standardized preoperative screening checklist with their existing preoperative screening checklist and incorporated any missing items.   

During this phase, December 1, 2012, through June 30, 2013, two additional interventions were introduced to the ASFs: initiating a second patient preoperative phone call and incorporating health literacy strategies into patient-staff interactions (e.g., teach-back method, phrasing of questions) and patient-friendly preoperative forms. The second preoperative phone call intervention was based on work done at the University of North Carolina at Chapel Hill.⁸ Haufler and Harrington (2011) found additional opportunities to reduce cancellations related to transportation, preoperative instruction issues (e.g., no food or drink after midnight), and patients not showing up on the DOS by making an additional call to each patient three business days before the scheduled surgery. Kimberly Haufler, BS, RN, provided an educational telephone conference during which she gave an overview of the project and discussed improvements in patient, physician, and employee satisfaction.⁸ When possible, the ASFs made a second phone call to patients to remind them about their upcoming surgery or procedure, review any preoperative instructions, and ascertain whether the patient had questions or needed clarification.   

The third intervention, a health literacy conference call provided by the Authority, addressed health literacy strategies (e.g., use teach-back method, eliminate medical jargon) that the ASFs used to evaluate and implement changes in patient-staff interactions, preoperative instructions, and other patient-related forms (e.g., history). The health literacy materials used in the conference call were adapted from the Hospital and Healthsystem Association of Pennsylvania Hospital Engagement Network health literacy webinar series.³² 

Monthly reports were instituted to provide timely feedback on the implementation of preoperative screening and assessment processes and trends in cancellations or transfers. The monthly reports contained the individual facility’s cancellation and transfer rates (with benchmarking data), individual facility cancellation event types, the time when the preoperative screening and assessment was completed for each DOS cancellation, a month-by-month aggregated table of deidentified transfer data, and the time when the preoperative screening and assessment was completed for each transfer.

Monthly coaching calls were held throughout the project to provide support and data updates and to promote collaborative learning among the facilities. One in-person meeting was held during each phase of the collaboration, and a capstone meeting was held at the end of the project, for a total of four in-person meetings.

A z-test rate ratio comparison test³³ was used to determine statistical changes in cancellation and transfer rates between the preintervention and postintervention phases.

Results

Cancellations

A DOS cancellation was defined as a cancellation of a scheduled procedure or surgery that occurred after 12:01 a.m. on the DOS for any reason. DOS cancellations occurred prior to admission, after admission, and after anesthesia. Cancellations that occurred after admission and after anesthesia were due to medical conditions and represented opportunities to prevent patient harm.

The ASFs achieved a 9.7%* reduction in their DOS cancellation rate, from 29.6 DOS cancellations per 1,000 completed procedures preintervention to 26.8 DOS cancellations per 1,000 completed procedures postintervention. This difference was statistically significant (p value = 0.023). Certain types of DOS cancellation rates had greater reductions in the postintervention phase compared with the preintervention phase: transportation-related DOS cancellations were reduced 28.5%, protocol-related DOS cancellations (e.g., patient screening criteria not met, history and physical missing or incomplete, equipment unavailable or not working) were reduced 22.4%, and no-show DOS cancellations were reduced 17.9%.

An analysis of preoperative screening implementation for DOS cancellations occurring in the postintervention time period showed that 28.4% (n = 234 of 824) of patients with a DOS cancellation had no preoperative screening and that 43.2% (n = 101 of 234) of these patients without a preoperative screening were patients the ASFs were not able to contact prior to the DOS. A closer examination of patients without a preoperative screening identified a greater percentage of no-show cancellations. In DOS cancellations in which an ASF was unable to contact a patient to perform a preoperative screening assessment, 49.5% (n = 50 of 101) were no-shows. In DOS cancellations in which a preoperative screening assessment was not performed, 30.1% (n = 40 of 133) were no-shows. Yet in DOS cancellations in which a preoperative screening assessment was performed, whether 24 hours prior to surgery, 48 hours prior to surgery, or greater than 48 hours prior to surgery, only 10% to 15% of these cancellations were no-shows. A comparison of no-show DOS cancellation rates for patients with versus without a preoperative screening assessment was statistically significant (p value < 0.001).

Transfers

A transfer was defined as an ASF admission requiring an unexpected hospital transfer or admission directly following discharge from the ASF. Transfer rates decreased 14.7%,* from 1.21 transfers per 1,000 admissions preintervention to 1.03 transfers per 1,000 admissions postintervention. This 14.7%* reduction was not statistically significant. A comparison of the ASF collaboration transfer rates and the Ambulatory Surgical Center Quality Collaboration national transfer rates from third quarter 2012 through second quarter 2013 revealed that the Pennsylvania ASFs in the collaboration had lower transfer rates for three of the four quarters measured (see the Figure).

Figure. Transfer Rates: Participating Pennsylvania Ambulatory Surgical Facilities and National Ambulatory Surgical Center Quality Collaboration Facilities

For the ASFs participating in the collaboration, preoperative transfer rates declined 44.7%, from 0.47 transfers per 1,000 admissions preintervention to 0.26 transfers per 1,000 admissions postintervention. This decrease in preoperative transfer rates was not statistically significant. Preoperative transfers comprised patients with medical conditions not likely to be identified during a preoperative telephone screening and assessment (e.g., cardiac arrhythmias, hypertension). Postoperative transfer rates increased by 3.9%,* from 0.75 transfers per 1,000 admissions preintervention to 0.77 transfers per 1,000 admissions postintervention. This increase in postoperative transfer rates was not statistically significant. Postoperative transfers consisted of medical conditions that arose during or as a result of the procedure and required further intervention beyond the scope of the ASF (e.g., respiratory monitoring, aspirations, perforations).

Evaluation of time of preoperative screening for patient transfers occurring in the postintervention phase revealed that 100% (n = 8 of 8) of patients transferred preoperatively received a preoperative screening and assessment, whereas 70.8% (n = 17 of 24) of patients transferred postoperatively received a preoperative screening and assessment.

An examination of 12 patients transferred postoperatively with potential contributing factors revealed that 75% (n = 9) had a preoperative screening and assessment and that 25% (n = 3) had no preoperative screening and assessment. The potential contributing factors for these 12 patients were reported as follows:

• Patient ill on day of surgery (n = 5)^†
• New (i.e., previously undiagnosed) medical issues (n = 2)
• Preexisting medical condition (n = 2)^†
• Surgery more difficult than expected (n = 1)^†
• Patient required additional time to monitor (n = 1)
• Questionable home care (n = 1)

_______________
* Due to rounding of rates to one decimal place for reporting purposes, the percentage change in rates appears differently than expected.

^† One patient was not screened preoperatively.

Discussion

Omitting a nurse-driven preoperative screening and assessment was associated with a high percentage of no-show DOS cancellations. The implementation of a nurse-driven preoperative screening and assessment was associated with reductions in clinical (e.g., protocol-related issues) and nonclinical (e.g., transportation-related issues) DOS cancellations. Several ASFs implemented health literacy principles (e.g., changes in their patient-staff interactions and written forms) that improved patient understanding of ASF expectations. As changes were put into place, expected reductions in areas such as compliance with preoperative instructions were not realized within the postintervention phase.   

Implementation of the second preoperative phone call was achieved intermittently at several ASFs. One ASF reported experiencing a decrease in DOS cancellations when staffing permitted a second preoperative telephone call. The results of this collaboration show that DOS cancellations increased as the time of the preoperative screening was greater from the DOS. Instituting a second preoperative telephone call for patients has the potential to decrease DOS cancellations when the initial preoperative screening and assessment is performed more than 48 hours prior to the DOS.

The monthly conference calls provided opportunities for the ASFs to share their experiences with each other. During the intervention time period, the monthly conference calls provided a setting for the ASFs to discuss and share the challenges they faced completing the preoperative screening and assessment and different successful actions they identified and implemented to address these challenges. Four themes arose with the challenges: staffing and time constraints, communication issues, education issues, and checklist implementation issues. The Table identifies the challenges facing the ASFs and how the ASFs addressed these challenges.

The reduction achieved in patient transfers was less than the goal. Having low numbers of transfers across the ASFs and starting with a transfer rate lower than the national average made it difficult to reach a 25% reduction. Three ASFs had two or fewer transfers throughout the collaboration; specifically, two ASFs had no transfers and one ASF had two transfers.   

Separating transfers by time of occurrence (i.e., preoperative and postoperative) and identifying the reasons for these transfers added a dimension to ASF transfers. Preoperative transfers identified new unanticipated medical conditions (e.g., cardiac arrhythmias, hypertensive conditions) that prevented patients from undergoing surgery or a procedure. While preoperative screening and assessment processes might not identify these types of problems prior to admission, they represent safe patient care. Postoperative transfers arose from problems encountered during the surgery or procedure and represented additional care needed beyond the scope of the ASF. In some cases (e.g., patient ill on the DOS), staff have an opportunity during the preoperative screening and assessment to educate patients on the importance of notifying staff as soon as possible about new medical information that could place them at risk for a surgical complication and transfer to a hospital.

Limitations

Missing data from DOS cancellation event forms in the preintervention period prevented testing differences in the specific types of DOS cancellations between the preintervention and postintervention periods. Very small numbers in work-related and language-barrier-related DOS cancellations (i.e., five or fewer events during each time period) limited inferences about reductions in these types of cancellations. In addition, small numbers of transfer events, coupled with an initial low patient transfer rate at the beginning of the collaboration, limited opportunities to achieve higher reductions and statistically significant results at the end of the collaboration.

Time constraints were one of the greatest challenges during this collaboration. Busy operating room schedules, staffing constraints, and administrative duties, combined with the data demands, made it difficult for the ASFs to implement the three interventions. ASFs were asked to implement changes to their checklist (or in one case, establish a checklist); evaluate, modify, and implement changes to existing patient forms and educational approaches; and institute a second preoperative patient phone call. Each intervention had different requirements of the ASF: leadership review and approval, staff education, updating existing patient forms, and in some cases, changes to administrative policies and procedures. Changing written patient forms required review and approval from administrative leaders that often exceeded the collaboration time frame. In situations in which approval processes exceeded the intervention time, temporary forms or pilot forms were developed by the individual ASFs to be used only during the collaboration.   

The time dedicated to each phase was determined as the objectives for each phase were reached and was agreed upon by the Authority staff and ASF participants. The seven-month postintervention phase placed constraints on establishing new practice patterns.

Conclusion

A nurse-driven preoperative screening and assessment requires a multifaceted approach consisting of a preoperative screening and assessment based on a standardized preoperative checklist; coordination of staff scheduling to provide time to screen patients preoperatively and provide a second preoperative phone call to patients; ongoing communication and education for staff and patients; and patient and staff feedback to improve processes and revise patient forms (e.g., preoperative instructions). This collaboration has shown reductions in DOS cancellations, particularly those related to transportation, protocol, and no-shows, after standardizing the preoperative screening and assessment process. This collaboration also identified an association between not performing a nurse-driven preoperative screening and assessment and no-show cancellations. In addition, reductions in preoperative transfers were noted during the postimplementation phase.   

Selecting appropriate patients for same-day surgery through the implementation of a nurse-driven preoperative screening and assessment can improve patient safety by identifying patients suited for outpatient surgery or procedures; reducing disruptions or delays in the surgery schedule, including disruptions in surgical staffing; and increasing patient accountability (e.g., in arranging for reliable transportation home).

Acknowledgments

Megan Shetterly, RN, MS, senior patient safety liaison, and Denise Martindell, RN, JD, former senior patient safety analyst, worked on this collaboration as team member and team lead, respectively. Jonathan R. Treadwell, PhD, associate director, Evidence-based Practice Center, ECRI Institute, consulted on and contributed to statistical testing for this article.

Notes

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