Why Pediatric Surgeries Get Canceled – PediaCast 610
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Show Notes
Description
Dr Brittany Willer visits the studio as we consider day-of-surgery cancellations. Preparing for surgery is an emotional journey. Parents arrange time off work, children fast overnight, and everyone braces for the day ahead. But what happens when surgery is canceled at the last minute? Why does this happen? How can families reduce the risk? And how can hospitals prepare and support families as surgery day approaches? Tune in for answers!
Topic
Day-of-Surgery Cancellations
Guest
Dr Brittany Willer
Pediatric Anesthesiologist
Nationwide Children’s Hospital
Links
Pediatric Anesthesiology at Nationwide Children’s Hospital
Preparing Your Child for Anesthesia: What to Expect on the Day of the Procedure
Transportation Resources – Ohio Department of Medicaid
Central Ohio Community Resources
Episode Transcript
[Dr Mike Patrick]
This episode of PediaCast is brought to you by Pediatric Anesthesiology at Nationwide Children’s Hospital.
[MUSIC]
[Dr Mike Patrick]
Hello, everyone, and welcome to another episode of PediaCast. We are a pediatric podcast for moms and dads.
This is Dr. Mike, coming to you from the campus of Nationwide Children’s Hospital. We’re in Columbus, Ohio. It’s episode 610.
We’re calling this one, Why Pediatric Surgeries Get Cancelled. I want to welcome all of you to the program. We are so happy to have you with us again.
You know, preparing for surgery can be an emotional journey. Families arrange time off work, children fast overnight, and everyone braces for the day ahead. But what happens when surgery is unexpectedly cancelled after you’ve already arrived at the hospital?
Why does this happen? How often does it occur? And what can families do to reduce the chances?
And just as important, how can hospitals prepare and support children, parents, and families as surgery day approaches? In this episode, we will explore answers to these questions and more. Of course, in our usual PediaCast fashion, we have a terrific guest joining us in the studio to discuss the topic, Dr. Brittany Willer. She is a pediatric anesthesiologist here at Nationwide Children’s Hospital. Before we get to her, I do want to remind you that the information presented in our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
If you’re concerned about your child’s health, be sure to call your healthcare provider. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at PediaCast.org.
So, let’s take a quick break We’ll get Dr. Brittany settled into the studio, and then we will be back to talk about the cancellation of pediatric surgeries. It’s coming up right after this.
[MUSIC]
[Dr Mike Patrick]
Our guest today is Dr. Brittany Willer. She is a pediatric anesthesiologist and director of research for the Department of Anesthesiology and Pain Medicine at Nationwide Children’s Hospital, and she is an associate professor of anesthesiology at The Ohio State University College of Medicine. Dr. Willer studies stressful moments families can experience, such as when a planned surgery does not happen as expected. Her research is helping hospitals understand why day-of-surgery cancellations occur, how social and logistical challenges contribute to missed surgeries, and what we can do to make surgical care more equitable, more efficient, and less stressful for kids and families.
Before we dive in, let’s offer a warm PediaCast welcome to our guest, Dr. Brittany Willer. Thank you for stopping by the studio today.
[Dr Brittany Willer]
Hi. Thanks so much for having me.
[Dr Mike Patrick]
Yeah, I am excited for this conversation. You know, the day of surgery can be really stressful for families. What exactly is a day-of-surgery cancellation, and how does that differ from simply rescheduling a procedure in advance?
[Dr Brittany Willer]
Yeah, a day-of-surgery cancellation is pretty much what it sounds like. It’s a cancellation of an anesthetic, a surgery, or a procedure that is occurring on the same day that it’s scheduled to happen. So, day-of-surgery cancellations can happen before the child comes to the hospital, or sometimes the child never even makes it to the hospital.
The cancellation can be initiated by either the family or, in some cases, the healthcare team for a variety of reasons. But it’s important because everyone and everything is ready for this procedure to happen. The OR is reserved.
The surgery team and the anesthesia team are ready to go. Parents have taken time off work and committed other resources like childcare or transportation to the day. And then it’s canceled.
And this differs from rescheduling a procedure in advance. Say a procedure is scheduled and you realize that you’re going to be out of town. Well, you can call and move that surgery days or weeks in advance.
And resources are easily adjusted or reused. So, all of this really to say that a day-of-surgery cancellation is more than just an inconvenience. It’s a missed opportunity for the child.
It’s a disruption for the family. And it’s healthcare resources that can’t be reused.
[Dr Mike Patrick]
Yeah, yeah. And when you think about, you know, oftentimes, especially for elective procedures, sometimes those are scheduled, you know, a couple months in advance. And so, when it suddenly gets canceled right there at the last minute, that’s an opportunity someone could have gotten in and had their procedure done.
So, it really impacts not only the family whose surgery gets canceled, but the whole system. I was really surprised as I was getting ready for this interview just how common this is. How often do day-of-surgery cancellations happen?
And are families usually surprised when it occurs?
[Dr Brittany Willer]
Yeah. So, across the country, day-of-surgery cancellations happen between 2 to 20 percent of cases. That’s one in five procedures potentially.
That’s a lot. At Nationwide, fortunately, it doesn’t happen that often. It occurs in about 5 percent of cases.
But really, that translates to a couple thousand procedures a year at Nationwide which are being canceled on the day of. You know, so hospitals really kind of view these as inevitable. They’re routine events.
Cancellations happen. But families are taken by surprise because they’re not expecting for all of the planning that was involved to just be suddenly disrupted like that and then to have to potentially do it all over again.
[Dr Mike Patrick]
Yeah, yeah. I will say that the fact that Nationwide children’s rate is 5 percent, which, as you said, is still, you know, thousands of surgeries every year, but we’re doing better than the national average for sure. And congratulations on your work in terms of helping to lower that number.
What are some of the most common medical reasons why a child’s surgery might need to be canceled on the day of surgery?
[Dr Brittany Willer]
Yeah, the most common reason is acute illness. So, think gastroenteritis or, in the case of children, respiratory infections are very common. And, you know, acute illnesses like this can make anesthesia less safe.
New medical conditions can potentially be discovered during a pre-op evaluation like maybe a heart murmur or a rash, things that need a little more attention before it’s safe to undergo anesthesia. A child could have worsening or an uncontrolled condition, like maybe an asthmatic shows up for their surgery and they’re actively wheezing. That’s a child who’s not totally optimized for anesthesia and might be better served having their procedure at another time.
On some occasions, lab results might come back which need attention, or maybe the child would really benefit from seeing a specialist about something. But I want to emphasize that when a surgery or procedure is canceled for a medical reason, the decision really is made in the child’s best interest to make sure that they are safe.
[Dr Mike Patrick]
Yeah. Do you encourage families to reach out to, and then who would you reach out to, if your child, let’s say, has a fever a couple days before their surgery or they start to have a new cough, or their asthma is acting up? Who should they talk to in the days leading up to the surgery to inform the team that that’s happening?
[Dr Brittany Willer]
Yeah, absolutely. Always best to reach out and just give the team a heads up, or in some cases, the team can make a decision to postpone that surgery before it even gets to that day. Probably the best people to call initially is the surgery team, the people that are going to do the procedure.
But also, when it gets closer to the surgery, you’ll have information for the anesthesia department and the pre-anesthesia nurses. And letting them know is very helpful because they’ll often reach out to an anesthesiologist and kind of ask their opinion on whether this needs to be postponed or whether they think the child would be safe to go forward.
[Dr Mike Patrick]
And I would imagine that there’s accommodations made, because you can’t always help when your kid gets sick. I mean, you can certainly sequester them at home for a week or week and a half before the procedure to try to keep them from getting sick, but that’s just not always possible. So, I’m sure that there is understanding on the part of your team, and sometimes these things are inevitable, but the earlier notice that you have, the less disruptive it’s going to be all around, correct?
[Dr Brittany Willer]
Absolutely. And there’s a lot of factors that weigh into whether it’s safe or not to do anesthesia when a child is sick. Sometimes it is safe and other times it’s not, kind of depending on how sick they are and what other conditions they have and even the type of surgery they’re undergoing.
But yes, the earlier we know about it, the earlier we can make decisions that are less disruptive to the family and to the healthcare system.
[Dr Mike Patrick]
Yeah. Now, another possible cause of a day of surgery cancellation is logistics. So maybe your child’s not sick, but perhaps you don’t have transportation to the hospital on that given day.
Or mom has to work and she’s maybe an only parent and she could lose her job if she misses. I mean, there’s all sorts of social things that can come up. What are some of the logistical challenges that you see that can unexpectedly sort of derail surgery day?
[Dr Brittany Willer]
Well, for context, let me say that the exact surgery time isn’t usually set in stone until the day before the procedure. So, you’ll know that your child is having surgery on a Friday, but you won’t know exactly what time until sometime on Thursday. And this presents problems for work schedules or flexibility.
Just as you said, you know, it might not be easy to tell your boss that you have to get your child to an appointment at, you know, 3 o’clock in the afternoon. It also presents problems for competing needs, like maybe there are other kids at home that need to get to appointments or need to be picked up from school. All of those can present challenges for getting your child to their surgical appointment.
Transportation problems are another one. So, this could be a car that breaks down or maybe runs out of gas. Or sometimes we have families that can’t afford gas.
Families might be using public transportation. And we’ve had some families that get to the bus stop only to realize that the bus doesn’t run as early as they would need it to be able to get to surgery on time for early morning procedure. They might have rideshare, which shows up late, or in some cases doesn’t show up at all.
And then there’s misunderstanding fasting instructions. That’s a common one, or misunderstanding which medications to have your child take or to not take before surgery. Difficulty with childcare can be a problem or really anything that leads to a late arrival.
If you arrive late, sometimes we can accommodate that. But sometimes we can’t because there’s so many different procedures and cogs in the wheel that go into getting a child through surgery.
[Dr Mike Patrick]
Yeah, yeah. You know, as you’re describing some of the reasons why this can happen, like I was actually feeling anxious. Like, you know, as you think about, okay, I’m trying to get my kid ready and out the door.
I’m relying on public transportation. I get to the bus stop and I discover that they don’t start running for another hour. And then that’s going to make me late.
Like, I start to feel anxious just hearing that story. So, I can imagine, you know, the anxiety that can be there for parents. So, it’s really a good idea to sort of think through every single step, you know, and check those things out beforehand.
Because you might not, you know, you just assume the bus is there. It’s always been there when I needed it. And you don’t think about it not being there early.
So, it’s probably a good idea to sort of run through your mind what sort of hurdles that you may have to jump over before the day of surgery, right?
[Dr Brittany Willer]
Absolutely. Always best to be prepared and think through these things. I always recommend, you know, read through your preoperative instructions as early as you can.
Don’t wait until the day of the procedure or even the day before the procedure to read through the instructions to get an idea as to what it’s going to take to get your child there for surgery successfully.
[Dr Mike Patrick]
Yeah, yeah. Have you seen that anxiety play out when folks end up showing up? I mean, I’m sure there is emotional impact when a day of surgery cancellation happens, especially if it’s something that maybe a parent felt like they could have controlled.
Again, we’re not placing blame on anyone, but like your child getting a fever, you really mean, you know, you do your best. But if it happens, it happens. But you do feel a little anxiety and guilt even if, you know, it has to be canceled because you weren’t paying attention to the bus schedule.
Do you see that emotional impact? And what do you do about it other than, you know, give them a hug?
[Dr Brittany Willer]
Yeah, absolutely we see it. From the parent’s point of view, these cancellations are very frustrating. You know, they’ve done whatever they needed to do to get there.
That might be, you know, taking time off work or losing out on those wages. They’ve arranged and probably paid for childcare for the other kids. They’ve had their child fast all day long.
So, they’re often very frustrated. Sometimes they do feel guilty. And mostly they just feel exhausted and tired because they know they’re going to have to repeat that entire process weeks or months later when they’re rescheduled.
And then, you know, from the kid’s standpoint, children are often very anxious the days ahead of a procedure. It’s very scary to them. And a day of surgery cancellation just delays this anticipation.
And so, they have to deal with that anxiety for much longer than they were, you know, going to have to originally. For some kids, they’re having their procedure because of pain or a disabling condition. And for those kids, when their procedures are canceled, it means that they have to continue to live with those symptoms.
Or maybe even those symptoms will get worse until their surgery can get rescheduled. Yeah. But I think no matter what, the reason is when these happen, families lose a little bit of trust in the healthcare system.
The healthcare system didn’t show up for them in the way that it needed to get their child through surgery.
[Dr Mike Patrick]
Yeah. So really, the best thing is to try to prevent this from happening as much as we can. And your research shows that these day of surgery cancellations aren’t always random.
What patterns have you discovered? Because if we can understand the patterns, then, you know, at the individual institutional level, you can figure out, well, what do we need to put into place for our population to try to prevent this from occurring? So, what are some of those patterns that you see?
[Dr Brittany Willer]
Yeah. So, my team and I have found that day of surgery cancellations are not evenly distributed across the population. So first of all, Black children tend to have higher rates of day of surgery cancellation than other races and ethnicities.
Children who live in neighborhoods with fewer resources, we call these low opportunity neighborhoods. These are neighborhoods that might have lower quality schools, less green space, environmental exposures, less access to transportation, these kinds of things. Those kids have higher rates of cancellation.
And then children who are from families whose language of care is other than English have higher rates of cancellation, too. We think this is likely reflecting communication barriers. And, you know, the thing is that the same families who are at higher risk for day of surgery cancellation are also more likely to experience repeat cancellations, to have longer delays in ultimately receiving their procedures, or some of them even fall through the cracks altogether and never receive their procedures at all after a cancellation.
[Dr Mike Patrick]
Yeah, yeah. So, there’s really an equity issue here because, you know, you’re having a surgery for a particular reason and you, you know, happen to have a family that has the means to make these things happen and, you know, be able to take off work and have reliable transportation. And then you have another child with the exact same condition that’s just not going to get the care that they need because of these challenges that they face.
So, then what can we do sort of as a system to help families and really raise the equity so that their kids are getting just as good a care as the next kid?
[Dr Brittany Willer]
Yeah, so one of the most important things that a hospital can do is to identify high-risk families early. So, this can start at a primary care visit or a surgical consultation. If it seems like a family might have difficulty getting their child through surgery, if we know early enough, we can help.
The second thing is to improve communication. So, instructions, preoperative instructions, should be written clearly, not just verbal instructions. They need to be written below a sixth grade reading level.
They need to be simple, and they need to be in a family’s preferred language. It’s really important that we’re using a professional interpreter for all interactions with a family whose preferred language is other than English. System improvements are really interesting.
There have been some studies on this, and healthcare systems who provide childcare, healthcare systems that provide transportation, and those that have started using perioperative care navigators have all seen improved appointment attendance. So those are some system options that can really help with this. But I think, you know, the simplest thing to do is every time we interact with a family, whether that’s me as an anesthesiologist, whether that’s a surgeon or a primary care physician or even the nurses when they’re talking to the families, is just to ask them, what do you need?
And then connect them with the appropriate resource for whatever it is that might serve as a barrier for them.
[Dr Mike Patrick]
Yeah. You know, for most families, you get a call from the pre-op nurse to kind of walk you through what you’re going to need the couple of days before surgery and when to not eat or drink anything the evening before. But it almost seems like there are families that need a social worker to reach out and find out what kind of social needs they need to make this happen.
Do you work with social workers? Are they part of the team of helping with these challenges? Yeah.
[Dr Brittany Willer]
So that’s a really important point. And we don’t have a perioperative social worker here at Nationwide. But the individual service lines, so for example, orthopedic surgery or neurosurgery, they usually do have access to a social worker.
And that person can really help to coordinate resources. As we’ve talked about, there’s a lot of things that have to go into a family planning to get their child to the hospital. And with the right amount of time, we do have folks that can help to get all of those moving pieces sorted out so that the child can get there for their procedure.
[Dr Mike Patrick]
Yeah. Yeah. You know, especially if a particular family, maybe it’s happened a couple of times, you can start to form some judgment about families who aren’t getting there.
And, you know, you start to think, well, maybe they’re not putting their child’s health high enough on the priority list. It’s easy to sort of jump to those conclusions. But we also need to have empathy for the challenges that people face that we just take, you know, the others just take for granted that we can do this.
But when you are in a situation where maybe you don’t have an alarm clock at home or maybe you don’t have the best public transportation, I think we all as a society need to have empathy for families in that situation and not jump to conclusions to judge them, but rather help them to be able to, you know, to be present and to make sure those things are getting done. That’s, you know, easy to say, but way more difficult to put into action, as I’m sure your research has shown.
[Dr Brittany Willer]
Yeah, absolutely. You know, I think it’s easy for people to make assumptions as to why a family struggled to get their child to surgery. But, you know, those are assumptions.
That’s not reality. We don’t know what the family is actually going through to what they have to overcome to get to surgery. You know, parents have usually been waiting for months for their child’s procedure, and they want it to happen.
So, motivation is never the issue. And many cancellations are driven by barriers that are just outside their control. Yeah.
[Dr Mike Patrick]
So, for families with a pending surgery, let’s say in the few days following up to surgery, can you kind of walk us through the sort of things that parents ought to be thinking about in order to make this all transition smoothly? Like if you had a how-to guide for parents in the days leading up to surgery, what should be on their minds? Yeah.
[Dr Brittany Willer]
So, parents really need to read over the preoperative instructions early, several days before the actual surgery, and ask questions. If anything is unclear, there are numbers on the instructions that they can call to get more information or get clarification on anything that seems confusing. They should be thinking how they’re going to follow these instructions, especially fasting instructions.
So, at what point do they need to cut their child off from eating breakfast or having a bottle? They really need to think about those things. As we talked about earlier, letting the surgical team know if their child develops an illness is really important.
We can save a lot of frustration if we know that the child is sick beforehand. And then I would suggest arriving early. Whatever they can do to minimize the risk of a cancellation because of a late arrival can be helpful.
And then let us know if barriers arise. Don’t be embarrassed to ask for help. We can help if we know, and if we know early, that there’s going to be a challenge.
[Dr Mike Patrick]
Yeah. All very, very important points. You know, besides just the inconvenience of missed surgery, it really can also impact the child’s health, right, depending on what the surgery is for.
Can you kind of just describe the importance of, you know, having surgical procedures done in a timely fashion? Which I know is sometimes we want them to be more timely than schedules allow.
[Dr Brittany Willer]
Yeah. So, a day of surgery cancellation ultimately means delayed care. And this can lead to a delayed diagnosis.
Think of maybe a child who’s scheduled to have a sedated MRI for headaches. It can mean persistent or progressive symptoms. This could be a child who has sleep apnea and needs to have their tonsils out.
So, their apnea gets worse when they’re waiting to be rescheduled. It can mean greater anesthetic or surgical risk when the procedure ultimately does occur. That kind of depends on what the surgery is and what the child’s medical conditions are.
And then it means missed school and emotional stress for the child. And both of those things can have developmental consequences. And I think the biggest take-home message is that children who are already at greater risk of having poor health outcomes are also the ones who are more likely to experience a day of surgery cancellation.
So that means that those cancellations don’t just delay care. They reinforce and widen already existing health inequities.
[Dr Mike Patrick]
Yeah. And then looking at your research, can you tell us a little bit more about the work that you’re doing to help families and also help hospitals to avoid these day of surgery cancellations?
[Dr Brittany Willer]
Yeah. My team and I are working on some really great stuff right now. One of the things that we have is a predictive model, which aims to help with early identification of the patients who need extra support to get to their procedures.
This kind of goes along with the notion that the earlier we recognize a family who needs help, the more effective we can be at preventing the cancellation. So, we’re kind of testing this out behind the scenes right now, and we’re really excited for when the time comes that we can roll it out and make good use of it. Another thing that we’re working on is communication.
You know, I think we recognize the importance of good communication to prevent day of surgery cancellations. And so, we’re working on developing new communication tools that will deliver better preoperative instructions and that can adapt to a family’s needs. Ultimately, my team and I have a vision to identify and overcome barriers to care so that fewer children experience preventable surgical delays.
And we hope that by reducing cancellations, we can ultimately improve access to surgery, promote more equitable care, and ultimately improve the long-term health outcomes of these kids.
[Dr Mike Patrick]
Yeah, yeah. So very important. Well, this has been a fantastic conversation, and we really appreciate you stopping by.
We’re going to have some informative links in the show notes for everyone. So, if you head over to pediacast.org and find the show notes for this episode, you will find links to Pediatric Anesthesiology at Nationwide Children’s Hospital. Also, an article, Preparing Your Child for Anesthesia, What to Expect on the Day of the Procedure.
We also have some transportation resources from the Ohio Department of Medicaid. And then we have a generic list of community resources for Central Ohio. And please, you know, if you obviously are not in Central Ohio, you’re in a different area of the country, just Google your area and community resources, and you’ll probably be able to find something pretty similar.
I also want to put in a plug for CAP for Kids, which is also just a list of community resources for folks. And I’ll put a link to that in the show notes as well. So once again, Dr. Brittany Willer, Pediatric Anesthesiologist at Nationwide Children’s Hospital. Thank you so much for stopping by and chatting with us today.
[Dr Brittany Willer]
Thank you.
[MUSIC]
[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. We really do appreciate your support. Also, thanks again to our guest this week, Dr. Brittany Willer, Pediatric Anesthesiologist at Nationwide Children’s Hospital. Don’t forget, you can find us wherever podcasts are found. We’re in the Apple Podcast app, Spotify, iHeartRadio, Amazon Music, Audible, YouTube, and most other podcast apps for iOS and Android. Our landing site is pediacast.org.
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Thanks again for stopping by, and until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everybody.
[MUSIC]
