Setting the PACE: understanding surgical postponements and cancellations.

Setting the PACE: understanding surgical postponements and cancellations.

Blog by NHS England Judith Hendley, Assistant Director, Elective Recovery and Transformation and Emma McCone, GIRFT National Lead for Preoperative Assessment

It is recognised that across the surgical pathway, on-the-day cancellations (OTDC) are extremely difficult for everyone involved, especially for patients and their families/carers. Perhaps less well recognised and appreciated, until recently, is the challenge of patients having their surgery postponed following their preoperative assessment (POA) as a result of both patient-related and pathway/process factors. These are often largely preventable.

Both can be markers of how well the perioperative pathway is working and raise three key questions:

  • Is there time and space for shared decision-making conversations with each patient about the benefits, risks, alternatives and ‘do-nothing’ options for them?
  • Is early risk stratification, screening and triage taking place to identify patients with underlying health conditions or health behaviour related risk factors for surgery to inform the right type of POA pathway?
  • Are optimisation and intervention pathways accessible and are patients able to benefit from these before surgery?

PACE (Postponement And Cancellations in Elective care) is a collaborative project to gain a better understanding about rates and reasons for postponements and cancellations led by the NIHR Central London Patient Safety Research Collaborative, University College London, the Centre for Research and Improvement at the Royal College of Anaesthetists and NHS England.

Building on the Royal College of Anaesthetists-led Super-SNAP 1 project (a one-week audit of cancellations of surgery in January 2022) and a smaller scale pilot audit of postponements at POA earlier this year, the collaborative is conducting a rapid service evaluation to take place between 11 and 18 November 2024

The postponement component of this audit is designed to be a simple, rapid  evaluation carried out at POA with the aim of generating clinically and operationally important data that we haven’t captured as a national standard before. It has two main aims:

  • Collect an overall national picture of how many patients are postponed at POA for a variety of reasons. We know this impacts on theatre efficiency, excess administration burden for perioperative teams and most importantly leads to patient disappointment especially when a to come in (TCI) date has been given.
  • Look at the reasons for postponements and review if they are related to patient factors or process and pathway challenges to identify the key themes for service improvement.

The cancellations component of this audit  focuses on cancellations within 24 hours of the planned operation date and aims to measure and understand:

  • The number of elective patient procedures cancelled;
  • The urgency of the procedures being cancelled; and
  • The reasons why cancellations are occurring.

There is a dedicated web page for PACE 24 with further information about the project and guidance and resources for local coordinators:

Postponements and Cancellations | NIHR CL PSRC

NHS England already has sign-ups via their networks in many sites, but not all. You can check to see if your site is registered via the PACE Trust clinical leads on the website, which will be regularly updated. If your site is not registered and you or a colleague can help, please contact england.electiverecoverypmo@nhs.net to express interest. 

We recognise the effort and work that goes into taking part in an audit like this for busy clinical and operational staff. However capturing this data in real time highlights the importance of perioperative care and the value this brings to improving and supporting patients preparing for surgery. We would like to share our appreciation and thanks in advance to our local coordinators and all colleagues working across the perioperative pathway for your collaboration in this national audit.

We aim to publish the national findings in early 2025 which will help give a baseline for providers, systems, regions and national teams to collectively collaborate and share best practice while understanding the barriers to successful implementation of early screening, triage and optimisation.