1. Cancellation of Cataract Operation in HKEH: an Audit Dr. Tommy Chan (Resident Hong Kong Eye Hospital)

2. Acknowledgements  Dr. NM Lam  Dr. Amy Wong

3. Introduction  Surgical operations require resources  Cancellation leads to wastage and opportunity cost  This audit aims at reducing cancellation of scheduled cataract operation on the day of surgery

4. Flow ConsultationPAPD Operation day Operation Listing

5. Cataract surgery in the HA  BCVA less than 6/12  Special circumstances Clinical judgment  3 levels Triage system: P I :Urgent case: <3/60 P II: Early case: <6/60, occupational needs Routine case

6. Method  Retrospective study  Elective cataract operation scheduled from Jul 11 to Nov 11  Cataract operation cancelled on the day of operation with reason of cancellation

7. Results Total cataract operation scheduled2829 Cataract operation cancelled119 Cancellation rate4.2% Cataract vs. total operation cancelled 77.3%

8. Reasons for cancellation Poor general conditions63 Absent for operation19 Patient decline operation 16 Poor eye conditions14 Good VA according to surgeon 5 Operation cancelled by anaesthetist 2 Cataract extracted1

9. Not suitable for operation: n = 79 Absent or decline operation: n = 35 No need according to surgeon: n = 6

10. Not suitable for operation PROBLEMS  Operation cancelled by anaesthetist Food intake before operation  Poor eye conditions Blepharitis, conjunctivitis, episcleritis, chalazion  Poor general conditions SOLUTIONS  Information sheet  PAPD education  Self-report system

11. Poor general conditions

12. Poor general condition 1 PROBLEM  Hypertension: Average BP: 212/97 190-259 / 61-129 Average BP at PAPD: 157/71 SOLUTIONS  Case rearrangement for elevated BP detected Resting area  Medication prior to operation: Oral nifedipine

13. Using low dose oral nifedipine to prevent cancellation of cataract surgery for patients with preoperative hypertension Nair et al. Eye (2009) 23, 989 – 990 On the day of surgery, if systolic BP >200 or diastolic >100 mmHg, despite a period of rest, patients were given nifedipine 5 mg orally regardless of existing treatment (not sublingually) Surgery proceeded uneventfully in all 17 cases.

14. Short-acting nifedipine and risk of stroke in elderly hypertensive patients Jung et al. Neurology (2011) 77(13):1229-34. Use of short-acting nifedipine was associated with increased risk of stroke occurrence in elderly hypertensive patients.

15. Poor general condition 2 PROBLEM  High Hstix: Mean Hstix: 22 12-28 More than half (60%) of cases have no blood sugar checked at PAPD because of negative urine sugar SOLUTIONS  Recent HbA1c CMS or blood at PAPD  Routine Hstix checking at PAPD for DM patients  Drug and dietary compliance on date of surgery Reminder call

16. Surgeon preferences in HKEH  Response rate: 80%  Mode BP cutoff SBP: 200 DBP: 100  Use of oral nifedipine: 61%  Mode Hstix cut off 20

17. Poor general condition 3 PROBLEM  Pulmonary problem: All cases have COPD exacerbation on date of surgery Severe coughing, dyspnea SOLUTIONS  Case arrangement Summer period  Assessment of respiratory function the day before operation Reminder call  Bronchodilators on the night or day before operation Reminder call

18. Absent or decline operation PROBLEMS  Absent for operation: Hospitalization, sick, dead  Decline operation: Worry at informed consent (50%), refuse after knowing of guarded prognosis (20%) SOLUTIONS  Self-report system  Information sheet  Emphasis on guarded prognosis in appropriate cases Checkbox at listing form

19. No need according to surgeon PROBLEMS  Good VA: VA or BCVA on operation day: 0.6 VA at operation listing: 0.4 VA at PAPD: 0.4  Cataract extracted: Operation done in private SOLUTIONS  At least pin-hole VA for cataract operation listing  ADL affected Checkbox at listing form  Encourage surgeon to complete operation Exchange cases with good VA to senior surgeons  Self-report system

20. Suggestions Listing for operation Consultation PAPD Date of operation Checkboxes for “Cataract affecting ADL” and “Guarded prognosis explained” Emphasis on Self-report system Special arrangement for COPD patients Routine Hstix for DM patients Reminder call Encourage operation