Patient safety and quality: can anaesthetists play a greater role?

An audit of level two and level three checks of anaesthesia delivery systems performed at three hospitals in South Australia

Anaesthetists may subject patients to unnecessary risk by not checking anaesthetic equipment thoroughly before use. Numerous adverse events have been associated with failure to check equipment. The Australian and New Zealand College of Anaesthetists and anaesthetic delivery system manufactures have made recommendations on how anaesthetic equipment should be maintained and checked before use and for the training required for staff who use such equipment. These recommendations are made to minimise the risk to patients undergoing anaesthesia. This prospective audit investigated the adherence of anaesthetic practitioners to a selection of those recommendations. Covert observations of anaesthetic practitioners were made while they were checking their designated anaesthetic machine, either at the beginning of a day's list or between cases. Structured interviews with staff who check the anaesthetic machine were carried out to determine the training they had received. The results indicated poor compliance with recommendations: significantly, the backup oxygen cylinders' pressure/contents were not checked in 45% of observations; the emergency ventilation device was not checked in 67% of observations; the breathing circuit was not tested between patients in 79% of observations; no documentation of the checks performed was done in any cases; and no assessment or accreditation of the staff who performed these checks was performed. It was concluded that the poor compliance was a system failing and that patient safety might be increased with training and accrediting staff responsible for checking equipment, documenting the checks performed, and the formulation and use of a checklist.

[Perioperative mortality: retrospective cross-sectional study of surgical patients who died between 2004 and 2008 in a tertiary care hospital]

OBJECTIVE

Retrospective analysis of all surgical, early postoperative, and 1-week to detect risk factors.

MATERIAL AND METHODS

A database was established to record clinical, anesthetic, and surgical variables, grouped as preoperative, intraoperative and postoperative factors, and reflecting comorbidities and postoperative complications. Each patient's cause of death was also recorded. Factors influencing mortality during surgery, at 48 hours, and at 1 week were explored by comparing frequencies to detect correlations.

RESULTS

From 2004 to 2008, a total of 809 deaths occurred in the 82412 hospitalized surgical patients. Patients who died during surgery or within 48 hours were younger, had a higher ASA physical status classification, had more cardiovascular risk factors, were less likely to have a diagnosis of cancer, and had spent less time in hospital before the operation. Intraoperative complications, particularly bleeding and cardiac events, were more frequent in patients whose condition was more complex and who died during surgery; that pattern was similar but less marked in patients dying within 48 hours. The patients who died within 48 hours had a higher rate of postoperative hemodynamic complications; the patients who died during the week following surgery had higher rates of septic, neurologic, and respiratory complications.

CONCLUSIONS

Emergency surgery stands out as an important predictor of death during or after surgery; other significant risk factors are postoperative complications.

[Mortality risk factors in surgical patients in a tertiary hospital: a study of patient records in the period 2004-2006]

OBJECTIVE

To determine mortality risk factors in surgical patients.

MATERIAL AND METHOD

A cross-sectional study was carried out on all surgical patients who died while in hospital, over a period of three years (2004-2006). Pre, intra and postoperative variables were analysed. Comparisons were made between patients operated on as emergencies and elective surgery patients. Multivariate analysis was performed on the pre, intra and postoperative variables, using chi(2) of Pearson correlation with a confidence interval of 95%.

RESULTS

Surgery was performed on a total of 38 815 patients, of which 6 326 were emergency procedures and 32 489 as elective. There were 479 deaths registered: 36 occurred in the operating theatre and 443 died after the operation. Arterial hypertension, diabetes mellitus and cancer were significant causes of death. Intraoperative complications were associated with mortality during the surgical procedure. Emergency surgery was an independent risk factor (mortality, 5.5% vs. 0.4% for elective surgery). Sepsis, cardiac and respiratory related deaths were the main risk factors for postoperative death.

CONCLUSIONS

Prevention and adequate treatment of perioperative risk factors should significantly reduce morbidity and mortality rates, mainly in those patient operated as emergencies.