Australian and New Zealand Audit of Surgical Mortality: concordance between reported and audited clinical events and delays in management in surgical mortality patients

Concordance between independent first-line assessors in the Western Australian Audit of Surgical Mortality

BACKGROUND

The Western Australian Audit of Surgical Mortality independently reviews deaths under a surgeon. A surgical case form completed by the surgeon is reviewed by a first-line assessor, who in 15% of cases recommends a detailed case note review. The aim of this study was to assess concordance between the original first-line assessment (FLA1) and an additional first-line assessment (FLA2) in relation to the necessity for a second-line assessment (SLA) and recognition of clinical management issues.

METHODS

Experienced assessors (n = 39) representing different specialties were invited to be FLA2 assessors for 170 random cases. They completed identical FLA forms. FLA2 assessors were consultant surgeons with experience of the peer review process. Inter-rater reliability was determined using Gwet's Agreement Coefficient.

RESULTS

A total of 170 FLAs, 158 (92.9%) were returned. Concordance between assessors for recommending an SLA was 70.5% (110 of 156), with an SLA recommended for 16 (10.3%) FLAs but not for 94 (60.3%) FLAs. When there was non-concordance, FLA1 assessors requested more SLAs than did FLA2 assessors (29 [18.6%] vs. 17 [10.9%], respectively). Three adverse events were recorded. In two the assessors differed, with one recording an adverse event and the other recording an area of concern. Additionally, in one instance the assessors differed on the preventability of the event but agreed that it may have contributed to death.

CONCLUSION

Concordance between assessors ranged between 'moderate' (requests for an SLA) through to 'almost perfect' (presence of an adverse event). This suggests the FLA screening process is reliable.

How participation in surgical mortality audit impacts surgical practice

Background

Surgical mortality audit is an important tool for quality assurance and professional development but little is known about the impact of such activity on professional practice at the individual surgeon level. This paper reports the findings of a survey conducted with a self-selected cohort of surgeons in Queensland, Australia, on their experience of participating in the audit and its impact on their professional practice, as well as implications for hospital systems.

Methods

The study used a descriptive cross-sectional survey design. All surgeons registered in Queensland in 2015 (n = 919) were invited to complete an anonymous online questionnaire between September and October 2015. 184 surgeons completed and returned the questionnaire at a response rate of 20%.

Results

Thirty-nine percent of the participants reported that involvement in the audit process affected their clinical practice. This was particularly the case for surgeons whose participation included being an assessor. Thirteen percent of the participants had perceived improvement to hospital practices or advancement in patient care and safety as a result of audit recommendations. Analysis of the open-ended responses suggested the audit experience had led surgeons to become more cautious, reflective in action and with increased confidence in best practice, and recognise the importance of effective communication and clear documentation.

Conclusions

This is the first study to examine the impact of participation in a mortality audit process on the professional practice of surgeons. The findings offer evidence for surgical mortality audit as an effective strategy for continuous professional development and for improving patient safety initiatives.

Potentially preventable deaths in the Victorian Audit of Surgical Mortality

BACKGROUND

The Victorian Audit of Surgical Mortality (VASM) seeks to peer-review all deaths associated with surgical care. This study aimed to examine the mortalities that were determined by the assessor to be potentially preventable, and identify the clinical factors associated with these cases. The assessment of preventability of death and its relationship to management issues at different stages of the admission episode, as opposed to whether the management issue(s) alone were preventable have not been reported previously.

METHODS

Mortality data from the VASM audit since 2007 that completed the peer-review process were retrospectively analysed. Mortalities identified as being preventable were assessed to determine any treatment errors.

RESULTS

A total of 6155 deaths were assessed. Of these, 14.6% (896/6155) were considered to be potentially preventable. Where a second-line assessment was requested (1113/6155, 17.5% cases), 48.3% of these deaths were considered potentially preventable. Elective patient deaths were more likely to be potentially preventable (P < 0.001), especially in public patients. Lack of timely involvement of senior staff, inappropriate treatment delay and failure of problem recognition were factors most frequently associated with potentially preventable mortality.

CONCLUSION

Overall assessment of the preventability of death is unique to VASM. This allows an additional level of analysis to be applied to the circumstances surrounding each mortality and correlation of preventability of death with clinical management issues provides important feedback to surgeons and health-care providers to further improve the safety and quality of care.