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Hansen D, Itotoh F, Helena K, Aitken RJ. Observations from Australia's National Surgical Mortality Audit. World J Surg 2023; 47:3140-3148. [PMID: 37882828 DOI: 10.1007/s00268-023-07205-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Australia is the only country with a national surgical mortality audit. Every Australian surgical mortality is independently and externally reviewed by another surgeon. Extensive educational feedback to surgeons and hospitals is provided through individual patient reviews, state and national symposia and reports, and the distribution of deidentified informative cases. This study reports a longitudinal analysis of the Australian surgical morality audit. METHODS The standardised mortality ratio (SMR) was calculated for each state and territory, nine surgical specialties and nationally. The index year used was 2016, or every 5 years for those states with earlier data. Overall data were analysed in three groups-all deaths, postoperative deaths and non-operative deaths. Overall specialty data were analysed nationally. RESULTS There was a consistent progressive fall, usually in excess of 20%, in the SMR in each state and territory and by specialty when compared to the index year. This was statistically significant nationally (p = 0.044). The same change was observed in earlier years in states with longer-term data. CONCLUSION The period of this observational study has been associated with a nationwide fall in surgical mortality. As other improvements in care will have occurred during this period, the contribution that Australia's national mortality audit made towards the lower surgical mortality cannot be stated with certainty.
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Affiliation(s)
- Dylan Hansen
- Royal Australasian College of Surgeons (RACS), Melbourne, Australia
| | - Franca Itotoh
- Royal Australasian College of Surgeons (RACS), Melbourne, Australia
| | - Kopunic Helena
- Royal Australasian College of Surgeons (RACS), Melbourne, Australia
| | - R James Aitken
- Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia.
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2
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Ashmore DL, Rashid A, Wilson TR, Halliday V, Lee MJ. Identifying malnutrition in emergency general surgery: systematic review. BJS Open 2023; 7:zrad086. [PMID: 37749757 PMCID: PMC10519817 DOI: 10.1093/bjsopen/zrad086] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/27/2023] [Accepted: 07/08/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Emergency general surgery practice is high risk. Surgery is a key part of treatment, with resultant catabolic stress and frequent need for nutritional support. The aim of this study was to examine the current methods of defining and determining malnutrition in emergency general surgery. This included examining the use of nutrition screening and assessment tools and other measures of malnutrition. METHODS MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, trial registries, and relevant journals published between January 2000 and January 2022 were searched for studies of adult patients with any emergency general surgery diagnosis, managed conservatively or operatively, with an assessment of nutritional status. Mixed populations were included if more than 50 per cent of patients were emergency general surgery patients or emergency general surgery results could be separately extracted. Studies in which patients had received nutritional support were excluded. The protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42021285897). RESULTS From 6700 studies screened, 324 full texts were retrieved and 31 were included in the analysis. A definition of malnutrition was provided in 23 studies (75 per cent), with nutritional status being determined by a variety of methods. A total of seven nutrition screening tools and a total of nine 'assessment' tools were reported. To define malnutrition, the most commonly used primary or secondary marker of nutritional status was BMI, followed by albumin level. CONCLUSION Wide variation exists in approaches to identify malnutrition risk in emergency general surgery patients, using a range of tools and nutrition markers. Future studies should seek to standardize nutrition screening and assessment in the emergency general surgery setting as two discrete processes. This will permit better understanding of malnutrition risk in surgical patients.
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Affiliation(s)
- Daniel L Ashmore
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
- Department of General Surgery, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Adil Rashid
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
| | - Timothy R Wilson
- Department of General Surgery, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Doncaster, UK
| | - Vanessa Halliday
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
| | - Matthew J Lee
- School of Medicine and Population Health, Faculty of Health, University of Sheffield, Sheffield, UK
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3
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Ramsay G, Wohlgemut JM, Bekheit M, Watson AJM, Jansen JO. Causes of death after emergency general surgical admission: population cohort study of mortality. BJS Open 2021; 5:6242418. [PMID: 33880531 PMCID: PMC8058150 DOI: 10.1093/bjsopen/zrab021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/19/2021] [Indexed: 02/05/2023] Open
Abstract
Background A substantial number of patients treated in emergency general surgery (EGS) services die within a year of discharge. The aim of this study was to analyse causes of death and their relationship to discharge diagnoses, in patients who died within 1 year of discharge from an EGS service in Scotland. Methods This was a population cohort study of all patients with an EGS admission in Scotland, UK, in the year before death. Patients admitted to EGS services between January 2008 and December 2017 were included. Data regarding patient admissions were obtained from the Information Services Division in Scotland, and cross-referenced to death certificate data, obtained from the National Records of Scotland. Results Of 507 308 patients admitted to EGS services, 7917 died while in hospital, and 52 094 within 1 year of discharge. For the latter, the median survival time was 67 (i.q.r. 21–168) days after EGS discharge. Malignancy accounted for 48 per cent of deaths and was the predominant cause of death in patients aged over 35 years. The cause of death was directly related to the discharge diagnosis in 56.5 per cent of patients. Symptom-based discharge diagnoses were often associated with a malignancy not diagnosed on admission. Conclusion When analysed by subsequent cause of death, EGS is a cancer-based specialty. Adequate follow-up and close links with oncology and palliative care services merit development.
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Affiliation(s)
- G Ramsay
- Department of General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK.,Rowett Institute for Health, Foresterhill, University of Aberdeen, Aberdeen, UK
| | - J M Wohlgemut
- Department of General Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - M Bekheit
- Department of General Surgery, Aberdeen Royal Infirmary, Aberdeen, UK.,Department of Surgery, Elkabbary Hospital, Alexandria, Egypt
| | - A J M Watson
- Department of Surgery, Raigmore Hospital, Inverness, UK
| | - J O Jansen
- Division of Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Ramsay G, Wohlgemut JM, Jansen JO. Twenty-year study of in-hospital and postdischarge mortality following emergency general surgical admission. BJS Open 2019; 3:713-721. [PMID: 31592102 PMCID: PMC6773630 DOI: 10.1002/bjs5.50187] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/06/2019] [Indexed: 12/13/2022] Open
Abstract
Background Emergency general surgery (EGS) patients have a higher mortality than those having elective surgery. Few studies have investigated changes in EGS-associated mortality over time or explored mortality rates after discharge. The aim of this study was to conduct a comprehensive, population-based analysis of mortality in EGS patients over a 20-year time frame. Methods This was a cross-sectional study of all adult EGS admissions in Scotland between 1996 and 2015. Data were obtained from national records. Co-morbidities were defined by Charlson Co-morbidity Index, and operations were coded by OPCS-4 classifications. Linear and multivariable logistic regression models were used to evaluate changes over time. Results Among 1 450 296 patients, the overall inpatient, 30-day, 90-day and 1-year mortality rates were 1·8, 3·8, 6·4 and 12·5 per cent respectively. Mortality was influenced by age at admission, co-morbidity, operation performed and date of admission (all P < 0·001), and improved with time on subgroup analysis by age, co-morbidity and operation status. Medium-term mortality was high: the 1-year mortality rate in patients aged over 75 years was 35·6 per cent. The 1-year mortality rate in highly co-morbid patients decreased from 75·1 to 57·1 per cent over the time frame of the study (P < 0·001). Conclusion Mortality after EGS in Scotland has reduced significantly over the past 20 years. This analysis of medium-term mortality after EGS admission demonstrates strikingly high rates, and postdischarge death rates are higher than is currently appreciated.
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Affiliation(s)
- G Ramsay
- Rowett Institute.,Department of General Surgery Raigmore Hospital Inverness
| | - J M Wohlgemut
- School of Medicine, Medical Sciences and Nutrition University of Aberdeen Aberdeen.,Department of General Surgery Inverclyde Royal Hospital Greenock UK
| | - J O Jansen
- Division of Acute Care Surgery University of Alabama at Birmingham Birmingham Alabama USA
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5
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Pucher PH, Carter NC, Knight BC, Toh SKC, Tucker V, Mercer SJ. Impact of laparoscopic approach in emergency major abdominal surgery: single-centre analysis of 748 consecutive cases. Ann R Coll Surg Engl 2018; 100:279-284. [PMID: 29364016 PMCID: PMC5958847 DOI: 10.1308/rcsann.2017.0229] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2017] [Indexed: 12/25/2022] Open
Abstract
Background Acute abdominal pathology requiring emergency laparotomy is a common surgical presentation. Despite its widespread implementation in other surgical procedures, laparoscopy, rather than laparotomy, is sparingly used in major emergency surgery. This study reports outcomes and impact of rising use of laparoscopy for a single high-volume district general hospital. Methods Data were retrieved from the prospective National Emergency Laparotomy Audit database for a 30-month period. Patient, procedural, and in-hospital outcome data were collated. Temporal trends were assessed and regression analysis conducted for clinical outcomes. Results A total of 748 consecutive cases were recorded. There was an increasing use of laparoscopy over the study period, with 49% of cases attempted laparoscopically in the final six-month interval. Patients treated laparoscopically were at reduced risk of mortality (odds ratio 0.114, 95% confidence interval 0.024 to 0.550) and experienced reduced length of intensive care stay (regression coefficient –1.571, 95% confidence interval –2.625 to –0.517) in multivariate adjusted analysis. Conclusions Laparoscopy is safe and feasible in a large proportion of cases. It is associated with improved outcomes versus laparotomy.
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Affiliation(s)
- PH Pucher
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - NC Carter
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - BC Knight
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - SKC Toh
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - V Tucker
- Department of Anaesthesia, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
| | - SJ Mercer
- Department of General Surgery, Queen Alexandra Hospital, Portsmouth, Hampshire, UK
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6
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Abstract
Surgical audit is a systematic, critical analysis of the quality of surgical care that is reviewed by peers against explicit criteria or recognized standards. It is used to improve surgical practice with the ultimate goal of improving patient care. As the pattern of surgical care is different in the developing world, we analyzed mortalities in a referral medical institute of India to suggest interventions for improvement. An analysis of total admissions, different surgeries, and mortalities over 1 year in an urban referral medical institute of northern India was performed, followed by "peer review" of the mortalities. Mortality rates as outcomes and classification was done to provide comparative results. Of 10,005 surgical patients, 337 (male = 221, female = 116) deaths were reported over 1 year. The overall mortality rate was 3.36%, while mortality in operative cases was 1.76%. Total deaths were classified into (1) Viable: 153 (45%), (2) Nonviable: 174 (52%), and (3) Indeterminate: 10 (3%). Exclusion of the nonviable group reduced the mortality rate from 3.36% to 1.62%. Trauma was the major cause of mortality (n = 235; 70%) as compared to other surgical patients (n = 102; 30%). Increased mortality was also associated with emergency procedures (3.66%) as compared to elective surgeries (0.34%). In conclusion, audit of mortality and morbidity helps in initiating and implementing preventive strategies to improve surgical practice and patient care, and to reduce mortality rates. The mortality and morbidity forum is an important educational activity. It should be considered a mandatory activity in all postgraduate training programs.
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Mak M, Hakeem AR, Chitre V. Pre-NELA vs NELA - has anything changed, or is it just an audit exercise? Ann R Coll Surg Engl 2016; 98:554-559. [PMID: 27502336 PMCID: PMC5392895 DOI: 10.1308/rcsann.2016.0248] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2016] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Following evidence suggestive of high mortality following emergency laparotomies, the National Emergency Laparotomy Audit (NELA) was set up, highlighting key standards in emergency service provision. Our aim was to compare our NHS trust's adherence to these recommendations immediately prior to, and following, the launch of NELA, and to compare patient outcome. METHODS This was a retrospective study of patients who underwent an emergency laparotomy over the course of 6 months - 3 months either side of the initiation of NELA. RESULTS There were 44 patients before the initiation of NELA (pre-NELA, PN group) and 55 in the first 3 months of NELA (N group). We saw a significant increase in the proportion of patients whose decision to operate was made by the consultant: 75.0% in the PN group vs 100% in N group (subsequent data presented in this order) (P < 0.001). The presence of a consultant surgeon (75.0% vs 83.6%, P = 0.321) and anaesthetist (100.0% vs 90.9%, P = 0.064) in theatres were comparable in both groups. Risk stratification based on Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (P-POSSUM) score showed no difference in high-risk patients in both groups (47.7% vs 36.4%, P = 0.306). With the NELA initiative, however, significantly more patients were admitted directly from theatres to the critical care unit, when compared with the pre-NELA period (9.1% vs 27.3%, P = 0.038). This also reflected a significant reduction in unexpected escalation to a higher level of care during this period (10.0% vs 0%, P = 0.036). Significantly more patients had uneventful recovery in the NELA period (52.3 vs 76.4%, P = 0.018), although there was no difference in 30-day mortality between the groups (2.3% vs 7.3%, P = 0.378). CONCLUSIONS This study demonstrated a greater degree of consultant involvement in the decision to operate during NELA. More high-risk patients have been identified preoperatively with diligent risk assessment and, hence, have been proactively admitted to critical care units following laparotomy, which may account for the significant reduction in unexpected escalation to level 2 or level 3 care and thus in overall better patient outcomes.
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Affiliation(s)
- M Mak
- Department of General Surgery, James Paget University Hospital NHS Trust , Great Yarmouth , UK
| | - A R Hakeem
- Department of General Surgery, James Paget University Hospital NHS Trust , Great Yarmouth , UK
| | - V Chitre
- Department of General Surgery, James Paget University Hospital NHS Trust , Great Yarmouth , UK
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8
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Clinical events reported by surgeons assessing their peers. Am J Surg 2016; 212:748-754. [DOI: 10.1016/j.amjsurg.2016.01.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/23/2015] [Accepted: 01/03/2016] [Indexed: 11/24/2022]
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Abstract
OBJECTIVE This article outlines the formation of the Australian and New Zealand Audit of Surgical Mortality (ANZASM) and describes its objectives, governance, functioning and challenges. BACKGROUND A nationwide audit of surgical mortality provides an overview of the leading causes of death in patients who require surgical care. It identifies system or process errors, trends in deficiency of care and helps develop strategies to reduce deaths in the surgical arena. METHODS A standardized tool is used to systematically collect data after every surgical death. Patient details are reviewed by a peer surgeon (and in certain cases a second) to identify issues with patient management and hospital processes. The treating surgeon is then offered confidential feedback and alternate views on patient management. RESULTS From January 2009 to December 2012, 19,096 deaths were reported to the ANZASM. Eighty-six percent of the audited deaths occurred in patients requiring an emergency admission. Significant criticism of patient care was reported in 13% of cases with 16% of clinical issues perceived to be preventable. Western Australia, which first began the audit process, has shown a 30% reduction in surgical deaths. CONCLUSIONS Nationwide mortality audits are a useful and worthwhile exercise. Recommendations identified in the audit reports direct educational workshops and seminars to address these issues. They allow Departments of Health to make informed decisions in their hospitals. Through this model, and the lessons learnt, we would encourage other countries planning to set up their own audits to follow a similar concept.
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10
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Treacy PJ, North JB, Rey-Conde T, Allen J, Ware RS. Outcomes from the Northern Territory Audit of Surgical Mortality: Aboriginal deaths. ANZ J Surg 2014; 85:11-5. [DOI: 10.1111/ans.12896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Peter J. Treacy
- Northern Territory Medical School; Flinders University; Darwin Northern Territory Australia
| | - John B. North
- Northern Territory Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
| | - Therese Rey-Conde
- Northern Territory Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
| | - Jennifer Allen
- Northern Territory Audit of Surgical Mortality; Royal Australasian College of Surgeons; Brisbane Queensland Australia
| | - Robert S. Ware
- School of Population Health; The University of Queensland; Brisbane Queensland Australia
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11
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Raju RS, Guy GS, Field JBF, Kiroff GK, Babidge W, Maddern GJ. Australian and New Zealand Audit of Surgical Mortality: concordance between reported and audited clinical events and delays in management in surgical mortality patients. ANZ J Surg 2014; 84:618-23. [PMID: 24754257 DOI: 10.1111/ans.12642] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Australian and New Zealand Audit of Surgical Mortality (ANZASM) is a nationwide confidential peer review of deaths associated with surgical care. This study assesses the concordance between treating surgeons and peer reviewers in reporting clinical events and delays in management. METHODS This is a retrospective cross-sectional analysis of deaths in 2009 and 2010. Cases that went through the process of submission of details by the surgeon in a structured surgical case form (SCF), first-line assessment (FLA) and a more detailed second-line assessment (SLA) were included. Significant clinical events reported for these patients were categorized and analysed for concordance. RESULTS Of the 11,303 notifications of death to the ANZASM, 6507 (57.6%) were audited and 685 (10.5%) required the entire review process. Nationally, the most significant events were post-operative complications, poor preoperative assessment and delay to surgery or diagnosis. The SCF submissions reported 338 events, as compared with 1009 and 985 events reported through FLA and SLA, respectively (P = 0.01). Treating surgeons and assessors attributed 29-30% of events to factors outside the surgeon's control. Surgeons felt that delay to surgery or diagnosis was a significant event in 6.6% of cases, in contrast to 20% by assessors (P = 0.01). Preoperative management could be improved in 19% of cases according to surgeons, compared with 45 and 36% according to the assessors (P < 0.001). CONCLUSION There is significant discordance between treating surgeons and assessors. This suggests the need for in-depth analysis and possible refinement of the audit process.
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Affiliation(s)
- Ravish S Raju
- Discipline of Surgery, The Queen Elizabeth Hospital, University of Adelaide, Adelaide, South Australia, Australia
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12
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Young JA, Shimi SM, Kerr L, McPhillips G, Thompson AM. Reduction in gastric cancer surgical mortality over 10 years: An adverse events analysis. Ann Med Surg (Lond) 2014; 3:26-30. [PMID: 25568781 PMCID: PMC4268482 DOI: 10.1016/j.amsu.2014.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 02/25/2014] [Accepted: 03/03/2014] [Indexed: 12/15/2022] Open
Abstract
Background The reduction in gastric cancer mortality is due to a reduction in incidence and of surgical mortality. This study was to examine adverse events in patients with gastric cancer dying under surgical care. Methods Adverse events in surgical care were prospectively audited in patients who died of gastric cancer in Scottish hospitals. A cohort retrospective study examining deaths and contributing adverse events was compared for the periods 1996–2000 and 2001–2005. Results Between 1996 and 2005, 1083 patients with gastric cancer died on surgical wards in Scottish hospitals. The annual number of deaths under surgical care fell significantly from an average of 128 deaths per annum in years 1996–2000 to 88 deaths per annum in 2001–2005 (p < 0.001). This occurred in parallel with the decline in gastric cancer incidence over the same period. There was an increase in the proportion of gastric cancer resections carried out in 7 major hospitals in Scotland in the second period of the study (p < 0.001). The mean number of deaths in the group of patients, who had gastric cancer resection and palliative surgery, were significantly lower in the second period of the study In addition, when all patients were considered as a group, the mean number of anaesthetic, critical care, medical management and technical surgery adverse events were significantly lower in the second study period. Conclusion There has been a reduction in deaths and adverse events for patients with gastric cancer under surgical care and this has been associated with surgical subspecialisation in oesophago-gastric cancer surgery.
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Affiliation(s)
- J A Young
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee DD1 9SY, United Kingdom
| | - S M Shimi
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee DD1 9SY, United Kingdom
| | - L Kerr
- Scottish Audit of Surgical Mortality, Cirrus Building, Marchburn Drive, Paisley PA3 2SJ, United Kingdom
| | - G McPhillips
- Scottish Audit of Surgical Mortality, Cirrus Building, Marchburn Drive, Paisley PA3 2SJ, United Kingdom
| | - A M Thompson
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee DD1 9SY, United Kingdom ; Scottish Audit of Surgical Mortality, Cirrus Building, Marchburn Drive, Paisley PA3 2SJ, United Kingdom
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Ferrada P, Anand RJ, Malhotra A, Aboutanos M. Obesity does not increase mortality after emergency surgery. J Obes 2014; 2014:492127. [PMID: 24693419 PMCID: PMC3945179 DOI: 10.1155/2014/492127] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 12/19/2013] [Accepted: 01/09/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The aim of this study is to evaluate the impact of obesity on patient outcomes after emergency surgery. METHODS A list of all patients undergoing emergent general surgical procedures during the 12 months ending in July 2012 was obtained from the operating room log. A chart review was performed to obtain the following data: patient characteristics (age, gender, BMI, and preexisting comorbidities), indication for surgery, and outcomes (pulmonary embolus (PE), deep venous thrombosis (DVT), respiratory failure, ICU admission, wound infection, pneumonia, and mortality). Obesity was defined as a BMI over 25. Comparisons of outcomes between obese and nonobese patients were evaluated using Fischer's exact test. Predictors of mortality were evaluated using logistic regression. RESULTS 341 patients were identified during the study period. 202 (59%) were obese. Both groups were similar in age (48 for obese versus 47 for nonobese, P = 0.42). Obese patients had an increased incidence of diabetes, (27% versus 7%, P < 0.05), hypertension (52% versus 34%, P < 0.05), and sleep apnea (0% versus 5%, P < 0.05). There was a statistically significant increased incidence of postoperative wound infection (obese 9.9% versus nonobese 4.3%, P < 0.05) and ICU admission (obese 58% versus nonobese 42%, P = 0.01) among the obese patients. Obesity alone was not shown to be a significant risk factor for mortality. CONCLUSIONS A higher BMI is not an independent predictor of mortality after emergency surgery. Obese patients are at a higher risk of developing wound infections and requiring ICU admission after emergent general surgical procedure.
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Affiliation(s)
- Paula Ferrada
- Trauma, Critical Care and Emergency Surgery, Virginia Commonwealth University, West Hospital, 15th Floor East, 1200 E. Broad Street, P.O. Box 980454, Richmond, VA 23298, USA
- Department of Surgery, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Rahul J. Anand
- Department of Surgery, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Ajai Malhotra
- Department of Surgery, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Michel Aboutanos
- Department of Surgery, Virginia Commonwealth University, Richmond, VA 23298, USA
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14
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Symons NRA, Moorthy K, Almoudaris AM, Bottle A, Aylin P, Vincent CA, Faiz OD. Mortality in high-risk emergency general surgical admissions. Br J Surg 2013; 100:1318-25. [DOI: 10.1002/bjs.9208] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2013] [Indexed: 11/12/2022]
Abstract
Abstract
Background
There is increasing evidence of variable standards of care for patients undergoing emergency general surgery in the National Health Service (NHS). The aim of this study was to quantify and explore variability in mortality amongst high-risk emergency general surgery admissions to English NHS hospital Trusts.
Methods
The Hospital Episode Statistics (HES) database was used to identify high-risk emergency general surgery diagnoses (greater than 5 per cent national 30-day mortality rate). Adults admitted to English NHS Trusts with these diagnoses between 2000 and 2009 were included in the study. Thirty-day in-hospital mortality was adjusted for patient and hospital factors. Trusts were grouped into high- and low-mortality outliers, and resource availability was compared between high- and low-mortality outlier institutions.
Results
Some 367 796 patients admitted to 145 hospital Trusts were included in the study; the 30-day mortality rate was 15·6 per cent (institutional range 9·2–18·2 per cent). Fourteen and 24 hospital Trusts were identified as high- and low-mortality outlier institutions respectively. Intensive care and high-dependency bed resources, as well as greater institutional use of computed tomography (CT), were independent predictors of reduced mortality (P < 0·001). Low-mortality outlying Trusts had significantly more intensive care beds per 1000 hospital beds (20·8 versus 14·0; P = 0·017) and made significantly greater use of CT (24·6 versus 17·2 scans per bed per year; P < 0·001) and ultrasonography (42·5 versus 30·2 scans per bed per year; P < 0·001).
Conclusion
There is significant variability in mortality risk between hospital Trusts treating high-risk emergency general surgery patients. Equitable access to essential hospital resources may reduce variability in outcomes.
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Affiliation(s)
- N R A Symons
- Clinical Safety Research Unit, Department of Surgery and Cancer, London, UK
| | - K Moorthy
- Clinical Safety Research Unit, Department of Surgery and Cancer, London, UK
| | - A M Almoudaris
- Clinical Safety Research Unit, Department of Surgery and Cancer, London, UK
| | - A Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - P Aylin
- Dr Foster Unit, Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - C A Vincent
- Clinical Safety Research Unit, Department of Surgery and Cancer, London, UK
| | - O D Faiz
- Surgical Epidemiology and Outcome Centre, St Mark's Hospital and Academic Institute, London, UK
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15
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Young JA, Waugh L, McPhillips G, Steele RJC, Thompson AM. Use of the high dependency unit, increased consultant involvement and reduction in adverse events in patients who die after colorectal cancer surgery. Colorectal Dis 2013; 15:824-9. [PMID: 23375051 DOI: 10.1111/codi.12161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 11/11/2012] [Indexed: 01/01/2023]
Abstract
AIM We prospectively audited adverse events for surgical patients with colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events. METHOD Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996 to 2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality. RESULTS In the 10-year study period, 3029 patients with colorectal cancer, mean age 76 (13-105) years, died under surgical care, of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) patients of whom 1030 (34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P = 0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P = 0.009), a 37% fall for surgical care (P = 0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P = 0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P = 0.016). CONCLUSION The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.
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Affiliation(s)
- J A Young
- Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee, UK.
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16
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Young J, Thompson A, Tait I, Waugh L, McPhillips G. Centralization of Services and Reduction of Adverse Events in Pancreatic Cancer Surgery. World J Surg 2013; 37:2229-33. [DOI: 10.1007/s00268-013-2108-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Anglès R, Llinás M, Alerany C, Garcia MV. [Incident reporting system and management of incidents: Implementation and improvement actions derived for patient safety]. Med Clin (Barc) 2013; 140:320-4. [PMID: 23246168 DOI: 10.1016/j.medcli.2012.09.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 09/27/2012] [Accepted: 09/27/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Roser Anglès
- Unidad Funcional para la Seguridad del Paciente, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Young J, Waugh L, McPhillips G, Levack P, Thompson A. Palliative care for patients with gastrointestinal cancer dying under surgical care: A case for acute palliative care units? Surgeon 2013; 11:72-5. [DOI: 10.1016/j.surge.2012.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 07/11/2012] [Accepted: 07/13/2012] [Indexed: 11/29/2022]
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Young J, Shimi S, Waugh L, McPhillips G, Thompson A. Improved short term surgical outcomes in Scotland for oesophageal cancer. Eur J Surg Oncol 2013; 39:131-5. [DOI: 10.1016/j.ejso.2012.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 08/23/2012] [Accepted: 10/04/2012] [Indexed: 11/25/2022] Open
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Barker A, Mengersen K, Morton A. What is the value of hospital mortality indicators, and are there ways to do better? AUST HEALTH REV 2012; 36:374-7. [PMID: 23116606 DOI: 10.1071/ah11132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 05/13/2012] [Indexed: 11/23/2022]
Abstract
Monitoring hospital performance using patient safety indicators is one of the key components of healthcare reform in Australia. Mortality indicators, including the hospital standardised mortality ratio and deaths in low mortality diagnosis reference groups have been included in the core national hospital-based outcome indicator set recommended for local generation and review and public reporting. Although the face validity of mortality indicators such as these is high, an increasing number of studies have demonstrated that there are concerns regarding their internal, construct and criterion validity. Use of indicators with poor validity has the consequence of potentially incorrectly classifying hospitals as performance outliers and expenditure of limited hospital staff time on activities which may provide no gain to hospital quality and safety and may in fact cause damage to morale. This paper reviews the limitations of current approaches to monitoring hospital quality and safety performance using mortality indicators. It is argued that there are better approaches to improving performance than monitoring with mortality indicators generated from hospital administrative data. These approaches include use of epidemiologically sound, clinically relevant data from clinical-quality registries, better systems of audit, evidence-based bundles, checklists, simulators and application of the science of complex systems.
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Affiliation(s)
- Anna Barker
- Centre of Research Excellence in Patient Safety, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, VIC. 3004, Australia
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21
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Wong THI, Guy G, Babidge W, Maddern GJ. Impact of consultant operative supervision and surgical mortality in Australia. ANZ J Surg 2012; 82:895-901. [DOI: 10.1111/j.1445-2197.2012.06310.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Teresa Hoi Ian Wong
- Discipline of Surgery; University of Adelaide and The Queen Elizabeth Hospital; Adelaide; South Australia; Australia
| | - Gordon Guy
- Australian Safety and Efficacy Register of New Interventional Procedures - Surgical; Royal Australasian College of Surgeons; Adelaide; South Australia; Australia
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22
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Godény S. [Quality assurance and quality improvement in medical practice. Part 3: Clinical audit in medical practice]. Orv Hetil 2012; 153:174-83. [PMID: 22275732 DOI: 10.1556/oh.2012.29293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The first two articles in the series were about the definition of quality in healthcare, the quality approach, the importance of quality assurance, the advantages of quality management systems and the basic concepts and necessity of evidence based medicine. In the third article the importance and basic steps of clinical audit are summarised. Clinical audit is an integral part of quality assurance and quality improvement in healthcare, that is the responsibility of any practitioner involved in medical practice. Clinical audit principally measures the clinical practice against clinical guidelines, protocols and other professional standards, and sometimes induces changes to ensure that all patients receive care according to principles of the best practice. The clinical audit can be defined also as a quality improvement process that seeks to identify areas for service improvement, develop and carry out plans and actions to improve medical activity and then by re-audit to ensure that these changes have an effect. Therefore, its aims are both to stimulate quality improvement interventions and to assess their impact in order to develop clinical effectiveness. At the end of the article key points of quality assurance and improvement in medical practice are summarised.
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Affiliation(s)
- Sándor Godény
- Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Népegészségügyi Kar, Megelőző Orvostani Intézet Debrecen.
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Mullen R, Scollay JM, Hecht G, McPhillips G, Thompson AM. Death within 48 h – Adverse events after general surgical procedures. Surgeon 2012; 10:1-5. [DOI: 10.1016/j.surge.2011.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 12/28/2010] [Accepted: 01/04/2011] [Indexed: 10/18/2022]
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Aga H, Readhead D, MacColl G, Thompson A. Fall in peptic ulcer mortality associated with increased consultant input, prompt surgery and use of high dependency care identified through peer-review audit. BMJ Open 2012; 2:e000271. [PMID: 22357569 PMCID: PMC3289989 DOI: 10.1136/bmjopen-2011-000271] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Patients with peptic ulceration continue to present to surgeons with complications of bleeding or perforation and to die under surgical care. This study sought to examine whether improved consultant input, timely interventions and perioperative care could reduce mortality from peptic ulcer. DESIGN Prospective collection of peer-review mortality data using Scottish Audit of Surgical Mortality methodologies (http://www.SASM.org) and analysed using SPSS. SETTING Secondary care; all hospitals in Scotland, UK, admitting surgical patients over 13 years (1994-2006). PARTICIPANTS 42 736 patients admitted (38 782 operative and 3954 non-operative) with peptic ulcer disease; 1952 patients died (1338 operative and 614 non-operative deaths) with a diagnosis of peptic ulcer. PRIMARY AND SECONDARY OUTCOME MEASURES Adverse events; consultant presence at operation, operations performed within 2 h and high dependency/intensive therapy unit (HDU/ITU) use. RESULTS Annual mortality fell from 251 in 1994 to 83 in 2006, proportionately greater than the reduction in hospital admissions with peptic ulcer. Adverse events declined over time and were rare for non-operative patients. Consultant surgeon presence at operation rose from 40.0% in 1994 to 73.4% in 2006, operations performed within 2 h of admission from 10.3% in 1994 to 28.1% in 2006 and HDU/ITU use from 52.7% in 1994 to 84.4% in 2006. Consultant involvement (p=0.005) and HDU/ITU care (p=0.026) were significantly associated with a reduction in operative deaths. CONCLUSION Patients with complications of peptic ulceration admitted under surgical care should be offered consultant surgeon input, timely surgery and HDU/ITU care.
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Affiliation(s)
- Hiba Aga
- Department of Surgery and Molecular Oncology, University of Dundee, Dundee, UK
| | | | - Gavin MacColl
- Quality Improvement Programme, ISD, NHS NSS, Edinburgh, UK
| | - Alastair Thompson
- Department of Surgery and Molecular Oncology, University of Dundee, Dundee, UK
- Scottish Audit of Surgical Mortality, Paisley, UK
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25
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Scollay JM, Mullen R, McPhillips G, Thompson AM. Mortality associated with the treatment of gallstone disease: a 10-year contemporary national experience. World J Surg 2011; 35:643-7. [PMID: 21181471 DOI: 10.1007/s00268-010-0908-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gallstones remain a common clinical problem requiring skilled operative and nonoperative management. The aim of the present population-based study was to investigate causes of gallstone-related mortality in Scotland. METHODS Surgical deaths were peer reviewed between 1997 and 2006 through the Scottish Audit of Surgical Mortality (SASM); data were analyzed for patients in whom the principal diagnosis on admission was gallstone disease. RESULTS Gallstone disease was responsible for 790/43,271 (1.83%) of the surgical deaths recorded, with an overall mortality for cholecystectomy of 0.307% (176/57,352), endoscopic retrograde cholangiopancreatography (ERCP) of 0.313% (117/37,345), and cholecystostomy of 2.1% (12/578) across the decade. However, the majority of patients who died were elderly (47.6% ≥ 80 years or older) and were managed conservatively. Deaths following cholecystectomy usually followed emergency admission (76%) and were more likely to have been associated with postoperative medical complications (n = 189) than surgical complications (n = 36). DISCUSSION Although cholecystectomy is a relatively safe procedure, patients who die as a result of gallstone disease tend to be elderly, to have been admitted as emergency cases, and to have had co-morbidities. Future combined medical and surgical perioperative management may reduce the mortality rate associated with gallstones.
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Affiliation(s)
- John M Scollay
- Department of Surgery, Ninewells Hospital and Medical School, Dundee D1 9SY, UK.
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26
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Characteristics of patients dying within 30 days of diagnosis of breast or colorectal cancer in Scotland, 2003-2007. Br J Cancer 2011; 104:60-7. [PMID: 21206498 PMCID: PMC3039825 DOI: 10.1038/sj.bjc.6606036] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Recent research has shown that most of the excess risk of death following breast and colorectal cancer in England compared with Norway and Sweden occurs in older age groups during the first year, and especially in the first month of follow-up. The aim of this study was to explore the characteristics of patients dying within 30 days of being diagnosed with one of these cancers in Scotland during 2003-2007. METHODS Anonymised cancer registry records linked to hospital discharge and death records were extracted. The study population was divided into patients who died within 30 days of diagnosis (cases) and those who survived beyond this threshold (controls). Differences in patient-, tumour-, and health service-related characteristics were assessed using the χ(2)-test and logistic regression. RESULTS Patients dying within 30 days were more likely to be elderly and to have experienced emergency admission to non-surgical specialities. Their tumours were less likely to have been verified microscopically, but they appeared more likely to be of high grade and advanced in stage. A substantial number of patients died from causes other than their cancer. CONCLUSION These results suggest that early mortality after a diagnosis of breast or colorectal cancer may be partly due to comorbidity and lifestyle factors, as well as due to more advanced disease. Further research is required to determine the precise explanation for these findings and, in particular, if any potentially avoidable factors such as delays in presentation, referral, or diagnosis exist.
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27
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Morton A, Cook D, Mengersen K, Waterhouse M. Limiting risk of hospital adverse events: avoiding train wrecks is more important than counting and reporting them. J Hosp Infect 2010; 76:283-6. [DOI: 10.1016/j.jhin.2010.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 06/18/2010] [Indexed: 11/15/2022]
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28
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Morton A, Mengersen K, Waterhouse M, Steiner S. Analysis of aggregated hospital infection data for accountability. J Hosp Infect 2010; 76:287-91. [DOI: 10.1016/j.jhin.2010.06.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 06/10/2010] [Indexed: 11/17/2022]
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29
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Morton A, Mengersen K, Waterhouse M, Steiner S, Looke D. Sequential analysis of uncommon adverse outcomes. J Hosp Infect 2010; 76:114-8. [PMID: 20656377 DOI: 10.1016/j.jhin.2010.04.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Accepted: 04/30/2010] [Indexed: 10/19/2022]
Abstract
Sequential analysis of uncommon adverse outcomes (AEs) such as surgical site infections (SSIs) is desirable. Short postoperative lengths of stay (LOS) result in many SSIs occurring after discharge and they are often superficial. Deep and organ space (complex) SSIs occur less frequently but are detected more reliably and are suitable for monitoring wound care. Those occurring post-discharge usually require readmissison and can be counted accurately. Sequential analysis of meticillin-resistant Staphylococcus aureus bacteraemia is also needed. The key to prevention is to implement systems based on evidence, e.g. using 'bundles' and checklists. Regular mortality and morbidity audit meetings are required and these may need to be followed by independent audits. Sequential statistical analysis is desirable for data presentation, to detect changes, and to discourage tampering with processes when occasional AEs occur in a reliable system. Tabulations and cumulative observed minus expected (O-E) charts and funnel plots are valuable, supplemented in the presence of apparent 'runs' of AEs by cumulative sum analysis. Used prospectively, they may enable staff to visualise and detect patterns or shifts in rates and counts that might not otherwise be apparent.
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Affiliation(s)
- A Morton
- Infection Management Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
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30
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Mace ATM, Mackenzie K. Scottish ENT surgical mortality over 13 years. Clin Otolaryngol 2010; 35:234-7. [PMID: 20636748 DOI: 10.1111/j.1749-4486.2010.02139.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A T M Mace
- Otology and Skull Base Surgery Department, St Vincent's Hospital, Sydney, Australia
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31
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32
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Folkesson J, Engholm G, Ehrnrooth E, Kejs AM, Påhlman L, Harling H, Wibe A, Gaard M, Þorvaldur J, Tryggvadottir L, Brewster DH, Hakulinen T, Storm HH. Rectal cancer survival in the Nordic countries and Scotland. Int J Cancer 2009; 125:2406-12. [DOI: 10.1002/ijc.24562] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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33
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McFarlane HJ, van der Horst N, Kerr L, McPhillips G, Burton H. The Scottish Audit of Surgical Mortality: a review of areas of concern related to anaesthesia over 10 years. Anaesthesia 2009; 64:1324-31. [PMID: 19849676 DOI: 10.1111/j.1365-2044.2009.06125.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The Scottish Audit of Surgical Mortality is a voluntary, peer reviewed, critical event analysis of patients who die under the care of consultant surgeons in acute hospitals in Scotland. The anaesthetic contribution to surgical mortality over a 10-year period from 1996 was reviewed. The total number of deaths was 44 230 or 1.5% of all admissions. Forty thousand, eight hundred and ninety-six deaths (92%) were audited. Deaths after elective surgery declined over 10 years. Over 80% of deaths followed emergency admission. The number of deaths where an anaesthetist was present was 16 981 or 0.6% of all admissions. Anaesthetic areas of concern were identified in 8% of deaths. Of these, 43% were related to pre-operative assessment. Anaesthesia also played a part in a further 18% of deaths where decision making was shared with the surgical team. Of these, 41% were related to access to critical care. A further 24% related to communication failures, principally when the operation should not have been done or was unnecessary.
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34
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Mair T. Clinical Governance, Clinical Audit, and the Potential Value of a Database of Equine Colic Surgery. Vet Clin North Am Equine Pract 2009; 25:193-8. [DOI: 10.1016/j.cveq.2009.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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35
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Mattioli G, Avanzini S, Pini-Prato A, Buffa P, Guida E, Rapuzzi G, Torre M, Rossi V, Montobbio G, Rosati U, Jasonni V. Risk management in pediatric surgery. Pediatr Surg Int 2009; 25:683-90. [PMID: 19562352 DOI: 10.1007/s00383-009-2407-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/26/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE To present the experience documented over 1 year of analysis and quality control on surgical complications and organizational accidents. METHODS All children admitted during the study period at our Institution were included in the analysis, which consisted of four phases: (1) definition and standardization of perioperative diagnostic and therapeutic tracks; (2) staff education; (3) documentation and data implementation, and (4) "Morbidity and Mortality" audit. RESULTS Over a 1-year study period, 3,116 children were admitted to our Institution: 2,222 out of 3,116 (71.3%) children underwent a surgical procedure. A total number of 184 complications were recorded in 149 patients. One hundred and seventy-one (92.9%) complications occurred following a surgical procedure. Fifty-six out of 149 complicated patients (37.6%) required a re-operation. Thirty-five out of 184 (19%) complications were classified as organizational. Infection represented the most common complication. All cases of anastomotic dehiscence and perforation, bowel obstruction, and stoma malfunction required reintervention. None of the postoperative bleedings required a second surgical procedure. CONCLUSION Although a proper statistical comparison with literature complication rates is not feasible, our experience confirms the importance of quality-control audit in health care systems. Prolonged observation, long-term follow up, and comparison with previous results will represent our future goal.
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Affiliation(s)
- Girolamo Mattioli
- Pediatric Surgery Department, G. Gaslini Children's Hospital, Largo G. Gaslini, 5, 16147, Genoa, Italy.
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Guru V, Tu JV, Etchells E, Anderson GM, Naylor CD, Novick RJ, Feindel CM, Rubens FD, Teoh K, Mathur A, Hamilton A, Bonneau D, Cutrara C, Austin PC, Fremes SE. Relationship Between Preventability of Death After Coronary Artery Bypass Graft Surgery and All-Cause Risk-Adjusted Mortality Rates. Circulation 2008; 117:2969-76. [PMID: 18541752 DOI: 10.1161/circulationaha.107.722249] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The goal of this study was to determine the relationship between all-cause, risk-adjusted, in-hospital mortality after coronary artery bypass graft surgery and the proportion of preventable in-hospital deaths as a measure of quality of care at an institution level.
Methods and Results—
We conducted a retrospective analysis of 347 randomly selected in-hospital deaths after isolated coronary artery bypass graft surgery at 9 institutions in Ontario over the period of 1998 to 2003. Nurse-abstracted chart summaries were reviewed by 2 experienced cardiac surgeons who were blinded to patient, surgeon, and hospital and used a standardized implicit tool to identify preventable death. A third reviewer reassessed all cases in which the first 2 reviewers disagreed. Rates of preventable deaths were estimated for each hospital and compared with all-cause mortality rates. A structured adverse event audit completed by each surgeon-reviewer was used to identify quality improvement opportunities for the preventable deaths. A total of 111 of 347 deaths (32%) were judged preventable despite a low risk-adjusted mortality range (1.3% to 3.1%) across hospitals. No significant correlation was found between all-cause, risk-adjusted in-hospital mortality rates and the proportion of preventable deaths at the hospital level (Spearman coefficient, −0.42;
P
=0.26). A large proportion of preventable deaths were related to problems in the operating room (86%) and intensive care unit (61%). Many deaths were associated with deviations in perioperative care (32% based on concurrence of 2 reviewers, and another 42% in cases in which 1 reviewer reached that opinion).
Conclusions—
Approximately one third of in-hospital coronary artery bypass graft deaths were judged preventable by surgeon reviewers. All-cause risk-adjusted mortality rates are convenient measures of institutional quality of care but were not correlated with preventable mortality in our jurisdiction. Providers should conduct detailed adverse event audits to drive meaningful improvements in quality.
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Affiliation(s)
- Veena Guru
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Jack V. Tu
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Edward Etchells
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Geoffrey M. Anderson
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - C. David Naylor
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Richard J. Novick
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Christopher M. Feindel
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Fraser D. Rubens
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Kevin Teoh
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Avdesh Mathur
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Andrew Hamilton
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Daniel Bonneau
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Charles Cutrara
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Peter C. Austin
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
| | - Stephen E. Fremes
- From the Institute For Clinical Evaluative Sciences, Toronto (V.G., J.V.T., G.M.A., C.D.N., P.C.A., S.E.F.); Divisions of Cardiac and Vascular Surgery (V.G., S.E.F.) and General Internal Medicine (J.V.T., E.E., C.D.N.), Sunnybrook Health Sciences Centre, the Division of Cardiovascular Surgery, University Health Network (C.M.F.), and the Division of Cardiovascular Surgery, St Michael’s Hospital (D.B.), University of Toronto, Toronto; Division of Cardiac Surgery, London Health Sciences Centre, London
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Ng JQ, Morlet N, Bremner AP, Bulsara MK, Morton AP, Semmens JB. Techniques to monitor for endophthalmitis and other cataract surgery complications. Ophthalmology 2007; 115:3-10. [PMID: 17997486 DOI: 10.1016/j.ophtha.2007.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Revised: 09/13/2007] [Accepted: 09/13/2007] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To report complication incidence to identify outliers more reliably, to provide feedback on performance, and to generate more timely alerts. DESIGN Data from a retrospective entire-population study was used as an example for the charting methods. PARTICIPANTS The Western Australian (WA) Data Linkage System identified all cataract or lens-related procedures undertaken in WA and those operations complicated with endophthalmitis over 20 years from 1980. METHODS Use of risk-adjusted charts to assess complication incidence between hospitals. We compare these with ones that demonstrate individual hospital performance. The latter also adjust for risk and enable reporting at the time of complication rather than after a data collection period. MAIN OUTCOME MEASURE Excessive complication risk (postoperative endophthalmitis). RESULTS Confidence limits allow comparison of hospitals performing different numbers of operations; the 95% Poisson prediction interval was exceeded by 4 possible-outlier hospitals. Case-mix risk adjustment better narrowed them to probable outliers (now only 2 hospitals). However, 2 high-volume nonoutlier hospitals had a short duration of significantly higher risk of endophthalmitis with cumulative sum analysis. Their endophthalmitis numbers were not excessive, and they were not identified as outliers by the other methods. CONCLUSION Simple ranking (or league) tables are not useful enough; someone is always first and last. Chance and circumstance will push all towards the middle with time. Risk-adjusted observed versus expected charting better identifies outliers than a funnel plot. Better still, the use of cumulative sum analysis can help surgeons distinguish between failures due to random processes and those that are associated with problems that require investigation to search for potentially correctable causes.
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Affiliation(s)
- Jonathon Q Ng
- Eye and Vision Epidemiology Research Group, School of Public Health, Curtin University, Perth, Australia
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Mort TC. Anesthesia practice in the emergency department: overview, with a focus on airway management. Curr Opin Anaesthesiol 2007; 20:373-8. [PMID: 17620848 DOI: 10.1097/aco.0b013e32825eabe7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review the need for interdisciplinary collaboration to reduce human and system-related errors in the emergency care setting. RECENT FINDINGS The complexities of airway management are immense and though great strides have been made to improve patient safety, patient injury continues. Airway management is being provided by several specialties who claim responsibility and expertise, sometimes at the exclusion of other specialties. Collaboration among specialties is needed to foster a healthy working relationship as synergism of each department's aptitude and talents may contribute to patient safety. To collaborate effectively with the goal of developing an executable action plan, we must first understand the underlying causation of errors based on human and system-related failures inherent in the medical system. A proactive approach to address these deficiencies is imperative towards improving nearly any aspect of patient care; however, this review will focus specifically on airway management issues in the emergency department. SUMMARY The implications of collaboration are sweeping; not only for optimizing patient care but leading to a 'win-win' situation for medical personnel by improving relationships to better address global needs and optimize the opportunities for collaboration, which is particularly true for urgent/emergent airway management.
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Affiliation(s)
- Thomas C Mort
- Hartford Hospital, University of Connecticut School of Medicine, Hartford, CT, USA.
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Vidal-Trécan G, Christoforov B, Papiernik E. [Mortality-morbidity conferences: evaluation of an intervention to expand their practice in a university hospital]. Presse Med 2007; 36:1378-84. [PMID: 17433617 DOI: 10.1016/j.lpm.2006.12.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2006] [Revised: 12/09/2006] [Accepted: 12/31/2006] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Mortality-morbidity conferences (M&MC) are a recognized technique for evaluating and improving medical practices as well as improving patient safety. OBJECTIVES To describe the current practices for identification and management of care-related adverse events and to evaluate the effectiveness of an intervention to promote M&MC in a university hospital. METHODS The study was designed as a before-and-after survey. In the first part of the survey (September-December 2004), we interviewed the heads of the clinical departments and units in a Parisian university hospital (n=37), using a semi-structured questionnaire. Questions concerned the management of adverse events or errors in their departments or units. The intervention took place during these interviews and consisted of providing information on methods currently available to improve inpatient safety, including broad-based M&MC. The second part involved a structured questionnaire sent by e-mail in December 2005. RESULTS In 2004, 24 of the 37 departments discussed adverse events, 11 kept a register of them, and 9 used M&MC, mostly covering a specific limited segment of their specialty field. Only 2 used structured M&MC that covered the entire specialty field. In 2005, 3 departments had expanded the field covered by their M&MC, and 9 had established M&MC for their entire field (n=12). Six departments had not changed the field of their M&MC and 14 had not introduced it. CONCLUSION Our survey of department heads allowed us both to collect information about the methods they used for managing and evaluating adverse events and to provide information to them. This intervention may have contributed to increasing and improving the use of M&MC.
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Affiliation(s)
- Gwenaëlle Vidal-Trécan
- Groupe hospitalier Cochin Saint Vincent de Paul, AP-HP, Faculté de médecine Paris 5, Université Paris Descartes, Paris.
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Stevenson KS, Gibson SC, MacDonald D, Hole DJ, Rogers PN, Byrne DS, Kingsmore DB. Measurement of process as quality control in the management of acute surgical emergencies. Br J Surg 2007; 94:376-81. [PMID: 17152046 DOI: 10.1002/bjs.5620] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Quality of care measured by adverse events cannot address errors of process that have no adverse outcomes. The aim of this study was to determine whether process could be used to assess quality of care and whether process analysis could be used to assess interventions designed to improve quality. METHODS A single-centre prospective cohort study was performed over 12 weeks in an acute surgical admission unit. Data were collected prospectively for the first 24 h of admission on three aspects of process: documentation, general management and presentation-specific criteria. After a period of observation, the impact of three interventions (active observation, increasing awareness and issuing a job description) on the mean number of process errors per patient (process score) was compared. RESULTS The analysis was based on 566 patients admitted with general surgical pathology. Awareness of being observed failed to improve the process score. Interventions that increased awareness of process reduced the overall process score from 4.79 to 2.38 errors per person (P < 0.001). The mean overall process score in patients with an adverse event was twice that of patients who did not have an adverse event (5.74 (95 per cent confidence interval 4.03 to 7.45) versus 3.43 (3.19 to 3.66)). CONCLUSION Process can be measured objectively and used as a measure of quality of care. Interventions to increase awareness reduced process error rates and adverse events.
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Affiliation(s)
- K S Stevenson
- Department of Surgery, Gartnavel General Hospital, Glasgow, UK
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Papiernik E, Pibarot ML, Vidal-Trécan G, Christoforov B. [Improving patient safety: decreasing adverse events associated with medical care]. Presse Med 2007; 36:1255-61. [PMID: 17408913 DOI: 10.1016/j.lpm.2007.03.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Awareness of the importance of what were previously called iatrogenic accidents is not new, but recent publications have demonstrated the frequency and severity of the accidents and incidents associated with care, which are now known simply as "adverse events". Research has helped us to understand the principal mechanisms underlying them and the circumstances that promote them. It shows that root causes, often linked to the organization of care, should be sought beneath the initial appearance of mistakes. Institutions providing health care must ascertain how to develop a new culture that makes it possible to improve patient safety by implementing new policies, that is, a group of several coordinated measures intended to decrease patient risk. These policies should use accepted techniques, such as reports and appropriate information management for events for which reporting is mandatory, but extended to medical accidents; critical activity analyses must also be used, for comparison with a standard, following the model used for evaluations of professional practices. New techniques are also necessary, such as operational feedback in the form of morbidity-mortality reviews and in-depth analyses of the most serious events. Institutions must establish indicators to prove the effectiveness of this new policy.
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Thornton H. Publish, or not publish? More regulation or better motivation? The enemy is apathy. Int J Surg 2007; 5:1-2. [PMID: 17386906 DOI: 10.1016/j.ijsu.2006.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Accepted: 07/21/2006] [Indexed: 11/15/2022]
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Semmens JB, Mountain JA, Sanfilippo FM, Barraclough JY, McKenzie A, Mukhtar SA, Haynes NS, Aitken RJ. PROVIDERS AND CONSUMERS SUPPORT THE WESTERN AUSTRALIAN AUDIT OF SURGICAL MORTALITY. ANZ J Surg 2006; 76:442-7. [PMID: 16768765 DOI: 10.1111/j.1445-2197.2006.03748.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Western Australian Audit of Surgical Mortality (WAASM) was established in June 2001 to independently peer-review all surgical deaths in Western Australia. The objectives of this study were (i) to evaluate whether participation in the WAASM has influenced clinical and hospital practice; and (ii) to ascertain the support and relevance of the WAASM to surgeons, hospitals and consumers. METHODS Three qualitative questionnaires were designed to evaluate the response of surgeons, hospital administrators and consumers to the WAASM. The outcomes measured included audit participation, value and use of feedback provided, changes to clinical and hospital practice and the future role of the WAASM. RESULTS The key findings were that 138 (73%) of 190 surgeons participating in the WAASM had changed their clinical practice in at least one way, 44 (24%) were aware of changes in hospital practice and 21 (11%) were aware of changes in a colleague's practice. Particular areas where changes in surgical practice had occurred included attention to deep vein thrombosis prophylaxis (81, 44%), increased constructive discussion among peers (78, 42%) and quality of documentation in case notes (68, 37%). All groups supported the continuation of the WAASM. Hospital executives and consumers recommended that the WAASM be included in accreditation. CONCLUSION Surgeons, hospitals and consumers supported the concept of independent peer review of surgical care. They confirmed the ability of audit to influence and change surgical and hospital practice. It strengthens the intention of the Royal Australasian College of Surgeons to extend the WAASM project throughout Australia and New Zealand.
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Affiliation(s)
- James B Semmens
- Centre for Health Services Research, School of Population Health, The University of Western Australia, Crawley, Australia.
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Polk HC, Birkmeyer J, Hunt DR, Jones RS, Whittemore AD, Barraclough B. Quality and safety in surgical care. Ann Surg 2006; 243:439-48. [PMID: 16552193 PMCID: PMC1448959 DOI: 10.1097/01.sla.0000205820.57261.76] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Hiram C Polk
- Department of Surgery, University of Louisville, Louisville, KY 40292, USA.
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Thompson A, Stonebridge PA, Spigelman AD. Surgical accountability: a framework for trust and change. Med J Aust 2006; 183:500. [PMID: 16296959 DOI: 10.5694/j.1326-5377.2005.tb07147.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Accepted: 10/09/2005] [Indexed: 11/17/2022]
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Semmens JB, Aitken RJ, Sanfilippo FM, Mukhtar SA, Haynes NS, Mountain JA. The Western Australian Audit of Surgical Mortality: advancing surgical accountability. Med J Aust 2005; 183:504-8. [PMID: 16296962 DOI: 10.5694/j.1326-5377.2005.tb07150.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2005] [Accepted: 08/22/2005] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe the peer review process of the Western Australian Audit of Surgical Mortality (WAASM), selected outcomes and recommendations. STUDY DESIGN Prospective audit using peer review of all cases of patients who died while under the care of a Western Australian surgeon between 1 January 2002 and 30 June 2004. Audit reviews were current to 30 September 2004. PARTICIPANTS AND SETTING 194 of 202 surgeons participated after a patient died under their care. MAIN OUTCOME MEASURES Surgeon participation, deficiencies of care, deep vein thrombosis (DVT) prophylaxis, futile surgery, postmortem reviews, proportion of operations performed by consultant surgeons. RESULTS The audit process was complete for 896 of 1647 reported deaths (54%), while a further 503 (31%) were still under review at 30 September 2004. Twenty deaths associated with terminal care were excluded from analysis. Median patient age was 80 years, and 799 of the 876 patients who died (91%) had significant comorbidities that increased the risk of death. Deficiencies of care were reported in 179/876 (20%). In 45/876 deaths (5%) the deficiency of care was assessed to have caused the death, and 15 deaths were considered preventable. The risk of a deficiency of care was 1.9 times higher in elective admissions than emergency admissions. Autopsy was undertaken in 83/768 (11%) deaths with complete data. Changes in practice were noted in some areas targeted by WAASM, such as improved DVT prophylaxis. A problem with fluid management was recorded. CONCLUSION Most patients who died were elderly, had complex comorbidities and were treated appropriately. The WAASM has helped to change surgical practice and emphasises the importance of ongoing systematic audit. The participation of surgeons demonstrates their commitment to accountability and supports the intention of the Royal Australasian College of Surgeons to extend the process throughout Australia and New Zealand.
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Affiliation(s)
- James B Semmens
- School of Population Health, M431, The University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia.
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Thompson AM, Ritchie W, Stonebridge PA. Could sequential individual peer reviewed mortality audit data be used in appraisal? Surgeon 2005; 3:288-92. [PMID: 16121777 DOI: 10.1016/s1479-666x(05)80094-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgeons have traditionally monitored mortality as part of their surgical practice. The aim of this study was to determine whether peer review surgical mortality data might be useful in appraisal. METHODS Since 1994, the Scottish Audit of Surgical Mortality (SASM) has performed critical event analysis of deaths under surgical care in Scotland. The anonymised, peer reviewed records of 16 consenting surgeons from a single Trust were reviewed over a three year period (2000-2002). RESULTS Compliance with this voluntary audit was high at 97%. Individual surgeon profiles and comparison with colleagues in similar surgical practice demonstrated adverse events were infrequent and usually due to problems with the process of care rather than individual surgeon errors. The number of case note reviews requested increased significantly over the three years (chi square 9.5, p<0.01) although there was no significant change in the mean number of deaths per surgeon (18) or mean number of adverse events per surgeon (4). CONCLUSIONS The use of sequential individual peer reviewed mortality data for anonymised comparison with local colleagues is now in use in appraisal and has potential for the revalidation process. This could provide reassurance that individual surgeons are complying with the General Medical Council concept of "good clinical practice" and highlight local problems in the process of care.
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Affiliation(s)
- A M Thompson
- Department of Surgery and Molecular Oncology, University of Dundee, Scotland, UK.
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