The Western Australian Audit of Surgical Mortality: advancing surgical accountability

Role of Perioperative Surgical Safety Checklist in Reducing Morbidity and Mortality among Patients: An Observational Study

Background:

Safe Surgery Saves Lives. Patient safety is a fundamental of good quality health care, and complications due to the health-care system are well-documented and constitute an important public health problem. Implementation of the checklist in medicine and surgery can help to decrease the risk of adverse events thus can improve patient safety.

Materials and Methods:

After the Institutional Ethical Committee clearance, a total of 500 patients were enrolled and divided into two equal groups. In Group 1 (n = 250), patients underwent surgery before regular implementation of the World Health Organization (WHO) surgical safety checklist (SSC), whereas in Group 2 (n = 250), patients underwent surgery after the WHO SSC was regularly implemented. All the patients were followed up after the surgery, and patients were looked for and compared for the postoperative complications.

Results:

We found that 27 patients (10.8%) in Group 1 and 13 patients (5.2%) in Group 2 developed major wound disruption (P < 0.05). There were 73 patients (29.2%) in Group 1 and 34 patients (13.6%) in the Group 2 who developed an infection of the surgical site (P < 0.05). There were five patients (2%) in Group 1 while none of the patients in Group 2 developed sepsis during the study (P < 0.05).

Conclusions:

We found that implementation of the WHO SSC significantly reduces surgical site infections, major disruptions of the wound, and sepsis.

Mortality pattern in otorhinolaryngology ward: A 5 years retrospective study at an urban tertiary health care center in India

Background

To recognize deaths in the otorhinolaryngology indoor wards, determine the reason behind the mortalities and recommend modifications for betterment of patient care and surgical outcomes.

Method

Data was collected from the mortality register, operation theatre registers, ward registers and case notes of patients declared dead at an urban tertiary health care center in India for a period of 5 years; from January 2012 to December 2016. The data included date of admission, age, sex, educational status, residence, and clinical diagnosis, course of hospital stay and medical cause of death. Data acquired was reviewed and statistically interpreted and presented in graphical and descriptive formats.

Results

6157 admissions were made in otorhinolaryngology (ENT) ward in the 5 year period which included 3969 males and 2188 female patients. 58 deaths were recorded during this period which gives overall death per admission crude mortality rate of 9.42% at an average of about 12 (11.60) deaths per year. The major causes of death were malignancy and septicemia.

Conclusion

The significance of health education, aggressive healthcare campaigns, enhancement of healthcare services and wide accessibility of healthcare services to remote areas has been emphasized. Role of structured study and protocols in the management of serious cases is highlighted along with the need for prompt referral and better interdepartmental cooperation.

The effect of systematic factors on the outcome of trauma laparotomy at a major trauma centre in South Africa

Introduction The aim of this study was to examine and interrogate outcomes in trauma laparotomy in a South African trauma centre to determine whether systematic factors were associated with any discrepancies in outcome. Methods This was a retrospective review of a prospectively entered trauma registry undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. The service has developed a hybrid electronic medical record system (HEMR) where clinical data were captured in real time, which were incorporated this into a database. Results During the period from December 2012 to July 2016, 562 patients underwent emergency laparotomy for trauma and the time and date of surgery was recorded in the HEMR. The mean age of all patients was 29.5 years. There were 256 operations during the weekend or over a public holiday, with a mortality of 8% (n = 21) compared with 306 during the week (mortality of 10%, n = 31). This difference was not statistically significant (P = 0.237). A total of 327 operations were performed at night (18:00 - 08:00) and 235 operations were performed during the day (08:00-18:00 Hours). This was a significant difference in mortality (10% (33) vs 7 % (16), P=0.013) These differences persisted if weekends and public holidays were separated out from normal working days. A total of 188 operations were performed on a week night, with a mortality of 11% (n = 20) and 121 operations were performed during a week day, with a mortality of 8% (n = 10). There were 139 operations on a weekend or public holiday night, with a mortality of 9% (n = 13). A total of 114 operations were performed on a weekend or public holiday day with a mortality of 7% (n = 8). A total of 208 procedures were performed with an consultant present. Of these, 32 patients (15%) died. A total of 368 procedures were performed without a consultant present and 8 (2%) died. Conclusions This study demonstrated a discrepancy in outcome for trauma laparotomy, depending on whether the operation was performed at night or during the day. The reasons for this are unclear, although the lack of consultant presence at night in comparison to during the day appears to be implicated.

Surgical Mortality Audit-lessons Learned in a Developing Nation

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.

Comparison of the Victorian Audit of Surgical Mortality with coronial cause of death

BACKGROUND

The Victorian Audit of Surgical Mortality (VASM) is designed to improve the level of patient care by educating surgeons of areas for improvement in patient management during a surgical admission. Coronial data obtained via the National Coronial Information System were used as an independent method to validate the cause of death as determined by the treating surgeon.

METHOD

The audit prospectively collected 4905 cases that underwent peer assessment and 842 (17%) received an in-depth second-line assessment of which 200 (24%) also underwent a coronial review. Using the coronial assessment as the reference standard, retrospective comparison of coronial diagnoses compared with the audit case outcomes was conducted to determine the overall accuracy of the stated cause of death. The degree of agreement was also analysed based on whether the patient received a full autopsy (internal examination) or an external examination only. The time taken to obtain the coronial and audit case closure was also analysed.

RESULTS

Overall, 195 of the 200 cases had a cause of death identified by the coroner. In 82%, the cause of death reported to VASM by the treating surgeon matched the cause of death determined by the coroner. Concordance was not affected by the extent of post-mortem performed. Time taken to finalize cases was slightly shorter for the coronial process, but unclosed coronial findings resulted in the exclusion of 103 cases.

CONCLUSION

The causes of death data in VASM are accurate when compared with the coronial data independent of whether the coronial investigation included a complete autopsy.

The Australian and New Zealand Audit of Surgical Mortality-birth, deaths, and carriage

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.

Mortality Pattern of Hospitalized Surgical Patients in a Nigerian Tertiary Hospital

There is paucity of reports describing the pattern of surgical mortality in Nigeria. The aim of this study was to determine the incidence and pattern of mortality associated with surgical care in our hospital and to identify areas of improvement. The records of all patients who died after admission for surgical care at the Federal Medical Centre Makurdi between January 2009 and December 2011 were studied retrospectively. Data extracted were patients' demographics, surgical diagnosis, co-morbidity, surgical procedures performed, duration of hospital admission and outcome of treatment. Data were analyzed with SPSS version 17. There were 2,273 admissions into the surgical wards within the study period. During this period, there were 151 deaths with a crude mortality rate of 6.6 %. Ninety-four (62.3 %) patients were males and 57 (37.7 %) were females (M:F = 1.6:1). The age of the patients ranged from 8 days to 95 years with a mean age of 36.1 ± 20.1 years. Acute abdomen (37, 24.5 %), traumatic brain injury (32, 21.2 %) and malignancy (28, 18.5 %) were the commonest surgical diagnosis. Trauma-related deaths accounted for 48 (31.8 %) of all the deaths. Road traffic crash (89.6 %) was the commonest cause of injury. Surgical operations were performed in 75 (49.7 %) of the patients who died, while 76 (50.3 %) did not have any operative intervention. Mortality in patients admitted into the surgical ward was 6.6 %. Trauma-related death was the commonest. Traumatic brain injury, typhoid perforation of the bowel and malignancy were the leading causes of surgical death in our centre.

Oesophagectomy rates and post-resection outcomes in patients with cancer of the oesophagus and gastro-oesophageal junction: a population-based study using linked health administrative linked data

Background

Hospital performance is being benchmarked increasingly against surgical indicators such as 30-day mortality, length-of-stay, survival and post-surgery complication rates. The aim of this paper was to examine oesophagectomy rates and post-surgical outcomes in cancers of the oesophagus and gastro-oesophageal junction and to determine how the addition of gastro-oesophageal cancer to oesophageal cancer impacts on these outcomes.

Methods

Our study population consisted of patients with a primary invasive oesophageal or gastro-oesophageal cancer identified from the NSW Cancer Registry from July 2000-Dec 2007. Their records were linked to the hospital separation data for determination of resection rates and post-resection outcomes. We used multivariate logistic regression analyses to examine factors associated with oesophagectomy and post-resection outcomes. Cox-proportional hazard regression analysis was used to examine one-year cancer survival following oesophagectomy.

Results

We observed some changes in resection rates and surgical outcomes with the addition of gastro-oesophageal cancer patients to the oesophageal cancer cohort. 14.6% of oesophageal cancer patients and 26.4% of gastro-oesophageal cancer patients had an oesophagectomy; an overall oesophagectomy rate of 18.2% in the combined cohort. In the combined cohort, oesophagectomy was associated with younger age, being male and Australian-born, having non-metastatic disease or adenocarcinoma and being admitted in a co-located hospital. Rates of length-of-stay >28 days (20.9% vs 19.7%), 30-day mortality (3.8% vs 2.7%) and one-year survival post-surgery (24.5% vs 23.1%) were similar between oesophageal cancer alone and the combined cohort; whilst 30-day complication rates were 21.5% versus 17.0% respectively. Some factors statistically associated with post-resection complication in oesophageal cancer alone were not significant in the overall cohort. Poorer post-resection outcomes were associated with some patient (older age, birthplace) and hospital-related characteristics (fiscal sector, area health service).

Conclusion

Outcomes following oesophagectomy in oesophageal and gastro-oesophageal cancer patients in NSW are within world benchmarks. Our study demonstrates that the inclusion of gastro-oesophageal cancer did alter some outcomes compared to analysis based solely on oesophageal cancer. As such, care must be taken with analyses based on administrative health data to capture all populations eligible for treatment and to understand the contribution of these subpopulations to overall outcomes.

Mortality and postoperative care after emergency laparotomy

BACKGROUND AND OBJECTIVE

Emergency laparotomy is a common high-risk surgical procedure, but with few outcome data and few data on postoperative care. We aimed to observe mortality within a mixed general surgical population and to explore the potential impact of postoperative care on mortality.

METHOD

A prospective observational study of 124 patients undergoing emergency laparotomy. For all patients, overall mortality and 30-day survival were observed; the predicted death rate (PDR) using the P-POSSUM (Portsmouth predictor - Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity) score and the standardised mortality ratio (SMR) were calculated.

RESULTS

Twenty-four patients died (19.4%); 21 in the first 30 days (16.9%). Twenty-six patients were over 80 years; 10 died (38%). PDR for all patients was 27.4%. The overall SMR was 0.71. Eighty-seven patients (70.2%) followed a postanaesthesia care unit (PACU)-ward pathway (observed mortality 13.6%; mean PDR 15.4%; SMR 0.82). Thirty (24.2%) patients followed an ICU-high dependency unit (HDU)-ward pathway (observed mortality 40.0%; mean PDR 57.2%; SMR 0.69). Six patients (4.8%) followed a PACU-HDU-ward pathway (observed mortality 0%, mean PDR 41.8%, SMR 0.0).

CONCLUSION

Mortality after emergency laparotomy was high and very high in patients more than 80 years of age. The SMR was higher in the PACU-ward pathway compared to the ICU-HDU-ward pathway, suggesting room for improvement in the postoperative period.

Introduction of a prehospital critical incident monitoring system--final results

BACKGROUND

Incident monitoring has been shown to improve patient care and has been adopted widely in the hospital care setting. There are limited data on incident monitoring in the prehospital setting.

HYPOTHESIS

A high-yield, systems-oriented, incident monitoring process can be implemented successfully in a prehospital setting.

METHODS

This prospective, descriptive study outlines the implementation of an incident monitoring process in a regional prehospital setting. Both trauma care and non-trauma care were monitored by a system of anonymous reporting and chart review with debriefing for trauma cases that met major trauma criteria. A committee reviewed all identified cases and coded and logged all incidents and provider recommendations.

RESULTS

There were 454 incidents identified from 230 cases (mean=2.0; 95% CI 1.8-2.1 per case). Anonymous reporting resulted in the identification of 113 incidents from 69 cases (1.6l per case 95% CI=1.4-1.9 per case) Major trauma cases generated 266 incidents from 134 cases (mean=2.0; 95% CI=1.8-2.2 per case), and there were 74 incidents from 26 combined cases (mean=2.9; 95% CI=2.2-3.5 per case). One incident was uncategorized. There were 315 (69.4%) incidents categorized as management problems and 123 (27.1%) were system problems. Prolonged scene time was the most common incident in both management and system categories; 56 (17.8%) and 18 (14.6%) respectively. Mitigating circumstances were found in 111 (24.4%) incidents. The most common incident-related patient outcome was none/near miss (127 (28%)). Incident monitoring most commonly led to generalized feedback (105 (23.1%)) or specific trend analysis (140 (30.8%)). Reports to higher or external bodies occurred in 18 incidents (4.0%).

CONCLUSIONS

The project has been implemented successfully in a regional prehospital settling. The methodology, utilizing a number of incident detection techniques, results in a high yield of incidents over a broad range of error types. The large proportion of "near miss" type incidents allows for incident assessment without demonstrable patient harm. Many incidents were mitigated and the majority represented management-type issues.

The acute surgical unit: improving emergency care

BACKGROUND

Acute care surgical teams are a new concept in the provision of emergency general surgery. Juggling emergency patients around the surgeons' and staffs' elective commitments resulted in semi-emergency procedures routinely being delayed. In an era of increasing financial pressure and the recent introduction of 'safe work hours' practices, the need for a new system which optimized available resources became apparent.

METHODS

At Fremantle Hospital we developed a new system in a concerted effort to minimize the waiting time for general surgical referrals in the Emergency Department, as well as to move semi-urgent operating from the afterhours to the daytime. To analyse the impact of the ASU, data were collected during February, March, and April 2009 and compared with data from the same period in 2008.

RESULTS

Although most referrals were received afterhours, over 85% of operations were performed during working hours compared with 72% in the 2008 period. The time from referral to review decreased from an average of 3.2 h in 2008 to 2.1 h. The mean duration of stay in 2009 was 3 days, which was a reduction from 4.2 days in 2008. An increase in weekend discharge rates was seen after the introduction of the ASU.

CONCLUSION

Despite an increased workload, more referrals were seen and more operations performed during working hours and the time from referral to review was reduced. Higher discharge rates and reduced length of stays increased the availability of beds. We have demonstrated a successful new model which continues to evolve.

Mortality pattern in the surgical wards: a five year review at Federal Medical Centre, Owerri, Nigeria

OBJECTIVE

To identify deaths in the surgical wards, elicit the cause of death and suggest changes that will ensure improved surgical care of patients and outcome.

STUDY DESIGN

Retrospective.

METHODS

Records collected from the theatre operation registers, ward registers and case notes of all patients who were admitted into the surgical wards Federal Medical Centre, Owerri whether elective or emergency from January 1997 to December 2001 were reviewed. Data extracted included date of admission, age, sex, educational status, residence; surgical diagnosis and clinical cause of death Data obtained were analyzed and presented in tabular and descriptive forms.

RESULTS

There were 4583 surgical admissions in all the surgical wards of which males were 2751 and females 1832. During this period there were 419 deaths with an overall death per admission crude mortality rate of 9.14%. The leading causes of death were acute abdomen (22.20%), RTA with head injury (18.14%) and malignances (14.56%). Of the 419 deaths males were 305 (72.79%) and females 114 (27.21%) in a ratio of 2.68:1.

CONCLUSION

Aggressive enlightenment and healthcare campaigns, health education, improvement of healthcare facilities and accessibility to healthcare facilities are highlighted. Structured study in the management of surgical cases is emphasized.

Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems

OBJECTIVES

To sustain an argument that harnessing the natural properties of sociotechnical systems is necessary to promote safer, better healthcare.

METHODS

Triangulated analyses of discrete literature sources, particularly drawing on those from mathematics, sociology, marketing science and psychology.

RESULTS

Progress involves the use of natural networks and exploiting features such as their scale-free and small world nature, as well as characteristics of group dynamics like natural appeal (stickiness) and propagation (tipping points). The agenda for change should be set by prioritising problems in natural categories, addressed by groups who self select on the basis of their natural interest in the areas in question, and who set clinical standards and develop tools, the use of which should be monitored by peers. This approach will facilitate the evidence-based practice that most agree is now overdue, but which has not yet been realised by the application of conventional methods.

CONCLUSION

A key to health system transformation may lie under-recognised under our noses, and involves exploiting the naturally-occurring characteristics of complex systems. Current strategies to address healthcare problems are insufficient. Clinicians work best when their expertise is mobilised, and they flourish in groupings of their own interests and preference. Being invited, empowered and nurtured rather than directed, micro-managed and controlled through a hierarchy is preferable.

Introduction of a prehospital critical incident monitoring system--pilot project results

BACKGROUND

Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited.

PROBLEM

Implementation of an incident monitoring process in a prehospital setting.

METHODS

This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents. A project committee coded and logged all incidents and developed recommendations.

RESULTS

Of 4,429 ambulance responses, 41 cases were analyzed. Twenty-four (58.5%; 95% CI = 49.7-67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03-2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98-1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91-8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04-2.16). A total of 56 of 77 (72.7%; CI = 65.5-80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7-68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4-50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3-49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6-91.3%); in three cases (3.9%; CI = 3.7-4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5-2.7%); three cases resulted in remedial action (3.9%; CI = 3.7-4.1%); four for trend/further observation and analysis responses (5.2%; CI = 4.9-5.5%).

CONCLUSIONS

The pilot project demonstrates successful implementation of an incident monitoring system within a regional, prehospital environment. The combination of incident detecting techniques has a high yield with potential to capture different error types. The large proportion of incidents in the "near miss" category allows analysis of incidents without patient harm. The majority of incidents were system related and many were mitigated by circumstance. The model used is appropriate for ongoing incident monitoring in this setting.

The Hospital Mortality Project: A Tool for Using Administrative Data for Continuous Clinical Quality Assurance

The increasing demand for greater clinical accountability requires development of convenient tools to measure healthcare safety and quality, which are able to provide information contemporaneously. The purpose of this paper is to describe the development of the Hospital Mortality Project, a quality assurance initiative designed to encourage and facilitate clinical accountability for hospital mortality by all clinical departments and clinicians. The project was carried out in two stages. Part 1: After registration of in-hospital patient deaths (1 May 2004 to 31 December 2007), the consultant in charge of patient care was notified and requested to assign the death to a predefined category. This categorisation leads to further investigation as appropriate. Part 2: Hospital administrative data from 1 April 1997 to 31 December 2007 were used to assess a defined index, the Hospital Mortality Index (HMI), which was the expressed in the form of an Attribute Control Chart ( p-CHART) and then used as a performance indicator for hospital departments and clinicians. Summary data are reported to the clinical departments and to the hospital executive via the Quality Improvement Committee on quarterly basis. The clinical review was complete for 2,990 of 3,132 (95%) inpatient deaths till 31 December 2007, while a further 142 (5%) deaths are still in the process of being reviewed as of 7 April 2008. The median age of all the cases was 78 years (IQR 67-86) of which 1,657 (53%) were male. The Poisson regression analysis showed that since 1997 departments with a minimum of 100 deaths in total showed no clinically significant change in HMI over time. The Hospital Mortality Project provides a simple and efficient tool to analyse data for clinical managers to facilitate accountability.

Techniques to monitor for endophthalmitis and other cataract surgery complications

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.

Postoperative complications and mortality in older patients having non-cardiac surgery at three Melbourne teaching hospitals

OBJECTIVE

To determine the incidence of postoperative complications, including 30-day mortality rate, and need for intensive care unit (ICU) admission in older patients after non-cardiac surgery.

DESIGN AND SETTING

Prospective observational study of all patients aged 70 years or older having elective and non-elective, non-cardiac surgery, and staying at least 1 night after surgery in one of three Melbourne teaching hospitals, June to September 2004.

MAIN OUTCOME MEASURES

Postoperative complications and 30-day mortality rate.

RESULTS

1102 consecutive patients were audited in mid 2004; 70% had pre-existing comorbidities. The 30-day mortality rate was 6%; 19% had postoperative complications; and 20% of patients spent at least 1 night in ICU. On multivariate analysis, preoperative factors associated with 30-day mortality included age (odds ratio [OR], 1.09 per year over 70 years; 95% CI, 1.04-1.13; P < 0.001); increasing severity of systemic disease (American Society of Anesthesiologists physical status classification) (OR, 2.53; 95% CI, 1.65-3.86; P < 0.001); and albumin level < 30 g/L (OR, 2.23; 95% CI, 1.09-4.57; P = 0.03). Postoperative factors associated with 30-day mortality were unplanned ICU admission (OR, 3.95; 95% CI, 1.63-9.55; P = 0.003); sepsis (OR, 2.75; 95% CI, 1.17-6.47; P = 0.02); and acute renal impairment (OR, 2.40; 95% CI, 1.06-5.41; P = 0.04). Thoracic surgery was the only surgical specialty significantly associated with mortality (OR, 3.96; 95% CI, 1.44-9.10; P = 0.008) in the multivariate analysis.

CONCLUSION

Older patients having surgery had high rates of comorbidities and postoperative complications, placing considerable demands on critical care services. Patient factors were often stronger predictors of mortality than the type of surgery.

Measurement of the safety and quality of health care

Measurement of safety and quality is fundamental to health care delivery. A variety of measures are needed to fully understand the system; quantitative and qualitative measures are both useful in different ways. Measures need to be valid, reliable, accurate, timely, collectable, meaningful, relevant and important to those who will use them. Clinicians value appropriate measures and respond to them.

Sea change: public reporting and the safety and quality of the Australian health care system

The pursuit of demonstrable safety and quality in health care is an evolving process; there has been notable progress in measuring safety and quality in Australia. The first attempts to measure outcomes were in the field of anaesthesia, while national perinatal mortality reports have provided clinically useful information for many years. Nationwide reporting by the Quality in Australian Health Care Study (QAHCS) in 2005 triggered a more systemic approach to safety and quality. Systemic reporting has begun to emerge in anaesthesia and surgery, for implantable devices, perinatal services and sentinel events; in some jurisdictions, statewide incident data are now reported annually. While debate continues about the issue of individual clinician performance, the real issue is the effectiveness of any reporting system to bring about change in both safety and quality.