Arkadiusz Peter Wysocki

Surgical mortality audit data validity.

Surgical audits provide constructive feedback to individual surgeons, hospitals and other healthcare sector professionals. Audits identify deficiencies in treatment processes, evaluate practice trends and detect practice gaps. The credibility and validity of the Queensland Audit of Surgical Mortality (QASM) relies on the accuracy of its data.

Analysis of deficiencies in care following cholecystectomy

INTRODUCTION Failure To Rescue was first defined in patients who died due to a complication following (open) cholecystectomy but research into the relevant factors has been scarce. This study was designed to determine a chronological sequence of deficiencies in care. METHODS Adult patients who died under the care of a surgeon following cholecystectomy in Queensland were identified from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database. RESULTS Not unexpectedly, this is a high-risk patient population: median age of the 48 patients was 74.5 years and the median number of comorbidities and American Society of Anesthesiologists class was 4. Death occurred on postoperative day 6. Most deaths occurred at the end of the week. Over 80% of deaths followed emergency cholecystectomy. In almost half the patients, there were no deficiencies in care. Most common deficiency was during postoperative management (i.e. Failure To Rescue), however, significant deficiencies also arose prior to surgical admission; choice and timing of intervention as well as intraoperative decision-making. CONCLUSION Surgeons who perform cholecystectomy need to be aware of the levels at which deficiencies arise given that many may be preventable.

Surgical care for the aged: a retrospective cross-sectional study of a national surgical mortality audit

Objectives It is assumed that increased age signifies increased surgical care. Few surgical studies describe the differences in care provided to older patients compared with younger patients. We aimed to examine the relationships between increasing age, preoperative factors and markers of postoperative care in adults who died in-hospital after surgery in Australia. Design This retrospective cross-sectional study extracted data from a national surgical mortality audit—an independent, peer-reviewed process. Setting From January 2009 to December 2012, 111 public and 61 private Australian hospitals notified the audit of in-hospital deaths after general anaesthetic surgery or if the patient was admitted under a surgeon. Participants Notified deaths totalled 19 723. We excluded deaths if patients were brain dead, younger than 17 years or never had an operation (n=11 376). From this baseline population, we divided 11 201 deaths into three patient age groups: youngest (17–64 years), medium (65–79 years) and oldest (≥80 years). Outcome measures Univariable and multivariable logistic regression analyses determined the relationships between increasing age and the measured preoperative factors and postoperative variables. Results The baseline populations median age was 78 years (IQR 66–85), 43.7% (4892/11 201) were 80 years or older and 83.4% (9319/11 173) had emergency admissions. The oldest group had increased trauma and emergency admissions than the medium and youngest age groups. Seven of the eight measured markers of postoperative care demonstrate strong and significant relationships with increasing age. The oldest group compared with the medium group had decreased rates of: unplanned returns to theatre (11.2% (526/4709) vs 20.2% (726/3586)), unplanned intensive care admissions (16.3% (545/3350) vs 24.0% (601/2504)) and treatment in intensive care units (59.7% (2689/4507) vs 76.7% (2754/3590)). Conclusions The oldest patients received lower levels of care than the medium and youngest age groups.

Snapshot of trauma laparotomy deaths in Queensland: Trauma laparotomy mortality

Trauma remains the most frequent cause of death for patients under 35 years of age. Head injury and catastrophic haemorrhage account for the majority of early deaths. A trauma laparotomy is often necessary to arrest haemorrhage.

To drain or not to drain: Supreme Court has the answer

In 2010, a 39-year-old underwent elective onlay mesh repair of an incisional hernia. Mesh was removed once infection was diagnosed and the patient subsequently took legal action. In the Supreme Court of New South Wales Justice Campbell posed two questions: (i) ‘whether the standard of care ... required the use of drains’ and (ii) whether ‘taking the precaution would have avoided’ infection. The answers are simple: SOMETIMES and NO, respectively. However, the Justice answered YES to both and found in favour of the plaintiff. The surgeon actively decided against placing a drain based on his assessment of the dead space. Statements from expert witnesses demonstrate clinical equipoise regarding the philosophy of drainage (Table 1). Placing a drain does not ‘avoid’ an infection. There is a lack of evidence drains even reduce the risk of infection. In a randomized trial of onlay repairs, Westphalen found use of a drain had no impact on the incidence of seroma or infection (4/21 versus 5/21 infection with and without drain, respectively; P = 0.7). Retrospectively, White et al. found use of a drain doubled the infection rate (19% with drain versus 10% without drain; P < 0.05). The Cochrane Intervention Review in 2007 (and again in 2013) concluded ‘There is insufficient evidence to determine whether wound drains after incisional hernia repair are associated with better or worse outcomes than no drains’. This judgement should be of great concern to surgeons, medical indemnifiers and our College given the surgeon practiced in line with the evidence base. As drain placement after incisional hernia repair now seems mandatory in Australia (at least in New South Wales), hopefully the next court case will inform surgeons when the drain should be removed. References

How participation in surgical mortality audit impacts surgical practice

BackgroundSurgical mortality audit is an important tool for quality assurance and professional development but little is known about the impact of such activity on professional practice at the individual surgeon level. This paper reports the findings of a survey conducted with a self-selected cohort of surgeons in Queensland, Australia, on their experience of participating in the audit and its impact on their professional practice, as well as implications for hospital systems.MethodsThe study used a descriptive cross-sectional survey design. All surgeons registered in Queensland in 2015 (n = 919) were invited to complete an anonymous online questionnaire between September and October 2015. 184 surgeons completed and returned the questionnaire at a response rate of 20%.ResultsThirty-nine percent of the participants reported that involvement in the audit process affected their clinical practice. This was particularly the case for surgeons whose participation included being an assessor. Thirteen percent of the participants had perceived improvement to hospital practices or advancement in patient care and safety as a result of audit recommendations. Analysis of the open-ended responses suggested the audit experience had led surgeons to become more cautious, reflective in action and with increased confidence in best practice, and recognise the importance of effective communication and clear documentation.ConclusionsThis is the first study to examine the impact of participation in a mortality audit process on the professional practice of surgeons. The findings offer evidence for surgical mortality audit as an effective strategy for continuous professional development and for improving patient safety initiatives.

Increasing number of comorbidities is related to delay to surgical management of a perforated peptic ulcer in patients who died.

Introduction: The incidence of peptic ulcer disease has declined since the introduction of medical therapy, but the rate of perforated peptic ulcer and associated mortality has remained relatively constant. Delay to definitive treatment is known to adversely affect survival. Methods: The Australian and New Zealand Audit of Surgical Mortality (ANZASM) retrospectively collects data on patients who died following surgery. To determine which patient characteristics are associated with delayed (not on the day of admission) surgical treatment of a perforated peptic ulcer, all patients who died in Queensland were identified from the ANZASM database. Results: There were 39 deaths between 2007 and 2013 with a median age was 76 years. The median number of comorbidities was three and American Society of Anaesthesiologists (ASA) class Original Research Article Wysocki et al.; BJMMR, 8(10): 842-847, 2015; Article no.BJMMR.2015.514 843 was 4. Twenty nine patients had operative intervention on the day of admission and 10 underwent surgery later. Those with delayed surgery had a greater number of comorbidities (4 vs. 3; p = 0.016) but did not differ with respect to other demographics compared to those who underwent repair on the day of admission. The reviewing surgeon found no management issues in two thirds of patients. Conclusion: Queensland patients with an increasing number of comorbidities were more likely to have delayed surgical intervention for a perforated peptic ulcer. Surgical delay is a known determinant of survival in patients with a perforated peptic ulcer and surgeons must be especially vigilant in multiply comorbid patients in making the diagnosis and expediting repair.

Mortality from acute appendicitis is associated with complex disease and co-morbidity: Acute appendicitis mortality

Studies evaluating mortality in patients with acute appendicitis focus on the outcomes of appendicectomy alone. We hypothesize this may not be representative of what happens in clinical practice as a small proportion of patients with acute appendicitis undergo procedures other than appendicectomy, for example, caecectomy or right hemicolectomy. To clarify the issue, the authors evaluated Australian adult patients who died with a primary diagnosis of acute appendicitis regardless of whether they underwent an operation or the type of operation performed.

The ASU – Are surgeons now unaccountable? (Re: ANZ J. Surg. 2010; 80: 419–24)

I seek clarification relating to the article on the Acute Surgical Unit (ASU) model of care as our unit is considering a similar change. The authors state the ASU ‘functions the same way 7 days a week’ and that a ‘consultant is in the hospital from 7 am to 7 pm’. How did you ensure compliance? Does being on site include having clinical commitments at the Nepean Private Hospital which is on the same grounds as the public hospital? How many registrars (fellows, trainees and non-trainees) are required to run the ASU? The authors state, ‘There are three registrars allocated. . . . ’ but two sentences later add ‘The fourth registrar . . .’ and then ‘There is a second experienced registrar . . .’ Am I correct in observing that five registrars are required to run the ASU? I agree that protocol-driven management in this model of care is vital. The fact that 96% of patients presenting with right iliac fossa pain underwent surgery seems high. I was surprised that only 81% of patients with acute cholecystitis and a meagre 60% of patients with colonic obstruction had surgery. Do the post-operative patients return to the ASU? Due to space restrictions, I have not focused on a number of fanciful unreferenced statements such as: 3 days on-call weekends created a significant risk of fatigue with subsequent poor patient outcomes. Are there any legal implications of a patient being admitted ‘under the ASU card’ rather than an individual clinician? Is the director of the ASU ultimately responsible and fill in the Audit of Surgical Mortality paperwork? As well as removing ‘responsibility for the care of acute surgical patients’, this model also removes accountability for clinical decisions (e.g. the decision to not operate). Is this what we wish to engender in our registrars?

Inter-surgeon Variability in Cystic Artery Lymph Node Excision during Laparoscopic Cholecystectomy

Introduction Expert opinion recommends that surgeons perform a laparoscopic cholecystectomy (LC) in a standardized manner by dissecting the hepatobiliary triangle lateral to the cystic artery lymph node (LN) to minimize the rate of a major bile duct injury. Methods To determine whether surgeons performed a laparoscopic cholecystectomy in a standardized manner, the study assessed the variability in the frequency of an LN excision. All LCs that were performed at a single hospital were identified from a prospective dataset. The presence of an LN was retrospectively determined from the histology report. Results Twenty-seven surgeons were recorded to have performed 2332 laparoscopic cholecystectomies. Out of the total number of patients, 76.8% were female. The median patient age was 42.4 years. About 60.8% of the LCs were elective, while 39.2% of them were acute. Nineteen pathologists reported that in 99% of the specimens – the LN status of 1831 (78.5%) gallbladders was reported and analyzed. Overall, the LN yield per surgeon varied from 0% to 50% (mean 18.7%). Conclusion The high inter-surgeon variability in the rate of LN excision during laparoscopic cholecystectomy shows that surgeons dissect the hepatobiliary triangle differently. The LN yield may also represent a surrogate marker of surgical technique (which is easy to measure).