Jennifer Allen

Analysis of the causes and effects of delay before diagnosis using surgical mortality data

The aim of the study was to assess the causes and effects of delay in diagnosis in surgical patients who died in 20 public hospitals participating in the Queensland Audit of Surgical Mortality (QASM) in Australia.

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.

Outcomes from the Northern Territory Audit of Surgical Mortality: Aboriginal deaths

A significant ‘gap’ in life expectancy exists for Australian Aboriginal people. The role of surgical care in this gap has been poorly addressed. This study has compared in‐hospital surgical deaths of Aboriginal and non‐Aboriginal persons in order to identify patient factors plus deficiencies of care that may have contributed to the gap.

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.

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.

Post-mortem general surgeon reflection on decision-making: a mixed-methods study of mortality audit data: Post-mortem general surgeon reflection

Surgical deaths in Australia require the treating surgeon to document the event via a standard report. A section of this report invites surgeons to reflect on changes to management they would initiate in retrospect. This study analyses these reflective statements and categorizes them in an effort to gain insight into reflective learning.

Analysis of Patients Who Died Following Hartmann’s Procedure

Introduction: Hartmann’s procedure is typically performed for sigmoid colon obstruction or perforation. The primary aim of this study was to compare patients who died after a Hartmann’s procedure for obstruction and perforation. The secondary aim was to collate opinions of surgeon reviewers of any clinical events. Methods: Patients who died in Queensland, Australia after a Hartmann’s procedure, between January 2009 and December 2014, were identified from the Queensland Audit of Surgical Mortality. Original Research Article Wieland et al.; AJMAH, 8(4): 1-7, 2017; Article no.AJMAH.38057 2 Results: 275 patients died; of those 56% underwent surgery for perforation, 20% for obstruction and 24% for other indications. Patients with perforation were of the same age as those with obstruction (p = 0.178) but those with perforation were more likely to be female (p = 0.059) and have a higher ASA class (p = 0.001). Patients with perforation underwent surgery one day earlier than those with obstruction (p = 0.066) but had the same postoperative length of stay as those with obstruction (p = 0.430). Surgeon reviewers identified between 1 and 7 clinical events per patient in 105 patients (38.2%). Conclusion: Patients with perforation who died following a Hartmann’s procedure were of a higher ASA class but had a shorter time to theatre compared to patients with obstruction. Clinical events were identified in one third of patients.

Mortality Audit of Octogenarians With Acute Cholecystitis

Background and Objectives: The mortality rate of patients with acute cholecystitis is low with either medical or surgical management. It is unclear how surgeons decide which patients will not undergo cholecystectomy. We postulated those who died following medical management would have a greater burden of comorbidities than those who died following cholecystectomy. Methods: Adults who died under the care of a surgeon with a diagnosis of acute cholecystitis were identified from the Australian and New Zealand Audit of Surgical Mortality database. Results: We identified 86 eligible patients, and two-thirds of them were managed medically. Cholecystectomy patients were younger (78 years vs 86 years, P .028) and had a lower American Society of Anesthesiologists class (3 vs 4, P .005). Both groups had a similar number of comorbidities (P .588). Length of stay for the surgical group was 11 days longer than that of the medical group (14 days vs 3 days, P .001). The frequency of hospital systems issues was the same in both groups. Conclusions: Patients with acute cholecystitis who died with medical management were older with a higher American Society of Anesthesiologists class than those who died following cholecystectomy. Research is required into the circumstances at time of admission for acute cholecystitis.