Building a framework for trust: critical event analysis of deaths in surgical care

Thompson, Alastair; Stonebridge, P. A.

doi:10.1136/bmj.330.7500.1139

Cited by 57 publications

(66 citation statements)

References 16 publications

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“…3 This is eight times higher when compared with elective admissions, with figures highly variable between trusts across the country, depending on the tertiary status. 4,5 Several sources, including National…”

Section: Introductionmentioning

confidence: 99%

Pre-NELA vs NELA – has anything changed, or is it just an audit exercise?

Mak

Hakeem

Chitre

2016

annals

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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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Section: Introductionmentioning

confidence: 99%

Pre-NELA vs NELA – has anything changed, or is it just an audit exercise?

Mak

Hakeem

Chitre

2016

annals

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“…[5][6][7] US Peer Review organizations and published adverse event audits have similarly applied and refined such methods in monitoring quality of care. [7][8][9][10][11] In Ontario (population, 12 million), in-hospital, all-cause mortality rates after coronary artery bypass graft (CABG) surgery have been publicly reported by hospital for many years. Risk-adjusted mortality rates since 1995 have been low (Ϸ2%), 12 and institutional outliers have been rare, a situation often attributed to the fact that CABG surgery in Ontario is regionalized with no low-volume providers (yearly institutional volumes Ն400).…”

Section: Editorial P 2963 Clinical Perspective P 2976mentioning

confidence: 99%

Relationship Between Preventability of Death After Coronary Artery Bypass Graft Surgery and All-Cause Risk-Adjusted Mortality Rates

Guru

Etchells

et al. 2008

Circulation

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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, Ϫ0.42; Pϭ0.26). 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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“…In total, emergency general surgery accounted for more than 600 000 admissions in 2011 1 . Mortality in this group of patients is highapproximately eight times that associated with elective surgical admission 2 . Numerous publications, including consensus statements 3 -5 , National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) reports 6,7 and small empirical studies 8 -10 , have described variable standards of care for emergency general surgery.…”

Section: Introductionmentioning

confidence: 99%

Mortality in high-risk emergency general surgical admissions

Symons¹,

Moorthy²,

Almoudaris³

et al. 2013

British Journal of Surgery

166

135

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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 hospitalTrusts 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 highrisk emergency general surgery patients. Equitable access to essential hospital resources may reduce variability in outcomes.

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Building a framework for trust: critical event analysis of deaths in surgical care

Cited by 57 publications

References 16 publications

Pre-NELA vs NELA – has anything changed, or is it just an audit exercise?

Pre-NELA vs NELA – has anything changed, or is it just an audit exercise?

Relationship Between Preventability of Death After Coronary Artery Bypass Graft Surgery and All-Cause Risk-Adjusted Mortality Rates

Mortality in high-risk emergency general surgical admissions

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