Clinical management issues vary by specialty in the Victorian Audit of Surgical Mortality: a retrospective observational study

Abstract

ObjectiveClinical management issues are contributory factors to mortality. The aim of this study was to use data from the Victorian Audit of Surgical Mortality (VASM), an educational peer-review process for surgeons, to discover differences in the incidence of these issues between surgical specialties in order to focus attention to areas of care that might be improved.DesignThis study used retrospectively analysed observational data from VASM. Clinical management issues between eight specialties were assessed using χ2 analysis.Data sourcesVASM data were reported by participating public and private health services, the Coroner and self-reporting surgeons across Victoria.ResultsA total of 2946 specific clinical issues as deficiencies of care were reported. 15% of cases had significant issues of care. The most common clinical management issue was the delay in delivery of treatment. Other clinical issues included the quality of communication and documentation, preoperative and postoperative care, adverse events and protocol issues. There were significant differences in issues between specialties.ConclusionsThe clinical management issues presented across surgical specialties were similar; however, five issues of clinical care differed significantly in frequency across surgical specialties. The three main issues varying among specialties were complications after operation, communication and postoperative care. Addressing these clinical management issues via the peer-review process may impact positively on patient care.

Potentially preventable deaths in the Victorian Audit of Surgical Mortality

“…Admission status, delays in patient care, requirement for critical care, the number of operations performed during the admission and presence of clinical management issues have all been identified as preventable issues associated with surgical care in previous reports. [2][3][4][8][9][10][11][12][13][14] These studies have focussed upon the preventability of the individual clinical management issues instead of our methodology, which provides a more holistic approach to the audit of the mortality. The VASM has previously shown that assessors found that inappropriate absence of either venous thromboprophylaxis or critical care unit use were not significant issues (only 6 and 8%, respectively, would have benefited), which emphasizes the importance of clinical management issues rather than risk management issues when examining surgical mortality.…”

“…There is a subtle but important difference in preventability of individual management issues that might be responsible for the death of a patient, which is the usual approach in the ANZASM audits, as opposed to issues identified in a mortality identified as potentially preventable. Admission status, delays in patient care, requirement for critical care, the number of operations performed during the admission and presence of clinical management issues have all been identified as preventable issues associated with surgical care in previous reports . These studies have focussed upon the preventability of the individual clinical management issues instead of our methodology, which provides a more holistic approach to the audit of the mortality.…”

“…2,3 The most frequently identified clinical management issues that have been reported across all specialties were delay in definitive treatment, inappropriate operation, and management and protocol issues. 4 Medical errors have been estimated to be the third leading cause of death in the USA. 5 VASM, unlike the other Australian and New Zealand Audit of Surgical Mortality (ANZASM) audits apart from Western Australia, also collects an opinion from the treating surgeon and assessors as to whether the mortality was potentially preventable and which individual management issues were associated with preventability.…”

“…Previous studies have indicated that a number of clinical factors such as comorbidities, patient and hospital admission type, usage of critical care unit, urgency status, American Society of Anesthesiologists status, delay in diagnosis, surgical procedures and clinical management issues contribute to potentially avoidable mortality . The most frequently identified clinical management issues that have been reported across all specialties were delay in definitive treatment, inappropriate operation, and management and protocol issues . Medical errors have been estimated to be the third leading cause of death in the USA …”

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

“…VASM and the Victorian Coroner both aim to improve public health and safety by way of investigation of mortality . However, it is important to note that their different approaches result in different patient populations, as evident by the relatively small crossover population available for this study.…”