Potentially preventable deaths in the Victorian Audit of Surgical Mortality

Chen, Andrew; Retegan, Claudia; Vinluan, Jessele; Beiles, Barry

doi:10.1111/ans.13804

Cited by 8 publications

(10 citation statements)

References 14 publications

(29 reference statements)

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“…The median age in the whole cohort in this study was 82 years, consistent with other Australian surgical mortality audits. 4 Our study revealed a much higher fraction of patients receiving critical care compared to the UK NCEPOD study (83% versus 22%), 12 and somewhat higher than the SNAP-2 EPICCS audit in the UK, Australia and New Zealand. 14 Although ADLs were documented in many cases, functional assessment and anaesthesia risk scores were only documented in 4%.…”

Section: Comparison With Previous Studiescontrasting

confidence: 50%

Section: Introductionmentioning

confidence: 99%

“…2 Similarly, the REASON study in Australia (2015) reported a 20% complication rate in surgical patients over 70 years of age, 3 compared with only a 0.3% rate for the overall surgical population. 4 In perioperative medicine, end-of-life decisionmaking is often needed because of the prevalence of life-threatening issues in older surgical patients. Although half of patients over 60 years of age required treatment decisions in their final days of life in a US study, 70% lacked the capacity to make such decisions themselves.…”

Section: Introductionmentioning

confidence: 99%

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An audit of perioperative end-of-life care practices and documentation relating to patients who died in a surgical unit in three Victorian hospitals

Keon-Cohen

Story

Moran

et al. 2022

Anaesth Intensive Care

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The number of older, frail patients undergoing surgery is increasing, prompting consideration of the benefits of intensive treatment. Despite collaborative decision-making processes such as advance care planning being supported by recent Australian legislation, their role in perioperative care is yet to be defined. Furthermore, there has been little evaluation of the quality of end-of-life care in the surgical population. We investigated documentation of the premorbid functional status, severity of illness, intensity of treatment, operative management and quality of end-of-life care in patients who died in a surgical unit, with a retrospective study of surgical mortality which was performed across three hospitals over a 23-month period in Victoria, Australia. Among 99 deceased patients in the study cohort, 68 had a surgical operation. Preoperative functional risk assessment by medical staff was infrequently documented in the medical notes (5%) compared with activities of daily living (69%) documented by nursing staff. Documented preoperative discussions regarding the risk of death were rarely and inconsistently done, but when done were extensive. Documented end-of-life care discussions were identified in 71%, but were frequently brief, inconsistent, and in 60% did not occur until 48 hours from death. In 35.4% of instances, documented discussions involved junior staff (registrars or residents), and 43.4% involved intensive care unit staff. Palliative or terminal care referrals also occurred late (1–2 days prior to death). Not-for-resuscitation orders were frequently changed when approaching the end of life. Overall, 57% of deceased patients had a documented opportunity for farewell with family. We conclude that discussions and documentation of end-of-life care practices could be improved and recommend that all surgical units undertake similar audits to ensure that end-of-life care discussions occur for high-risk and palliative care surgical patients and are documented appropriately.

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Section: Comparison With Previous Studiescontrasting

confidence: 50%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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An audit of perioperative end-of-life care practices and documentation relating to patients who died in a surgical unit in three Victorian hospitals

Keon-Cohen

Story

Moran

et al. 2022

Anaesth Intensive Care

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“…Although our POMR is low, despite many late presentations, the service, for those who can access it, delivers safely. However, we can still learn to improve the safety and quality of service provided by reviewing individual mortalities on a case by case basis and by identifying preventable factors where patients suffer morbidity or mortality 19–21 . The strong public health message, is that surgical, anaesthetic and obstetrics care will save more lives when there is greater access and less delay.…”

Section: Discussionmentioning

confidence: 99%

Universal access to safe, affordable, timely surgical and anaesthetic care in Papua New Guinea: the six global health indicators

James¹,

Borchem²,

Talo³

et al. 2020

ANZ Journal of Surgery

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Background: The unmet global burden of surgical disease is substantial. The Lancet Commission on Global Surgery (LCoGS) estimated that 5 billion people do not have access to safe, affordable and timely surgical care, with 80% of those without access living in lowand middle-income countries. The Milne Bay Province (pop 331 000) of Papua New Guinea, with an archipelago of islands up to 750 km from its capital, Alotau, has only one hospital capable of performing Caesarean Section, Emergency Laparotomy and managing an open fracture, the three Bellwether procedures. This paper aims to report the six Lancet Commission on Global Surgery metrics for Milne Bay Province. Methods: The study was conducted between January and August 2019. Bellwether access was investigated by a prospective study on 115 patients presenting to hospital. The surgical, anaesthesia and obstetric (SAO) workforce, surgical volume and perioperative mortality rate, were calculated for 2012-2018 from hospital records and operation registers. Financial risk metrics were calculated by surveying 50 patients at discharge from hospital. Results: Bellwether access: Only 27.8% (n = 32) of the study population (n = 115) experienced less than 2-hours second delay (journey time to hospital). The average SAO provider density was 1.8 per 100 000 population. There were 606 procedures performed per 100 000 with a mean annual perioperative mortality rate of 0.3%. Catastrophic expenditure is a risk for 29% of the population. Conclusion: Milne Bay Province can perform surgery safely, but there is limited access to timely surgical care when needed with a significant proportion put at financial risk by requiring it.

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“…All CMIs are further classified as either preventable or not preventable. 4 The previous study identified that over a two-year period 46 patient deaths from the large health service should have been referred to VASM according to the reporting criteria. The total number of deaths that were reported over the same period was 316 meaning that 12.7% (46/316 + 46) of reportable surgical deaths were not reported.…”

Section: Methodsmentioning

confidence: 99%

Analysis of potential clinical management issues in unreported mortality data from an Australian health service

Qin

Vinluan

McCahy

2023

ANZ Journal of Surgery

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Background:We have previously reported incomplete data submission to the Victorian Audit of Surgical Mortality (VASM) by a large health service. We have further examined the source health service clinical data to assess whether any clinical management issues (CMI) occurred and should have been reported. Methods: The previous study identified 46 deaths that should have been reported to VASM. The hospital records of these patients were further analysed. Data recorded included the patient's age, gender, admission type and clinical course. Any potential clinical management issues were recorded and classified using the VASM definitions (area of consideration or concern, adverse event). Results: Median age of the deceased patients was 72 (range 17-94), with 17 (37%) being female. Patients were under the care of nine different specialties with general surgery being the most common (18/46). Only four (8.7%) of the cases were electively admitted. 17 (37%) patients had at least one CMI with 10 (21.7%) classified as adverse events. Most deaths were not considered preventable. Conclusion:The proportion of CMI in the unreported deaths was consistent with the previously reported VASM data, however current findings show a high percentage of adverse events. The underreporting may be due to inexperienced medical staff or coders, poor quality notes or confusion about what should be reported. These findings reinforce the importance of data collection and reporting at the health service level, and a number of important lessons and opportunities to improve patient safety have been lost.

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Potentially preventable deaths in the Victorian Audit of Surgical Mortality

Cited by 8 publications

References 14 publications

An audit of perioperative end-of-life care practices and documentation relating to patients who died in a surgical unit in three Victorian hospitals

An audit of perioperative end-of-life care practices and documentation relating to patients who died in a surgical unit in three Victorian hospitals

Universal access to safe, affordable, timely surgical and anaesthetic care in Papua New Guinea: the six global health indicators

Analysis of potential clinical management issues in unreported mortality data from an Australian health service

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