The South African Surgical Outcomes Study: A 7-day prospective observational cohort study

Abstract

MethodsThis was a 7-day, SA national multicentre prospective observational cohort study of patients aged ≥16 years undergoing inpatient noncardiac surgery. The study was registered on ClinicalTrials.gov (NCT02141867).Departments of anaesthesia, surgery, critical care and gynaecology affiliated to all the medical schools in SA agreed to participate. A sample of 50 participating hospitals was obtained by approaching all the hospitals in which training by these academic departments took place. Additional hospitals were recruited through professional contacts. All SA provinces were represented. Hospital-specific data were collected, including number of operating rooms and number and level of critical care beds. Ethics approval was obtained for all sites.The ethics review board of each medical school (University of Cape Town, University of the Free State, University of KwaZuluNatal, University of Limpopo, University of Pretoria, Stellenbosch University, University of the Witwatersrand (Wits) and Walter Sisulu University) approved the study. For the majority of sites, a waiver of consent was approved. Wits and the Free State Provincial Administration stipulated that informed consent be required from all patients, with deferred consent for patients who could not give consent prior to surgery. Wits stipulated that only patients aged ≥18 years could consent to participate. The intention was to recruit all eligible patients in order to minimise data selection bias. Background. Non-cardiac surgical morbidity and mortality is a major global public health burden. Sub-Saharan African perioperative outcome data are scarce. South Africa (SA) faces a unique public health challenge, engulfed as it is by four simultaneous epidemics: (i) poverty-related diseases; (ii) non-communicable diseases; (iii) HIV and related diseases; and (iv) injury and violence. Understanding the effects of these epidemics on perioperative outcomes may provide an important perspective on the surgical health of the country. Objectives. To investigate the perioperative mortality and need for critical care admission in patients undergoing inpatient non-cardiac surgery in SA. Methods. A 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient noncardiac surgery between 19 and 26 May 2014 at 50 public sector, government-funded hospitals in SA. The South African Surgical OutcomesResults. The study included 3 927/4 021 eligible patients (97.7%) recruited, with 45/50 hospitals (90.0%) submitting data that described all eligible patients. Crude in-hospital mortality was 123/3 927 (3.1%; 95% confidence interval (CI) 2.6 -3.7). The rate of postoperative admission to critical care units was 255/3 927 (6.5%; 95% CI 5.7 -7.3), with 43.5% of admissions being unplanned. Of the surgical procedures 2 120/3 915 (54.2%) were urgent or emergency ones, with a population-attributable risk for mortality of 25.5% (95% CI 5.1 -55.8) and a risk of admission to critical care of 23.7% (95% CI 4.7 -51.4).Conclusions. Mo...

Provision of an emergency theatre in tertiary hospitals is cost-effective: Audit and cost of cancelled planned elective general surgical operations at Pietersburg Hospital, Limpopo Province, South Africa

“…[10] The most common reason for cancellation in our study (64.4%) was the addition of emergency cases to elective lists, which seriously interrupted the schedule of elective procedures. A study by Biccard et al [11] showed that 54.2% of operations done in SA are urgent or emergency. PTB Hospital had no separate theatre dedicated to emergency cases during the daytime throughout the study period.…”

An investigation of barriers to the use of the World Health Organization Surgical Safety Checklist in theatres

“…An Australian study that investigated negative events associated with surgery found that 21.9% of surgical admissions were associated with an adverse event, and that 47.6% of these were preventable complications. [2] In more recent studies, the International Surgical Outcomes Study (ISOS) showed that 16.8% of patients developed complications, with a mortality rate of 2.8%, [3] the European Surgical Outcomes Study (EuSOS) showed a mortality of 4%, [4] and in the South African Surgical Outcomes Study (SASOS) the mortality was 3.1%, with the highest hospital mortality being 9.5% [5] Efforts to decrease adverse events and improve patient safety led to the Safe Surgery Saves Lives programme and subsequently to the World Health Organization Surgical Safety Checklist (WHO SSCL). [6] The WHO SSCL was introduced in 2008 and is aimed at improving patient safety and inter-discipline communication and preventing avoidable complications by emphasising current safety procedures.…”

Editor's Choice

“…The South African Surgical Outcomes Study, [3] a 7-day prospective observational cohort study contributed to by surgeons from across the country, sought to investigate perioperative mortality and need for critical care admission in patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 public sector, government-funded hospitals.…”