Mortality Audit Research Articles

Development and validation of a novel tool for identification and categorization of non-technical errors associated with surgical mortality.

Up to half of all surgical adverse events are due to non-technical errors, making non-technical skill assessment and improvement a priority. No specific tools are available to retrospectively identify non-technical errors that have occurred in surgical patient care. This original study aimed to develop and provide evidence of validity and inter-rater reliability for the System for Identification and Categorization of Non-technical Error in Surgical Settings (SICNESS). A literature review, modified Delphi process, and two pilot phases were used to develop and test the SICNESS tool. For each pilot, 12 months of surgical mortality data from the Australian and New Zealand Audit of Surgical Mortality were assessed by two independent reviewers using the SICNESS tool. Main outcomes included tool validation through modified Delphi consensus, and inter-rater reliability for: non-technical error identification and non-technical error categorization using Cohen's κ coefficient, and overall agreement using Fleiss' κ coefficient. Version 1 of the SICNESS was used for pilot 1, including 412 mortality cases, and identified and categorized non-technical errors with strong-moderate inter-rater reliability. Non-technical error exemplars were created and validated through Delphi consensus, and a novel mental model was developed. Pilot 2 included an additional 432 mortality cases. Inter-rater reliability was near perfect for leadership (κ 0.92, 95% c.i. 0.82 to 1.00); strong for non-technical error identification (κ 0.89, 0.84 to 0.93), communication and teamwork (κ 0.89, 0.79 to 0.99), and decision-making (κ 0.85, 0.79 to 0.92); and moderate for situational awareness (κ 0.79, 0.71 to 0.87) and overall agreement (κ 0.69, 0.66 to 0.73). The SICNESS is a reliable and valid tool, enabling retrospective identification and categorization of non-technical errors associated with death, occurring in real surgical patient interactions.

An Audit of Post-neonatal Infant Morbidity and Mortality from Admissions in an Emergency Unit of a Tertiary Hospital in Sokoto, Northwest Nigeria

Background The first year of life is a critical period of adaptation for a young infant during which the child becomes exposed to a lot of infectious agents and other environmental problems as its immune systems and other organs are developing. Magnitude of deaths within the first year of life is a significant socioeconomic index of any population. Challenges can also be brought to the forefront which can be tackled by appropriate authorities. Objectives To assess the causes of morbidity and mortality amongst infants aged 29 days to 12 months admitted in the emergency Paediatric unit (EPU) of Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto over a 5- year period. Materials and Methods The admission records of children aged 29 days to 12 months were retrieved. Information extracted included socio-demographic data, diagnosis and outcome of admission. These were entered into a study proforma and analysed with SPSS version 23. Results Total admissions were 1776 in the five-year review. Majority were males accounting for 1030 (58%) with M:F ratio of 1.38:1. 972 (55.4%) were aged 6 to 12 months. Top causes of admissions were diarrhoea disease 328 (18.5%), pneumonia 280 (15.8%), sepsis 211 (11.9%), malaria 202 (11.4%) and malnutrition 154 (8.7%). Mortalities were 223 (12.6%). Highest fatalities out of 223 were from sepsis 47 (21.1%), pneumonia 40 (17.9%), malaria 27 (12.1%), malnutrition 25 (11.2%) and diarrhoea disease 20 (9.0%). Higher proportion of the mortalities were in females 14.5% vs 11.2% (X2 = 4.3; p=0.038). Sepsis mortality was high throughout likewise pneumonia but mortality pattern of other disease conditions varied throughout infancy. Conclusion Post-neonatal admissions were mainly due to infections, likewise mortality of which the top causes varied throughout infancy. Females were more proportionately affected by mortality. These insights on the morbidity and mortality patterns calls for more concerted efforts on child survival strategies and targeting this group of infants is imperative.

Accuracy of surgical death information: comparison of data held by Victorian Audit of Surgical Mortality and Victorian Agency for Health Information.

The Victorian Audit of Surgical Mortality (VASM) investigates all surgically related deaths in Victoria. The Victorian Admitted Episodes Database (VAED) is an administrative dataset maintained by the Health Department's Victorian Agency of Health Information (VAHI). We have reviewed clinical records to assess the correlation between deaths reported to the databases. Data July 2019 to June 2020 were compared. All hospitals that had surgical deaths not reported to VASM were asked to provide clinical summaries which were analysed to assess the deaths should have been reported. Case note review of 280 deaths only reported to VAHI through VAED was undertaken to establish whether these should have been reported to VASM. VASM received 1763 reported surgical deaths with VAHI recording 1907. Using individual patient identifiers, 517 (29.3%) of the VASM deaths were not reported to VAHI but subsequent data analysis revealed they were correctly identified as reportable deaths in 385 (74.5%). There were 914 (47.9%) VAED recorded deaths that were not reported to VASM. 280/914 (30.6%) were reviewed from 21 hospitals. Only 24 (8.6%) of these had a surgical procedure in the patient's final admission and should have been reported. This suggests that the current method of VASM capture of surgical mortality only missed 4% cases for the 2019/20 year. There were major differences between surgical deaths reported to VASM and those reported by health services and recorded in VAED. Less than 5% of cases are not reported to VASM and thus not subjected to peer review.

670 Investigating Delay During Presentation of Trauma in Young Adults: A UK Major Trauma Centre Retrospective Audit and a Systematic Review of the Literature

Abstract Introduction The current evidence in major trauma highlights that delays at multiple points along the patient care pathway, from incident to surgery, are associated with decreased survival. The aim of this audit was to assess performance across select delay parameters in juveniles aged 16-18 presenting to an adult MTC service following a systematic review of the literature. Method Patient records were interrogated between 1/10/2022-1/3/2023 and audited against 3 national standards: (1) Ambulance Response and Transfer (7 and 45mins respectively) (2) Tranexamic Acid infusion (<3hrs) and (3) CT scan (<60mins). A systematic search was also performed using EMBASE and OVID databases (01/01/2005-/01/11/2023). All studies assessing impact of time to theatre in patients with acute trauma were considered. Results 32 consecutive patients (3F:29M) (median 18 years[16-18]) were identified within the audit period. 40%(n=13) presented following penetrating injury and 35%(n=11) following a road traffic accident. Mean time from incident to admission was 83mins[±36], from incident to tranexamic acid infusion 50mins[±35], and from admission to CT Trauma Series 61mins[+/-100]. Median length of stay was 4 days [IQR=5]. The systematic search yielded 25 studies which were included in the analysis. An Incident2Surgery framework is presented which highlights key time-critical points for diagnosis and intervention. Conclusions Local compliance to national standards for tranexamic acid infusion in appropriate patients and performance of trauma CT was excellent with poor compliance to ambulance arrival and transfer time. The proposed Incident2Surgery framework could be incorporated into mortality prediction and audit tools and assist in the assessment of interventions.

Mortality Audit in the Head and Neck Surgery Ward: A Retrospective Study in a Tertiary Care Hospital of Pakistan.

Background Mortality audit is important for healthcare workers, but this data is lacking in developing countries. It helps to providematerial about the cause of death, mortality rate, age, and gender. In a surgical department, such information can help identify key public health challenges that are contributing to morbidity and mortality, and this information can helphealthcare workers better tackle those pathologies and focus on their prevention and treatment. Materials and methods A retrospective study was conducted at the Department of ENT - Head and Neck Surgery, Pakistan Institute of Medical SciencesHospital, Islamabad. Five-year data was collected from the mortality register of the ward from January 2019 to December 2023, including the age, gender, surgical diagnosis, course of hospital stay, and cause of death. The collected data was statistically analyzed and presented in the form of tables and figures. Results A total of 53 deaths in 3890 admissions were found on record, with an overall mortality rate of 1.4%. The median age of participants was 61.5 years, with a preponderance of the male gender (n=34; 64.2%). The most common cause of death was head and neck malignancy (n=39; 73.6%), followed by head and neck abscesses (n=9; 17%). The least common cause of death was diphtheria (n=2; 3.8%). Conclusion Death was more common in old-age patients, with more prevalence in the male population. The most common cause of mortality was head and neck malignancy. The total death count almost remained constant through the years.

Mortality Audit of Cancer Patients in the Department of Medical Oncology at a Tertiary Cancer Care Centre in South India.

Considerable advances in the diagnosis and treatment of cancer have made a huge impact on morbidity and mortality from neoplastic diseases. However, cancer remains the leading cause of death across the world. This is a retrospective study carried out at a tertiary cancer care centre (Kidwai Memorial Institute of Oncology, Bangalore) in South India. Case records of all cancer patients who died while receiving inpatient treatment between January 2022 and December 2022 under the Department of Medical Oncology were reviewed and studied. There was a total of 240 deaths. Out of these, the majority of deaths 147 (61.25%) were patients with haematological malignancies while the remaining 93 (38.75%) were patients with solid tumours. In patients with solid tumours, the majority 49 (52.7%) were in the age group of 40 to 60 years while only 18 (19.35%) patients were less than 40 years. The majority of patients weremale sex i.e. 55(59.1%) and undergoing treatment with palliative intent 81 (87%). The most common organ was the lung in 21 patients (22.6%) followed by the breast while the most common system involved was the gastrointestinal tract in 28 (30.1%) patients. The most frequent cause of death was progressive disease in 72 (77.4%) while sepsis (11 patients; 11.8%) was the second most frequent cause of death in solid tumours. In haematological malignancies, also a significant number of 57 (38.8%) patients were in the age group of 40 to 60 years. Fifty-two (35.3%) patients were in the age group of 22 to 40 years. The majority weremale sex (79 patients; 53.7%). About the phase of treatment, the majority of deaths 45 (30.6%) were during induction and under evaluation. Those with relapse/refractorydisease were 38 (25.9%). A substantial number of patients had acute myeloid leukaemia47 (32%) and five (3.4%) deaths were acute promyelocytic leukaemiapatients. Twenty-three patients (15.6%) hadacute lymphoblastic leukaemia. The most common cause of death was sepsis in 76 patients (51.7%) whileintracranial bleeding was in 34 patients (23.1%). In some patients, there were multiple causes leading to death. Mortality audits are important to evaluate the services being provided at any centre. One can appreciate the lacunae in handling a particular disease or flaws in a treatment protocol or the staff delivering the treatment. Sepsis is the leading cause of death in patients with haematological malignancy; even in solid malignancy sepsis accounts for a substantial proportion of deaths and should be handled aggressively to save lives.

Nationwide Audit of Postoperative Mortality and Complications After Digestive Cancer Surgery: Will New Legal Thresholds be Sufficient?

French policymakers recently chose to regulate high-risk digestive cancer surgery (DCS). A minimum of five cases per year should be performed for each of the following types of curative cancer surgery: esophagus/esogastric junction (ECS), stomach (GCS), liver (LCS, metastasis included), pancreas (PCS), and rectum (RCS). This study aimed to evaluate the hypothetical beneficial effects of the new legal minimal volume thresholds on the rates of 90-day postoperative mortality (90POM) for each high-risk DCS. This nationwide observational population-based cohort study used data extracted from the French National Health Insurance Database from 1 January 2015-31 December 2017. Mixed-effects logistic regression models were performed to estimate the independent effect of hospital volume. During the study period, 61,169 patients (57.1 % male, age 69.7 ±12.2 years) underwent high-risk DCS including ECS (n = 4060), GCS (n = 5572), PCS (n = 8598), LCS (n = 10,988), and RCS (n = 31,951), with 90POM of 6.6 %, 6.9 %, 6.0 %, 5.2 %, and 2.9 %, respectively. For hospitals fulfilling the new criteria, 90POM was lower after adjustment only for LCS (odds ratio [OR],15.2; 95 % confidence interval [CI], 9.5-23.2) vs OR, 7.6; 95 % CI, 5.2-11.0; p < 0.0001) and PCS (OR, 3.6; 95 % CI, 1.7-7.6 vs OR, 2.1; 95 % CI, 1.0-4.4; p<0.0001). With higher thresholds, all DCSs showed a lower adjusted risk of 90POM (e.g., OR, 0.38; 95 % CI, 0.28-0.51) for PCS of 40 or higher. Based on retrospective data, thresholds higher than those promulgated would better improve the safety of high-risk DCS. New policies aiming to further centralize high-risk DCS should be considered, associated with a clear clinical pathway of care for patients to improve accessibility to complex health care in France.

Facility Based Audit of Maternal Near Miss, Maternal and Neonatal Mortality in a Tertiary Hospital, South-West Nigeria: One-Year Review

Background: There is a poor linkage between MPDSR audits on the one hand, and the quality improvement processes proffered by them. This usually leads to varied implementation of recommendations. Buy-in from the community and health facilities are needed for full implementation. To better identify and track causes of maternal and perinatal mortality, it is necessary to combine review of maternal near-miss morbidities with findings at MPDSR meetings. Objectives: A. Evaluate near-miss morbidity and near-miss to mortality ratio. B. To compare the nature of near-miss morbidity with maternal mortality. C. To compare findings of near-miss maternal morbidity with maternal mortality among women who registered for care and those who did not. Design: Retrospective study. Methods: Monthly review of data collected on maternal near-miss morbidity and maternal mortality at MPDSR meetings for all women who delivered at our facility from 1st December 2022 till 31st December 2023. Results: The near-miss incidence ratio was 70 per 1000 live births while the maternal mortality ratio was 1399 per 100000 live births. Hypertensive disorders of pregnancy and sepsis were responsible for 85.8% of maternal mortality. Despite contributing 62.4% to maternal near-miss events, obstetric haemorrhage was responsible for 14.2% of maternal mortality. Unbooked patients were responsible for 83% near-miss morbidity and 95% of mortality occurred in this same group. Conclusion: While we have made some progress in our care of women with Postpartum haemorrhage, hypertensive disorders of pregnancy remains a cause for concern for both maternal near-miss morbidity and maternal mortality. Health workers should be trained to recognise and promptly refer women with hypertensive disorders for expert care pre-delivery, intrapartum and postpartum. Antenatal care and facility delivery for all pregnant women remain the pathways towards reducing near-miss morbidity and maternal mortality ratio.

Medical versus surgical causes of death following colorectal resection: a Queensland Audit of Surgical Mortality (QASM) study.

The causes of death following colorectal resection remain poorly explored. Few studies have addressed whether early post-operative mortality is predominantly caused by a patient's medical co-morbidities, or from factors pertaining to the presenting surgical disease process itself. This study analyses data from the Queensland audit of surgical mortality (QASM) to report the causes of in-hospital death following colorectal resection, identifies whether these were due to either medical or surgical factors, and determines the patient characteristics associated with a medical cause of death. Through analysis of QASM Surgical Case Forms, the causes of in-hospital death were determined in 750 patients who died in Queensland following colorectal resection between January 2010 and December 2020. Deaths were attributed to a specific medical or surgical cause, with multivariate analysis used to identify independent risk factors associated with a medical cause of death. In total, 395 patients (52.7%) died due to surgical causes and 355 (47.3%) died due to medical causes. Respiratory co-morbidities (OR 1.832, 95% CI: 1.267-2.650), advanced malignancy (OR 1.814, 95% CI: 1.262-2.607), neurological co-morbidities (OR 1.794, 95% CI: 1.168-2.757) and advanced age (OR 1.430, 95% CI: 1.013-2.017) were independent risk factors associated with increased risk of a medical cause of death. Even in the absence of complicating surgical factors, a significant number of patients died in hospital following colorectal resection due to their underlying co-morbidities. Multi-disciplinary models of care which allow for the early recognition and treatment of medical complications may reduce post-operative mortality in these patients.

Facility-Based Audit System With Integrated Community Engagement to Improve Maternal and Perinatal Health Outcomes in Rural Pakistan: Protocol for a Mixed Methods Implementation Study.

Maternal and newborn mortality in Pakistan remains as a major public health challenge. Pakistan faces significant infrastructure challenges and inadequate access to quality health care, exacerbated by sociocultural factors. Facility-based audit systems coupled with community engagement are key elements in achieving improved health system performance. We describe an implementation approach adapted from the World Health Organization audit cycle in real-world settings, with a plan to scale-up through mixed methods evaluation plan. This study aims to implement a locally acceptable and relevant audit system and evaluate its feasibility within the rural health system of Pakistan for scale-up. The implementation of the audit system comprises six phases: (1) identify facility and community leadership through consultative meetings with government district health offices, (2) establish the audit committee under the supervision of district health officer, (3) initiate audit with ongoing community engagement, (4) train the audit committee members, (5) launch the World Health Organization audit cycle (monthly meetings), and (6) quarterly review and refresher training. Data from all deliveries, live births, maternal deaths, maternal near misses, stillbirths, and neonatal deaths will be identified and recorded from four sources: (1) secondary-level care rural health facilities, (2) lady health workers' registers, (3) community representatives, and (4) project routine survey team. Concurrent quantitative and qualitative data will be drawn from case assessments, process analysis, and recommendations as components of iterative improvement cycles during the project. Outcomes will be the geographic distribution of mortality to measure the reach, proportion of facilities initiated to implement an audit system for measuring the adoption, proportion of audit committees with community representation, and proportion of audit committee members' sharing feedback regularly to measure acceptability and feasibility. In addition, outcomes of effectiveness will be measured based on data recording and reporting trends, identified modifiable factors for mortality and morbidity as underpinned by the Three Delays framework. Qualitative data will be analyzed based on perceived facilitators, barriers, and lessons learned for policy implications. Results will be summarized in frequencies and percentages and triangulated by the project team. Data will be analyzed using Stata (version 16; StataCorp) and NVivo (Lumivero) software. The study will be implemented for 20 months, followed by an additional 4-month period for follow-up. Initial results will be presented to the district health office and the District Health Program Management Team Meeting in the districts. This study will generate evidence about the feasibility and potential scale-up of a facility-based mortality audit system with integrated community engagement in rural Pakistan. Audit committees will complete the feedback loop linking health care providers, community representatives, and district health officials (policy makers). This implementation approach will serve decision makers in improving maternal and perinatal health outcomes. DERR1-10.2196/49578.

Audit of 30-day mortality following palliative radiotherapy: are we able to improve patient care at the end of life?

Several measurements defining the expected 30-day mortality (30-DM) to use in audit of radiation oncology departments have been proposed. However, its external validity is limited because of the lack of data from non-English speaking countries. This study assessed 30-DM in patients treated with palliative radiotherapy (PRT) in a Chilean-reference radiotherapy centre and explored if there had been tailored treatment at the end of life. Retrospective data collection was carried out for all patients treated at our institution between 1st January 2018 and 31st December 2021. Individual factors were modelled first to check for univariate association with 30-DM, those variables with a significance level of < 0.05 were considered for the final multivariable model. 3,357 patients were included. The most common primary malignancies were breast (22%) and lung (16.1%). The most common treatment sites were bone (47.7%) and brain (12.2%). Overall, 30-DM was 14.7%, this rate was higher in patients treated for brain metastases (25.7%) and thoracic palliation (22.1%). 30-DM was associated with poor performance status (p < 0.01), lung and esophageal-gastric cancer (p = 0.04 and p = 0.02, respectively), metastases other than bone (p < 0.01), brain metastases (p < 0.01) and private health insurance (p <0.01). In patients treated for brain metastasis and thoracic palliation 30-DM was higher than suggested benchmarks. Moreover, in these groups long courses of PRT were often performed. Audit data should be useful for planning interventions that improve selection of patients and prompting review of policies for indication and fractionation schedules of PRT.

Quality in neonatal mortality audits: Results of pilot study from district of Dhule, Maharashtra.

As per WHO guidelines, it is important to have quality among mortality audit documents to improve outcome in health services. To assess quality of facility-based neonatal mortality audits implementation. Mixed-method descriptive analysis was conducted. Totally, 96 death review documents were reviewed. The 25 healthcare workers were interviewed in depth. Observation analysis done for audit meetings using WHO modified checklist for quality in audit toolkit. The observation of audit meetings highlighted that almost half of the members were not communicated regarding vision of audit and framework of audit and review meetings. In quantitative analysis, it was found that secondary care hospitals were not having accuracy and consistency in audit documentation. The quality of neonatal death audit was poor due to challenges faced by the hospitals in creating an enabling atmosphere, which can be overcome by sharing the vision of audit with the whole staff of the hospital. A standard operating procedure for audit committee to be adopted to implement action plans. Commitment, investment, and intentional leadership from everyone, including all healthcare workers, can make these ambitious goals attainable.

44-Year Temporal Trends and Causes of Maternal Mortality at the Lagos University Teaching Hospital, LUTH, Lagos, Nigeria (1976-2019)

ABSTRACT Background: Nigeria has committed to global initiatives aimed at improving maternal and child health. Institutional audit of maternal mortality over a long period can provide useful information on the trends in maternal death and the impact of interventions. Aim: To evaluate the trends in annual deliveries, maternal mortality ratio and causes of maternal death at a tertiary institution in Nigeria over a period of 44 years (1976–2019). Materials and Methods: We conducted a temporal trend analysis of annual births, maternal deaths, maternal mortality ratio (MMR), and ranking of causes of maternal deaths at a Teaching Hospital, in Southwest Nigeria using available data from 1976 to 2019. Overall and segmental annual percent change (APC) of the observed trends were conducted using Joinpoint version 4.5.0.1 software. Results: Over the 44-year study period, 1323 maternal deaths occurred at approximately 30 maternal deaths per annum. There was a four-fold increase in MMR from 881/100,000 total births in 1976 to 3389.8/100,000 total births in 2019, at an average increase of 3.1% per annum. (APC: 3.1%; P value &lt; 0.001). The leading causes of maternal mortality were hypertension, sepsis, haemorrhage, and abortion, which together contributed to more than 70% of maternal deaths. All the leading causes of maternal deaths except abortion had constant ranking during the study period. Conclusion: The four-fold increase in MMR at our hospital from 1976–2019 is worrying and may suggest that previous efforts at reducing maternal mortality in our institution did not lead to significant improvement toward the attainment of Sustainable Development Goal 3 (SDG3). The hospital increasingly managed complex cases especially the unbooked patients who were referred to the hospital as a last resort.

223. UNDERSTANDING POTENTIALLY PREVENTABLE MORTALITY FOLLOWING ESOPHAGO-GASTRIC CANCER SURGERY: ANALYSIS OF A NATIONAL AUDIT OF SURGICAL MORTALITY

Abstract Introduction At a national level, understanding preventable mortality after esophago-gastric cancer surgery can direct quality-improvement efforts. Here, we utilized the Australian and New Zealand Audit of Surgical Mortality (ANZASM) database to 1) determine the causes of death following esophago-gastric cancer resections in Australia, 2) quantify the proportion of potentially preventable death, and 3) identify clinical management issues contributing to preventable mortality. Methods All in-hospital mortalities following esophago-gastric cancer surgery from 01/01/2010 to 31/12/2020 were analyzed from ANZASM data. Potentially preventable and non-preventable cases were compared. Thematic analysis was used classify clinical management issues. Overall, we reviewed 636 complications and 123 clinical management issues in 105 mortalities. Results The most common causes of death were cardio-respiratory in etiology. Forty-nine (46.7%) mortalities were potentially preventable. These cases were characterized by higher rates of sepsis (59.2% vs. 33.9%, p = 0.011), multiorgan dysfunction syndrome (40.8% vs. 25.0%, p = 0.042), reoperation (63.3% vs. 41.1%, p = 0.031), and other complications compared with non-preventable mortality. Potentially preventable mortalities also had more clinical management issues per patient [median (IQR): 2 (1–3) vs. 0 (0–1), p &amp;lt; 0.001), which adversely impacted preoperative (30.6% vs. 7.1%, p = 0.002), intraoperative (18.4% vs. 5.4%, p = 0.037), and postoperative (51.0% vs. 17.9%, p &amp;lt; 0.001) care. Thematic analysis highlighted recurrent areas of deficiency in patient management. Conclusions Almost 50% of deaths following esophago-gastric cancer resections were potentially preventable. These were characterized by higher complication rates and clinical management issues. We highlighted recurrent themes in patient management to improve future quality-of-care.

Evaluation of an online education program for healthcare professionals on best practice management of perinatal deaths: IMPROVE eLearning.

The IMPROVE (IMproving Perinatal Mortality Review and Outcomes Via Education) eLearning, developed by the Stillbirth Centre of Research Excellence in partnership with the Perinatal Society of Australia and New Zealand was launched in December 2019. Based on the successful face-to-face program, the eLearning aims to increase availability and accessibility of high-quality online education to healthcare professionals providing care for families around the time of perinatal death, to improve the delivery of respectful and supportive clinical care and increase best practice investigation of perinatal deaths. To evaluate participants' reported learning outcomes (change in knowledge and confidence) and overall acceptability of the program. Pre- and post-eLearning in-built surveys were collected over two years (Dec. 2019-Nov. 2021), with a mix of Likert and polar questions. Pre- and post-eLearning differences in knowledge and confidence were assessed using McNemar's test. Subgroup analysis of overall acceptability by profession was assessed using Pearson's χ2 . One thousand, three hundred and thirty-nine participants were included. The majority were midwives (80.2%, n = 1074). A significant improvement in knowledge and confidence was shown across all chapters (P < 0.01). The chapter showing the greatest improvement was perinatal mortality audit and classification (21.5% pre- and 89.2% post-education). Over 90% of respondents agreed the online education was relevant, helpful, acceptable, engaging. Importantly, 80.7% of participants considered they were likely to change some aspect of their clinical practice after the eLearning. There was no difference in responses to relevance and acceptability of the eLearning program by profession. The IMPROVE eLearning is an acceptable and engaging method of delivery for clinical education, with the potential to improve care and management of perinatal deaths.

Low mortality rate after emergency laparotomy in Australia is a reflection of its national surgical mortality audit influencing futile surgery.

Australia's unique national surgical mortality audit has had a long-term focus on the avoidance of futile surgery. The 30-day mortality rate after emergency laparotomy in Australia is lower than in other countries. Early death (within 72 h) after emergency laparotomy may reflect futile surgery. This paper considers whether Australia's national mortality audit is the reason for its lower mortality rate after emergency laparotomy. Data were extracted from the Australia and New Zealand Emergency Laparotomy Audit-Quality Improvement (ANZELA-QI) from 2018 to 2022. The time elapsed from emergency laparotomy to death was determined for each patient. The cumulative daily mortality rate was calculated for the first 30 days and expressed as a proportion of all emergency laparotomies, and 30-day and in-hospital mortality. Mortality data were compared with those in the only three similar overseas studies. The mortality rate after emergency laparotomy for patients who required but did not undergo surgery was calculated for each hospital. The proportion of patients with high-risk characteristics was compared with that in the National Emergency Laparotomy Audit (NELA). Compared with overseas studies, there was a lower early (within 72 h) mortality rate in ANZELA-QI. Although the lower mortality rate in ANZELA-QI persisted to 30 days, there was a relative increase after 14 days that likely reflected known poor compliance with care standards. Australian patients had fewer high-risk characteristics than those in NELA. The present findings support the hypothesis that the lower mortality rate after emergency laparotomy in Australia is likely a consequence of its national mortality audit and the avoidance of futile surgery.

Potentially avoidable mortality after endoscopic retrograde cholangiopancreatography in Australia: an 8-year qualitative analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed procedure worldwide. The aim of this study was to examine cases of mortality after ERCP to identify clinical incidents that are potentially preventable, to improve patient safety. The Australian and New Zealand Audit of Surgical Mortality provides an independent and externally peer-reviewed audit of surgical mortality pertaining to potentially avoidable issues. A retrospective review of prospectively collected data within this database was performed for the 8-year audit period from 1 January 2009 to 31 December 2016. Clinical incidents were identified by assessors through first- or second-line review, and thematically coded into periprocedural stages. These themes were then qualitatively analysed. There were 58 potentially avoidable deaths following ERCP, with 85 clinical incidents. Preprocedural incidents were most common (n = 37), followed by postprocedural (n = 32) and then intraprocedural (n = 8). Communication issues occurred across the periprocedural period (n = 8). Preprocedural incidents included delay to procedure, inadequate resuscitative management, decision to perform procedure and inadequate assessment. Intraprocedural incidents comprised technical factors and inadequate support. Postprocedural incidents involved inappropriate treatment, delay in definitive surgical treatment or in recognizing complications, inappropriate second-line intervention and inadequate assessment. Communication incidents comprised inadequate documentation, failure to escalate care and poor inter-clinician communication. Causes of mortality following ERCP are wide-ranging, and reviewing clinical incidents associated with potentially avoidable mortality can serve to inform and educate practitioners. In collating a subset of cases in which procedure-related mortality was deemed avoidable, a series of cautionary tales about ERCP is presented that may provide cues to practitioners on improving patient safety and inform future surgical practice.

Understanding Potentially Preventable Mortality Following Oesophago-Gastric Cancer Surgery: Analysis of a National Audit of Surgical Mortality

IntroductionAt a national level, understanding preventable mortality after oesophago-gastric cancer surgery can direct quality-improvement efforts. Accordingly, utilizing the Australian and New Zealand Audit of Surgical Mortality (ANZASM), we aimed to: (1) determine the causes of death following oesophago-gastric cancer resections in Australia, (2) quantify the proportion of potentially preventable deaths, and (3) identify clinical management issues contributing to preventable mortality.MethodsAll in-hospital mortalities following oesophago-gastric cancer surgery from 1 January 2010 to 31 December 2020 were analysed using ANZASM data. Potentially preventable and non-preventable cases were compared. Thematic analysis with a data-driven approach was used to classify clinical management issues.ResultsOverall, 636 complications and 123 clinical management issues were identified in 105 mortalities. The most common causes of death were cardio-respiratory in aetiology. Forty-nine (46.7%) deaths were potentially preventable. These cases were characterized by higher rates of sepsis (59.2% vs 33.9%, p = 0.011), multiorgan dysfunction syndrome (40.8% vs 25.0%, p = 0.042), re-operation (63.3% vs 41.1%, p = 0.031) and other complications compared with non-preventable mortality. Potentially preventable mortalities also had more clinical management issues per patient [median (IQR): 2 (1–3) vs 0 (0–1), p < 0.001), which adversely impacted preoperative (30.6% vs 7.1%, p = 0.002), intraoperative (18.4% vs 5.4%, p = 0.037) and postoperative (51.0% vs 17.9%, p < 0.001) care. Thematic analysis highlighted recurrent areas of deficiency with preoperative, intraoperative and postoperative patient management.ConclusionsAlmost 50% of deaths following oesophago-gastric cancer resections were potentially preventable. These were characterized by higher complication rates and clinical management issues. We highlight recurrent themes in patient management to improve future quality of care.

Stigma, Confidentiality, and Blame: Qualitative Focus Groups of Ghanaian Obstetric Providers After Maternal and Perinatal Losses [ID: 1377293

INTRODUCTION: Despite maternal and perinatal mortality disproportionately occurring in low- and middle-income countries, there are limited data on the emotional toll these losses have on obstetric providers. In a series of focus groups discussions (FGDs), this study delves into the experiences of physicians and midwives in Ghana after maternal and perinatal losses. METHODS: Participants were obstetrician/gynecologists and midwives at the two largest tertiary hospitals in Ghana. Five FGDs were conducted by a trained facilitator, using a semi-structured guide. Questions explored experiences after patient deaths and perspectives on supportive interventions for providers. FGDs were audio-recorded and transcribed verbatim. Using an iteratively developed codebook, transcripts were thematically analyzed with NVivo. Written informed consent and IRB approvals were obtained. RESULTS: Twenty obstetricians and 32 midwives participated in five FGDs in Accra and Kumasi, Ghana. Most providers (84%) had completed training, and almost half (46%) had been in practice for above 10 years. Three major themes emerged: 1) pervasive stigma about seeking mental health services, especially from psychiatrists, rooted in cultural norms; 2) skepticism about departmental and peer confidentiality if providers seek support after poor outcomes; 3) profound sense of blame, both from self and peers, that resulted in poor mortality audit attendance and effects on workplace performance. Despite numerous barriers, providers expressed a strong need for improved departmental and institutional support systems. CONCLUSION: This study uncovers key barriers for providers to access mental health care and support after experiencing maternal and perinatal mortalities. Findings should inform interventions to better support struggling providers.

Predictors of mortality and survival probability distribution among patients on tuberculosis treatment in Vihiga County, Kenya.

Tuberculosis (TB) related mortality remains a serious impediment in ending TB epidemic. To estimate survival probability and identify predictors, causes and conditions contributing to mortality among TB patients in Vihiga County. A cohort of 291 patients from 20 purposively selected health facilities were prospectively considered. Data was obtained by validated questionnaires through face-to-face interviews. Survival probabilities were estimated using Kaplan-Meier method while Cox proportional hazard model identified predictors of TB mortality through calculation of hazard ratios at 95% confidence intervals. Mortality audit data was qualitatively categorized to elicit causes and conditions contributing to mortality. 209 (72%) were male, median age was 40 (IQR=32-53) years while TB/HIV coinfection rate was 35%. Overall, 45 (15%) patients died, majority (78% (log rank<0.001)) during intensive phase. The overall mortality rate was 32.2 (95% CI 23.5 - 43.1) deaths per 1000 person months and six months' survival probability was 0.838 (95% CI, 0.796-0.883). Mortality was higher (27%) among HIV positive than HIV negative (9%) TB patients. Independent predictors of mortality included; comorbidities (HR = 2.72, 95% CI,1.36-5.44, p< 0.005), severe illness (HR=5.06, 95% CI,1.59-16.1, p=0.006), HIV infection (HR=2.56, 95% CI,1.28-5.12, p=0.008) and smoking (HR=2.79, 95% CI,1.01-7.75, p=0.049). Independent predictors of mortality among HIV negative patients included; comorbidities (HR = 4.25, 95% CI; 1.15-15.7, p = 0.03) and being clinically diagnosed (HR = 4.8, 95% CI; 1.43-16, P = 0.01) while among HIV positive; they included smoking (HR = 4.05, 95% CI;1.03-16.0, P = 0.04), severe illness (HR = 5.84, 95% CI; 1.08-31.6, P = 0.04), severe malnutrition (HR = 4.56, 95% CI; 1.33-15.6, P = 0.01) and comorbidities (HR = 3.04, 95% CI; 1.03-8.97, p = 0.04). More than a half (52%) of mortality among HIV positive were ascribed to advanced HIV diseases while majority of (72%) of HIV negative patients died to TB related lung disease. Conditions contributing to mortality were largely patient and health system related. Risk of TB mortality is high and is attributable to comorbidities, severe illness, HIV and smoking. Causes and conditions contributing to TB mortality are multifaceted but modifiable. Improving TB/HIV care could reduce mortality in this setting.