Mortality Audit Research Articles

Maternal mortality after cesarean section in the Netherlands.

Maternal mortality is rare in high-resource settings. This hampers studies of the association between maternal mortality and mode of birth, although this topic remains of importance, given the changing patterns in mode of birth with increasing cesarean section rates in most countries. Purpose of this study was to examine incidence of cesarean section-related maternal mortality in the Netherlands and association of surgery with the chain of morbid events leading to death. We performed a retrospective cohort study using the Confidential Enquiry into Maternal Deaths, including all 2,684,946 maternities in the Netherlands between January 1st, 1999, and December 31st, 2013, registered in the Dutch Perinatal Registry. All available medical records of cases reported to the Dutch Maternal Mortality and Severe Morbidity Audit Committee were assessed by two researchers, and one or two additional experts in case of contradicting opinions, based on a set of pre-identified clinical criteria. Main outcome measures were (1) incidence and relative risk of maternal death following cesarean section and vaginal birth and (2) incidence of death directly related to cesarean section and death in which cesarean section was one of the contributing factors. Risk of death after cesarean section was 21.9 per 100.000 cesarean sections (86/393,443) versus 3.8 deaths per 100.000 vaginal births (88/2,291,503): Relative Risk (RR) 5.7 (95% Confidence Interval [CI] 4.2-7.7). Death directly related to complications of cesarean section occurred in 8/86 women: 2 per 100,000 cesarean sections. With addition of 43 women in which cesarean section did not initiate, but contributed to the chain of events leading to mortality, risk of death increased to 13 per 100,000 cesarean sections (51/393,443; RR 3.4; 95%CI 2.4-4.8). At the start of cesarean section, pre-existing morbidity was present in 70/86 women (81.4%). Compared to vaginal birth, maternal mortality after cesarean section was three times higher following exclusion of deaths that had no association with surgery. In approximately one in ten deaths after cesarean section, surgery did in fact initiate the chain of morbid events.

Post-mortem general surgeon reflection on decision-making: a mixed-methods study of mortality audit data.

Surgical deaths in Australia require the treating surgeon to document the event via a standard report. A section of this report invites surgeons to reflect on changes to management they would initiate in retrospect. This study analyses these reflective statements and categorizes them in an effort to gain insight into reflective learning. This audit-based cross-sectional study involves patients who died in-hospital under the care of general surgeons in Queensland, Australia, between July 2007 and December 2016. Retrospective surgeon statements were analysed using both quantitative and qualitative methods. Of the 2575 surgeons, 459 (18%) indicated they would manage their patient differently in retrospect. Half of these statements (46%) concerned changes to an operative decision. Of this group, most of these concerned either the decision to operate or not (26%), what operation to perform (32%) or earlier timing of surgery (32%). Overall, one-third of statements (29%) concerned retrospective changes to clinical decisions not related to operative management. Communication considerations, ceiling of care decisions and technical operative changes made up smaller proportions of statements. This mixed-methods study has identified a minority of surgeons proffer retrospective management changes after their patient has died. Of those who do, decision-making around operative management is the most common area of reflective consideration.

Maternal deaths from hypertensive disorders: lessons learnt.

Hypertensive disorders of pregnancy have been the most frequent cause of maternal death in Norway since 1996 and are strongly associated with substandard care. In the UK, the number of maternal deaths due to hypertensive disorders has decreased drastically due to the implementation of updated guidelines, indicating a potential for reducing the number of deaths in other countries as well. Through audits of maternal deaths, we aim to prevent future deaths from hypertensive disorders in pregnancy by identifying suboptimal factors in treatment. Maternal deaths in Norway from 1996 to 2014 were identified through linked registries. The Norwegian Maternal Mortality Audit Group performed all case assessments included in this study, classified the cause of death, evaluated the treatment, and identified suboptimal factors to care in each case. Emphasis was placed on antihypertensive treatment, timing of delivery, stabilization before delivery, and quality of care. Learning points were prepared to improve the treatment of hypertensive disorders of pregnancy. We identified 74 maternal deaths. The maternal mortality rate was 6.5 deaths per 100000 live births. The most common cause of death was hypertensive disorders (n=16 deaths). In 14 of these deaths (87%), the audit group concluded that improvements to care could have made a difference to the outcome. In 1996-2014, hypertensive disorders were the most common cause of maternal death in Norway. Our study indicates that such deaths can be prevented by improvements in antihypertensive treatment and the timing of delivery.

Clinicians’ perception of the preventability of inpatient mortality

PurposeThe purpose of this paper is to assess whether clinicians have an accurate perception of the preventability of their patients’ mortality. Case note review estimates that approximately 5 percent of inpatient deaths are preventable.Design/methodology/approachThe design involved in the study is a prospective audit of inpatient mortality in a single NHS hospital trust. The case study includes 979 inpatient mortalities. A number of outcome measures were recorded, including a Likert scale of the preventability of death- and NCEPOD-based grading of care quality.FindingsClinicians assessed only 1.4 percent of deaths as likely to be preventable. This is significantly lower than previously published values (p<0.0001). Clinicians were also more likely to rate the quality of care as “good,” and less likely to identify areas of substandard clinical or organizational management.Research limitations/implicationsThe implications of objective assessment of the preventability of mortality are essential to drive quality improvement in this area.Practical implicationsThere is a wide disparity between independent case note review and clinicians assessing the care of their own patients. This may be due to a “knowledge gap” between reviewers and treating clinicians, or an “objectivity gap” meaning clinicians may not recognize preventability of death of patients under their care.Social implicationsThis study gives some insight into deficiencies in clinical governance processes.Originality/valueNo similar study has been performed. This has significant implications for the idea of the preventability of mortality.

Post-operative Complications Following Emergency Operations Performed by Trainee Surgeons: A Retrospective Analysis of Surgical Deaths.

Adequate surgical care of patients and concurrent training of residents is achieved in elective procedures through careful case selection and adequate supervision. Whether this applies when trainees are involved in emergency operations remains equivocal. The aim of this study was therefore to compare the risk of post-operative complications following emergency procedures performed by senior operators compared with supervised trainees. This is a retrospective cohort study examining in-hospital deaths of patients across all surgical specialties who underwent emergency surgery in Australian public hospitals reported to the national surgical mortality audit between 2009 and 2015. Multivariable logistic regression was used to explore whether there was an association between the level of operator experience (senior operator vs trainee) and the occurrence of post-operative surgical complications following an emergency procedure. Our population consisted of 6920 patients. There were notable differences between the trainees and senior operator groups; trainees more often operated on patients aged over 80years, with cardiovascular and neurological risk factors. Senior operators more often operated on very young and obese patients with advanced malignancy and hepatic disease. Supervised trainees had a lower rate of post-operative complications compared with senior operators; 18% (n=396) and 25% (n=1210), respectively (p<0.05). Operations performed by trainees were associated with an 18% decrease (95% CI 5-29%; p<0.05) in odds of post-operative complications compared with senior operators, adjusting for potential confounders. Contrary to popular belief, our results suggest that supervised trainees safely perform emergency operations, provided that cases are judiciously selected.

Deaths in Incorrectly Identified Low-Surgical-Risk Patients.

The American Society of Anesthesiologists (ASA) physical classification system was developed for assessing anaesthetic risk, but is often also used to estimate surgical death risk. Patients with low ASA grades (ASA 1 or 2) are expected to have better surgical outcomes than patients with higher ASA grades (ASA≥4). This study examined the course to death in patients classified as ASA 1 or 2 was examined, to investigate possible factors in unexpected deaths, in addition to evaluating the use of ASA grades by clinicians. Patient data from the national surgical mortality audit of Australian hospitals were examined. The patient group was listed as ASA grade 1 or 2 by surgeons. Patients over 60 or under 20 were excluded in the final analysis, as were cases from New South Wales due to data not being available. A total of 357 cases were examined. Assessor summaries of the cases were examined, and ASA score reassessed to determine accuracy. More than 95% (n=339) of cases listed as ASA 1 or 2 were found to have an incorrectly low grade, with 17.6% (n=63) of cases listed as "expected" deaths. ASA grades appear to be misunderstood in the reporting of patient surgical risk. Many patient summaries list patients with severe systemic disease or expected deaths as ASA 1 or 2, contrary to the intended use of this classification system. Improved education on the use of the ASA grading system would be beneficial to clinicians.

Maternal mortality audit based on district maternal health performance in East Java Province, Indonesia

Background: Maternal mortality rate (MMR) in Indonesia is still high, including in East Java Province. Although the successful decline in MMR has been achieved, more action still needed to maintain and accelerate the process. Several factors that affect the maternal mortality, especially referral factor, and districts maternal health services quality, need to analyze. This study was conducted to analyze the correlation between maternal mortality with labour referral and maternal health service quality in 10 regencies/cities in East Java Province, Indonesia. Methods: The case-control study among 2 groups of 5 regencies/cities with the highest and lowest MMR in East Java Province in 2015. The indicators used, were maternal referral relay in maternal mortality report, frequencies of antenatal care, labor by health care provider, puerperal health care, obstetric complication management, detection of high-risk pregnancy by community and healthcare personnel, and family planning program. Results: Total number of maternal mortality in East Java province in 2015 was 531, with MMR were 89,6/100.000 living birth. From the comparative study, we found a significant difference in indicators of high-risk pregnancy detection by healthcare personnel (p=0,035) and obstetrics complications management (p=0,006). There were no significant differences in frequencies of antenatal care, labor by health care provider, puerperal health care, detection of high-risk pregnancy by the community, and family planning program in 10 regencies/cities in East Java Province, Indonesia. Conclusion: High-risk pregnancy detection by healthcare personnel and obstetrics complications management were related with MMR in 10 districts in East Java province, Indonesia.

A 5-year audit of maternal mortality in Mansoura University Hospital, Egypt

Background: This 5-year audit aims to estimate maternal mortality ratio (MMR) and describe causes of deaths as well as demographic and obstetric characters of dead mothers in Mansoura University Hospital (MUH), Egypt. Methods: A hospital-based retrospective descriptive study was carried out during the period from 2011 to 2015. All obstetric records (case notes, records of labor room, emergency records, and ward admission files) were reviewed for maternal deaths. The following data were abstracted: age, residence, occupation, cause of deaths, gestational age, gravidity, and mode of termination of pregnancy. Causes of maternal deaths were classified as direct and indirect. Results: During the study period, 23,078 obstetric admissions, 22,323 live births, and 61 maternal deaths were recorded. The MMR declined from 380.8 in 2011 to 145.5/100,000 live births in 2015. Hemorrhage and hypertensive disorders with pregnancies were the two main direct causes of maternal deaths. Out of the total deaths, 83.6% were in the age group of 21 to 35 years. The majority of maternal deaths (72.1%) belonged to rural areas and 91.8% were non-working. Most of the women who died were primigravida (49.2%). Only 26.2% of the mothers who died received antenatal care. More than half (57.4%) of deaths occurred after 48 hours of admission. Conclusion: The MMR in MUH is higher than national and regional figures. Adequate antenatal care and early referral of mothers with complications could contribute to reduction of maternal mortality. It is important to establish an audit committee for maternal deaths to determine the trends, causes, quality of care provided, and preventability of the death.

Measuring Outcomes of Clinical Care: Victorian Emergency Laparotomy Audit Using Quality Investigator.

The Australian and New Zealand Audit of Surgical Mortality (ANZASM) National Report 2015 found that within the cohort of audited deaths, 85% were emergencies with acute life-threatening conditions, and by far, the most common procedures were laparotomy and colorectal procedures. Emergency laparotomy outcomes have shown improvement through audit and reporting in the UK. The purpose of this study was to determine the outcome of emergency laparotomy in the state of Victoria, Australia. The Dr Foster Quality Investigator (DFQI) database was interrogated for a set of Australian Classification of Health Intervention (ACHI) codes defined by the authors as representing an emergency laparotomy. The dataset included patients who underwent emergency laparotomy from July 2007 to July 2016 in all Victorian hospitals. There were 23,115 emergency laparotomies conducted over 9years in 66 hospitals. Inpatient mortality was 2036/23,115 (8.8%). Mortality in the adult population increased with age and reached 18.1% in those patients that were 80years or older. 51.3% were females, and there was no significant difference in survival between genders. Patients with no recorded comorbidities had a mortality of 4.3%, whereas those with >5 comorbidities had 19.3% mortality. Administrative data accessed via a tool such as DFQI can provide useful population data to guide further evidence-based improvement strategies. The mortality for emergency laparotomy within Victorian hospitals is comparable, if not better than that seen in overseas studies. There is a need to continue routine audit of mortality rates and implement systems improvement where necessary.

Making stillbirths visible: a systematic review of globally reported causes of stillbirth.

Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention. To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM. We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016. Reports of stillbirth causes in unselective cohorts. Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC). Eighty-five reports from 50 countries (489089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes. There is a paucity of quality information on causesof stillbirth globally. Improving investigation of stillbirthsand standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings. HR, SH, SHL, and AW were supported by an NHMRC-CRE grant (APP1116640). VF was funded by an NHMRC-CDF (APP1123611). Urgent need to improve data on causes of stillbirths across all settings to meet global targets. Background and methods Nearly three million babies are stillborn every year. These deaths have deep and long-lasting effects on parents, healthcare providers, and the society. One of the major challenges to preventing stillbirths is the lack of information about why they happen. In this study, we collected reports on the causes of stillbirth from high-, middle-, and low-income countries to: (1) Understand the causes of stillbirth, and (2) Understand how to improve reporting of stillbirths. Findings We found 85 reports from 50 different countries. The information available from the reports was inconsistent and often of poor quality, so it was hard to get a clear picture about what are the causes of stillbirth across the world. Many different definitions of stillbirth were used. There was also wide variation in what investigations of the mother and baby were undertaken to identify the cause of stillbirth. Stillbirths in all income settings (low-, middle-, and high-income countries) were most frequently reported as Unexplained, Other, and Haemorrhage (bleeding). Unexplained and Other are not helpful in understanding why a baby was stillborn. In low-income countries, stillbirths were often attributed to Infection and Complications during labour and birth. In middle- and high-income countries, stillbirths were often reported as Placental complications. Limitations We may have missed some reports as searches were carried out in English only. The available reports were of poor quality. Implications Many countries, particularly those where the majority of stillbirths occur, do not report any information about these deaths. Where there are reports, the quality is often poor. It is important to improve the investigation and reporting of stillbirth using a standardised system so that policy makers and healthcare workers can develop effective stillbirth prevention programs. All stillbirths should be investigated and reported in line with the World Health Organization standards.

An audit of head trauma care and mortality.

To analyze the factors contributing to deaths from head trauma by using standardized assessment parameters and to provide a peer-review of head injury deaths with focus on identifying deficiencies and analyzing contributory factors. Descriptive study. The study was carried out at the Emergency, Aga Khan University Hospital during January 1998 to December 1999. One hundred and three patients above the age of 15 years presenting alive to the Aga Khan University Hospital (AKUH) emergency with head injury were included in this study. Identified deaths data was reviewed by the Hospital Trauma Peer Review Committee and consensus arrived at for categorization of deaths. The potential deficiencies in care were identified and final recommendations made. The data was computed on CDC Trauma Registry (V 3.0) and SPSS (V 8.0). Mean age was 31.9 years (n=103) with predominant male population (4:1). Severe head injury (GCS<8) accounted for 21.3 % (n=22) of all cases with a total number of deaths being 12.6 % (n=13). Deaths were categorized preventable in 3 cases with non-preventable and potentially preventable in 4 and 6 cases respectively. Road traffic accidents were the predominant mechanism (n=8) in all deaths (n=13). The time interval in relation to mortality was biphasic, most deaths occurring either within 24 hours or between 3-7 days of injury. Inappropriate pre-hospital treatment, pre-hospital delays and inappropriate mode of transportation without inter-hospital communication were the process-related defects in pre-hospital care with major determinant of deaths outside AKUH (n=5). Prolonged emergency stay, delayed intensive care availability were the process-related deficiencies whereas inappropriate initial resuscitation, inappropriate initial head injury management were provider-related deficiencies in in-hospital care. Transfer of inappropriately managed patients, lapses in inter-hospital communications, delayed transfers were identified as the major pre-hospital factors whereas lack of ICU beds, portable ventilators in emergency room, delays in CT scan facilities were the deficiencies in the hospital services. Opportunities for improvement in head trauma care are needed to focus on initial resuscitation and appropriate surgical management.

Processes of care in surgical patients who died with hospital-acquired infections in Australian hospitals

Infection may complicate surgical patients' hospital admission. The effect of hospital-acquired infections (HAIs) on processes of care among surgical patients who died is unknown. To investigate the effect of HAIs on processes of care in surgical patients who died in hospital. Surgeon-recorded infection data extracted from a national Australian surgical mortality audit (2012-2016) were grouped into HAIs and no infection. The audit included all-age surgical patients, who died in hospital. Not all patients had surgery. Excluded from analysis were patients with community-acquired infection and those with missing timing of infection. Multivariate logistic regression was used to determine the adjusted effects of HAIs on the processes of care in these patients. Costs associated with HAIs were estimated. One-fifth of surgical patients who died did so with an HAI (2242 out of 11,681; 19.2%). HAI patients had increased processes of care compared to those who died without infection: postoperative complications [51.0% vs 30.3%; adjusted odds ratio (aOR): 2.20; 95% confidence interval (CI): 1.98-2.45; P<0.001]; unplanned reoperations (22.6% vs 10.9%; aOR: 2.38; 95% CI: 2.09-2.71; P<0.001) and unplanned intensive care unit admission (29.3% vs 14.8%; aOR: 2.18; 95% CI: 1.94-2.45; P<0.001). HAI patients had longer hospital admissions and greater hospital costs than those without infection. HAIs were associated with increased processes of care and costs in surgical patients who died; these outcomes need to be investigated in surgical patients who survive.

Maternal mortality audit in Suriname between 2010 and 2014, a reproductive age mortality survey

BackgroundThe fifth Millennium Development Goal (MDG-5) aimed to improve maternal health, targeting a maternal mortality ratio (MMR) reduction of 75% between 1990 and 2015. The objective of this study was to identify all maternal deaths in Suriname, determine the extent of underreporting, estimate the reduction, audit the maternal deaths and assess underlying causes and substandard care factors.MethodsA reproductive age mortality survey was conducted in Suriname (South-American upper-middle income country) between 2010 and 2014 to identify all maternal deaths in the country. MMR was compared to vital statistics and a previous confidential enquiry from 1991 to 1993 with a MMR 226. A maternal mortality committee audited the maternal deaths and identified underlying causes and substandard care factors.ResultsIn the study period 65 maternal deaths were identified in 50,051 live births, indicating a MMR of 130 per 100.000 live births and implicating a 42% reduction of maternal deaths in the past 25 years. Vital registration indicated a MMR of 96, which marks underreporting of 26%. Maternal deaths mostly occurred in the urban hospitals (84%) and the causes were classified as direct (63%), indirect (32%) or unspecified (5%). Major underlying causes were obstetric and non-obstetric sepsis (27%) and haemorrhage (20%). Substandard care factors (95%) were mostly health professional related (80%) due to delay in diagnosis (59%), delay or wrong treatment (78%) or inadequate monitoring (59%). Substandard care factors most likely led to death in 47% of the cases.ConclusionDespite the reduction in maternal mortality, Suriname did not reach MDG-5 in 2015. Steps to reach the Sustainable Development Goal in 2030 (MMR ≤ 70 per 100.000 live births) and eliminate preventable deaths include improving data surveillance, installing a maternal death review committee, and implementing national guidelines for prevention and management of major complications of pregnancy, childbirth and puerperium.

National surgical mortality audit may be associated with reduced mortality after emergency admission.

The Western Australian Audit of Surgical Mortality was established in 2002. A 10-year analysis suggested it was the primary driver in the subsequent fall in surgeon-related mortality. Between 2004 and 2010 the Royal Australasian College of Surgeons established mortality audits in other states. The aim of this study was to examine national data from the Australian Institute of Health and Welfare (AIHW) to determine if a similar fall in mortality was observed across Australia. The AIHW collects procedure and outcome data for all surgical admissions. AIHW data from 2005/2006 to 2012/2013 was used to assess changes in surgical mortality. Over the 8 years surgical admissions increased by 23%, while mortality fell by 18% and the mortality per admission fell by 33% (P < 0.0001). A similar decrease was seen in all regions. The mortality reduction was overwhelmingly observed in elderly patients admitted as an emergency. The commencement of this nation-wide mortality audit was associated with a sharp decline in perioperative mortality. In the absence of any influences from other changes in clinical governance or new quality programmes it is probable it had a causal effect. The reduced mortality was most evident in high-risk patients. This study adds to the evidence that national audits are associated with improved outcomes.

Quality Assurance Audit of Technique Failure and 90-Day Mortality after Program Discharge in a Canadian Home Hemodialysis Program.

Little is known about patients exiting home hemodialysis. We sought to characterize the reasons, clinical characteristics, and pre-exit health care team interactions of patients on home hemodialysis who died or underwent modality conversion (negative disposition) compared with prevalent patients and those who were transplanted (positive disposition). We conducted an audit of all consecutive patients incident to home hemodialysis from January of 2010 to December of 2014 as part of ongoing quality assurance. Records were reviewed for the 6 months before exit, and vital statistics were assessed up to 90 days postexit. Ninety-four patients completed training; 25 (27%) received a transplant, 11 (12%) died, and 23 (25%) were transferred to in-center hemodialysis. Compared with the positive disposition group, patients in the negative disposition group had a longer mean dialysis vintage (3.15 [SD=4.98] versus 1.06 [SD=1.16] years; P=0.003) and were performing conventional versus a more intensive hemodialysis prescription (23 of 34 versus 23 of 60; P<0.01). In the 6 months before exit, the negative disposition group had significantly more in-center respite dialysis sessions, had more and longer hospitalizations, and required more on-call care team support in terms of phone calls and drop-in visits (each P<0.05). The most common reason for modality conversion was medical instability in 15 of 23 (65%) followed by caregiver or care partner burnout in three of 23 (13%) each. The 90-day mortality among patients undergoing modality conversion was 26%. Over a 6-year period, approximately one third of patients exited the program due to death or modality conversion. Patients who die or transfer to another modality have significantly higher health care resource utilization (e.g., hospitalization, respite treatments, nursing time, etc.).

How participation in surgical mortality audit impacts surgical practice

BackgroundSurgical mortality audit is an important tool for quality assurance and professional development but little is known about the impact of such activity on professional practice at the individual surgeon level. This paper reports the findings of a survey conducted with a self-selected cohort of surgeons in Queensland, Australia, on their experience of participating in the audit and its impact on their professional practice, as well as implications for hospital systems.MethodsThe study used a descriptive cross-sectional survey design. All surgeons registered in Queensland in 2015 (n = 919) were invited to complete an anonymous online questionnaire between September and October 2015. 184 surgeons completed and returned the questionnaire at a response rate of 20%.ResultsThirty-nine percent of the participants reported that involvement in the audit process affected their clinical practice. This was particularly the case for surgeons whose participation included being an assessor. Thirteen percent of the participants had perceived improvement to hospital practices or advancement in patient care and safety as a result of audit recommendations. Analysis of the open-ended responses suggested the audit experience had led surgeons to become more cautious, reflective in action and with increased confidence in best practice, and recognise the importance of effective communication and clear documentation.ConclusionsThis is the first study to examine the impact of participation in a mortality audit process on the professional practice of surgeons. The findings offer evidence for surgical mortality audit as an effective strategy for continuous professional development and for improving patient safety initiatives.

Preliminary outcomes of laparoscopic versus open common bile duct exploration: the mater experience

Objective: ERCP is the gold standard treatment for stones in the common bile duct (CBD). Open or laparoscopic exploration of the CBD is only warranted where ERCP is unsuccessful, or if the patient's anatomy is unamenable to ERCP such as in cases of prior gastrectomy. We report the outcomes of open and preliminary outcomes of laparoscopic approaches. Methods: An audit of outcomes of CBD exploration for gallstones from 1 Jan 2008 to July 2016 was performed. Demographic and clinical data of patients in the study group is included below. Mater Morbidity and Mortality Audit data was used to identify complications, which were then graded using the Clavien–Dindo classification. Results: A total of 30 patients underwent CBD exploration: 20 open and 10 via laparoscopic approach. The mean age at surgery was 67 in the open group, 61 in laparoscopic group, (range: 30–80). In the open CBD cohort, 10% (2/20) were performed due to complication of ERCP compared to 0% in the laparoscopic cohort. The duct was cleared in 90% (18/20) of cases in those who underwent open procedure compared to 70% duct clearance (7/10) of those who underwent laparoscopic approach. The 30-day mortality in the open cohort was 5% (1/20) compared to 0% in patients explored laparoscopically. Conclusion: Laparoscopic CBD exploration is a new treatment modality available for CBD stones. Preliminary results suggest that both open and laparoscopic approaches are safe and effective in cases of unsuccessful ERCP.

Audit of Neonatal Morbidity and Mortality in A Tertiary Care Hospital, Sylhet

Background: To know the disease pattern and causes of morbidity &amp; mortality of patients admitted to the neonatal unit in a tertiary care hospital in Sylhet, Bangladesh.Methods: This retrospective study was conducted in the neonatal unit from December 2014 to November 2015. Data of all the patients admitted to the neonatal unit during study period was analyzed for, age, sex, weight, gestational age, place and mode of delivery, maternal antenatal events, disease pattern and their outcome.Results: A total of 985 patients were admitted during study period. Among 985 cases 566(57.5%) were male and 419(42.5%) were female. 450(45.6%) were admitted at the age of less than 24 hours. 122 (12.4%) were preterm babies. 202(20.5%) were low birth weight. 693(70.4%) were delivered in hospital. Main causes of admission were perinatal asphyxia 398(40.4%), neonatal sepsis164 (16.6%), preterm LBW 122(12.4%), Meconium Stained Baby (MSB) 88(8.9%), Intrauterine Growth Retardation (IUGR) 80(8.1%), neonatal jaundice 62(6.2%), Infant of Diabetic Mother (IDM) 30(3.0%), Transient Tachypnoea of Newborn (TTN) 15(1.5%), Meconium Aspiration Syndrome (MAS) 10(1.1%), Respiratory Distress Syndrome (RDS) 6(0.6%) and congenital anomaly 10(1.1%). Most of the deaths were associated with preterm LBW (6.5%), perinatal asphyxia with Hypoxic Ischaemic Encephalopathy (HIE) (4.5%), sepsis (2.4%), RDS (16.7%), MAS (10%).Conclusion: Preterm LBW, perinatal asphyxia and neonatal sepsis were the three leading cause of neonatal morbidity &amp; mortality. These findings could be important in identifying the areas requiring attention to improve the perinatal care and also to manage the problems associated with them.Chatt Maa Shi Hosp Med Coll J; Vol.15 (2); Jul 2016; Page 45-48

Most Liver Related Deaths in India Are Caused by Alcohol: An Audit of Liver Mortality From Tertiary Care Center in North India

Most Liver Related Deaths in India Are Caused by Alcohol: An Audit of Liver Mortality From Tertiary Care Center in North India

A Ten Year Audit of Maternal Mortality: Millennium Development Still a Distant Goal.

Objective:To assess various causes of maternal mortality over a ten year periodDesign:Retrospective audit of hospital case recordsSetting:Tertiary care hospitalPopulation:Pregnant women who expired in the premises of GTB Hospital.Materials and Methods:A retrospective audit of case records of maternal deaths was conducted for a ten year period (January 2005 to December 2014).Results:There were a total of 647 maternal deaths out of 1,16,641 live births. Sixty-eight percent (n = 445) of women were aged 21-30 years, while 10.5% (n = 68) were <20 years of age. The most common direct causes of maternal mortality were preeclampsia/eclampsia in 24.4% (n = 158), obstetric hemorrhage in 19.1% (n = 124) and puerperal sepsis in 14.5% (n = 94). With regards to indirect causes, anemia accounted for 15.3% (n = 99) mortality. There was only 1 (0.1%) mortality because of HIV/AIDS. Other notable causes of maternal mortality were infective hepatitis in 7.1% (n = 46). Tuberculosis, that is a disease of tropical countries, accounted for 3.0% (n = 20) of the total deaths.Conclusion:High maternal mortality in GTB hospital can be due to it being a tertiary hospital with referrals from all neighbouring states. Accessible antenatal care can help prevent these maternal deaths. Female education can be of immense help in dealing with the problem and improving the utilization of public health facilities.Key Message:Preeclampsia/eclampsia and obstetric hemorrhage have been the main causes of maternal mortality for ages. Regular antenatal visits and the judicious training of grassroot level workers to pick-up complications early on in the pregnancy can be an effective way to deal the morbidity and mortality associated with these problems. The Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) in India are pioneer steps in this direction.