Audit Of Morbidity Research Articles

Operative caseload of general surgeons working in a rural hospital in Central Australia.

There is limited published data on the caseload of general surgeons in Central Australia. The region has a significant Indigenous population, who often face higher rates of chronic diseases and require more frequent surgical interventions compared to non-Indigenous individuals. This study aims to outline the workload of surgeons at Alice Springs Hospital to determine the necessary skill set and surgical education for future surgeons. A retrospective review of all general surgery operative cases performed in Central Australia, Alice Springs Hospital was conducted between January 2012 and December 2021. The RACS Morbidity Audit and Logbook Tool was used to classify surgical procedures along with Medicare Benefits Schedule item numbers. Tables were created to present the annual and specialty-specific data on the types and volumes of procedures. From January 2012 to December 2021, 35 318 cases were performed, with 92.5% being general surgery, 3% plastics and reconstructive surgery and 2.8% vascular procedures. Indigenous patients received a higher proportion of procedures (50-60%) compared to non-Indigenous patients (30-50%). Common procedures included incision and drainage of abscesses and debridement of wounds, while trends across specialties showed a decline in ENT and plastic surgeries, stable thoracic and vascular cases, and increased numbers of urology operations. General surgeons in rural centres must possess a wide range of skills and be capable of performing a variety of procedures. Trainees should be encouraged to consider practicing in rural areas, and those interested should account for the specific needs of the communities they plan to serve.

Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey

BackgroundThe methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown.The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. MethodsUsing a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. ResultsThe survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population.Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients’ discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. ConclusionsThis study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.

Assessment of postoperative morbidity in Spanish hospitals: Results from a national survey

BackgroundThe methodology used for recording, evaluating and reporting postoperative complications (PC) is unknown.The aim of the present study was to determine how PC are recorded, evaluated, and reported in General and Digestive Surgery Services (GDSS) in Spain, and to assess their stance on morbidity audits. MethodsUsing a cross-sectional study design, an anonymous survey of 50 questions was sent to all the heads of GDSS at hospitals in Spain. ResultsThe survey was answered by 67 out of 222 services (30.2%). These services have a reference population (RP) of 15 715 174 inhabitants, representing 33% of the Spanish population.Only 15 services reported being requested to supply data on morbidity by their hospital administrators. Eighteen GDSS, with a RP of 3 241 000 (20.6%) did not record PC. Among these, 7 were accredited for some area of training. Thirty-six GDSS (RP 8 753 174 (55.7%) did not provide details on all PC in patients’ discharge reports. Twenty-four (37%) of the 65 GDSS that had started using a new surgical procedure/technique had not recorded PC in any way. Sixty-five GDSS were not concerned by the prospect of their results being audited, and 65 thought that a more comprehensive knowledge of PC would help them improve their results. Out of the 37 GDSS that reported publishing their results, 27 had consulted only one source of information: medical progress records in 11 cases, and discharge reports in 9. ConclusionsThis study reflects serious deficiencies in the recording, evaluation and reporting of PC by GDSS in Spain.

Effective peer review audit and identification of the surgeon outlier.

Surgical audit aims to identify ways to maintain and improve the quality of care for patients, in part by assessment of a surgeon's activities and outcomes. However effective data systems to facilitate audit are uncommon. We aimed to assess the effectiveness of a tool for Peer Review Audit. All General Surgeons in Darwin and the Top End were encouraged to self-record their surgical activity, including procedures and adverse events related to procedures, using the College's Morbidity Audit and Logbook Tool (MALT). A total of 6 surgeons and 3518 operative events were recorded in MALT between 2018 and 2019. De-identified reports of each surgeon's activities, compared directly to the audit group, were created by each surgeon, with correction for complexity of procedures and ASA status. Nine complications Grade 3 and greater were recorded, plus 6 deaths, 25 unplanned returns to theatre (8% failure to rescue rate), 7 unplanned admissions to ICU and 8 unplanned readmissions. One surgeon outlier was identified (>3 standard deviation over group mean) for unplanned returns to theatre. This surgeon's specific cases were reviewed at our morbidity and mortality meeting using the MALT Self Audit Report and changes were implemented as a result, with future progress monitored. The College's MALT system effectively enabled Peer Group Audit. All participating surgeons were readily able to present and validate their own results. A surgeon outlier was reliably identified. This led to effective practice change. The proportion of surgeons who participated was low. Adverse events were likely under-reported.

Current approach and attitudes toward neonatal near-miss and perinatal audits: An exploratory international survey.

Combined with perinatal mortality review, neonatal near-miss (NNM) audit has the potential to inform strategies to better prevent adverse perinatal outcomes. Nonetheless, there is lack of standardised definitions of NNM and limited evidence of implementation of NNM audits. To describe definitions of NNM and assess current approaches and attitudes toward perinatal mortality and morbidity audit. Online survey from December 2021 to February 2022, with a mix of Likert scales, polar, pool, multi-choice, and open-ended questions, disseminated through national and international organisations to perinatal healthcare workers from high-income countries. One hundred and twenty participants came from Australia (n=86), New Zealand (n=18), Canada (n=7), USA (n=4), Netherlands (n=2), other countries (n=3). Neonatologists (35%), midwives (21.7%), obstetricians (12.5%), neonatal nurse practitioners (11.7%) and others (23.3%) responded. Most respondents thought the main characteristics to define NNM were birth asphyxia needing therapeutic hypothermia (68.3%), unexpected resuscitation at birth (67.5%), need for intubation/chest compression/adrenaline (65.0%) and metabolic acidosis at birth (60.0%). There were 97.5% of participants who considered NNM important for identifying cases for perinatal morbidity audits. However, only 10.0% of their institutions used a NNM definition. Overall, 98.4% of participants considered perinatal mortality and morbidity audits important to prevent adverse outcomes. Neonatal near-miss audit is viewed as a valuable tool to reduce adverse neonatal outcomes. There was reasonable consensus that NNM encompassed evidence of birth asphyxia and/or advanced neonatal resuscitation. Data from this international survey identifies a starting point for a consensus definition of NNM, which can be used for perinatal audits to identify opportunities for improvement.

Exploring healthcare workers\u2019 perceptions on the use of morbidity and mortality audits as an avenue for learning and care improvement in Kenyan hospitals\u2019 newborn units

BackgroundIn many sub-Saharan African countries, including Kenya, the use of mortality and morbidity audits in maternal and perinatal/neonatal care as an avenue for learning and improving care delivery is sub-optimal due to structural, organizational, and human barriers. While attempts to address these barriers have been reported, lots of emphasis has been paid to addressing the role of tangible inputs (e.g., availing guidelines and training staff in the success of mortality and morbidity audits), while process-related factors (i.e., the role of the people, their experiences, relationships, and motivations) remain inadequately explored. We examined the processes of neonatal audits, their potential in promoting learning from gaps in care and improving care delivery, with a deliberate focus on process-related factors that generally influence mortality and morbidity (M&M) audits.MethodsThis was an exploratory qualitative study, conducted in three hospitals, in Nairobi and Muranga counties. We employed a mix of in-depth interviews (17) and observation of 12 mortality and morbidity audit meetings. Our study participants included: nurses, doctors, trainee clinicians (i.e., junior doctors on internships), and nursing students involved in providing newborn care. These data were coded using NVivo12 employing a thematic content analysis approach.ResultsPerceived shortcomings in the conduct of M&M audits such as unclear structure was reported to have contributed to its sub-optimal nature in promoting learning. These shortcomings, in addition to hierarchy and power dynamics, poor implementation of audit recommendations, and negative experiences, (e.g., blame) also demotivated health workers from attendance and participation in audits. Despite these, positive outcomes linked to audit recommendations, such as revision of care protocols, were reported. Overall, leadership and a blame-free culture enabled positive changes and promoted learning from audit-identified modifiable factors.ConclusionOur findings indicate that M&M audits provide a space for meaningful discussions, which may lead to learning and improvement in care delivery processes. However, a lack of participation, lack of observed positive outcomes, and negative experiences may reduce their usefulness. An enabling environment characterized by minimized effects of hierarchy and positive use of power and a blame-free culture may promote active participation, enhancing positive relationships and interactions thus promoting team learning.

Combined Clinical Audits and Low-Dose, High-frequency, In-service Training of Health Care Providers and Community Health Workers to Improve Maternal and Newborn Health in Mali: Protocol for a Pragmatic Cluster Randomized Trial.

BackgroundAlthough most births in Mali occur in health facilities, a substantial number of newborns still die during delivery and within the first 7 days of life, mainly because of existing training deficiencies and the challenges of maintaining intrapartum and postpartum care skills.ObjectiveThis trial aims to assess the effectiveness and cost-effectiveness of an intervention combining clinical audits and low-dose, high-frequency (LDHF) in-service training of health care providers and community health workers to reduce perinatal mortality.MethodsThe study is a three-arm cluster randomized controlled trial in the Koulikoro region in Mali. The units of randomization are each of 84 primary care facilities. Each trial arm will include 28 facilities. The facilities in the first intervention arm will receive support in implementing mortality and morbidity audits, followed by one-day LDHF training biweekly, for 6 months. The health workers in the second intervention arm (28 facilities) will receive a refresher course in maternal neonatal and child health (MNCH) for 10 days in a classroom setting, in addition to mortality and morbidity audits and LDHF hands-on training for 6 months. The control arm, also with 28 facilities, will consist solely of the standard MNCH refresher training delivered in a classroom setting. The main outcomes are perinatal deaths in the intervention arms compared with those in the control arm. A final sample of approximately 600 deliveries per cluster was expected for a total of 30,000 newborns over 14 months. Data sources included both routine health records and follow-up household surveys of all women who recently gave birth in the study facility 7 days postdelivery. Data collection tools will capture perinatal deaths, complications, and adverse events, as well as the status of the newborn during the perinatal period. A full economic evaluation will be conducted to determine the incremental cost-effectiveness of each of the case-based focused LDHF hands-on training strategies in comparison to MNCH refresher training in a classroom setting.ResultsThe trial is complete. The recruitment began on July 15, 2019, and data collection began on July 23, 2019, and was completed in November 2020. Data cleaning or analyses began at the time of submission of the protocol.ConclusionsThe results will provide policy makers and practitioners with crucial information on the impact of different health care provider training modalities on maternal and newborn health outcomes and how to successfully implement these strategies in resource-limited settings.Trial RegistrationClinicalTrials.gov NCT03656237; https://clinicaltrials.gov/ct2/show/NCT03656237International Registered Report Identifier (IRRID)DERR1-10.2196/28644

Prevalence and Pattern of Birth Defects among Pediatric Surgical Patients: A 12-Year Analysis in a Tertiary-level Government Hospital in Bangladesh

Aims: Birth defects are structural or functional abnormalities which occur during the intrauterine life but can be identified at birth or a later age. Birth defects are major public health concerns and the World Health organization (WHO) is supporting countries for earlier diagnosis and better treatment of these conditions. The aim of the study was to assess the hospital-based prevalence and types of birth defects among the surgical children from a part of the world where these are underreported.
 Materials and Methods: We retrospectively analyzed patients of birth defects admitted in the Department of Pediatric Surgery, Chattogram Medical College Hospital, Bangladesh for a period of 12 years (2008-2019). Data were extracted from annual admission reports, annual audits, mortality and morbidity audits, death registers and computerize data base. Yearly distribution of birth defects, type of defects and their systemic distribution and mortality were analyzed.
 Results: Among a total of 30,301 admitted patients 30.72% (9307 patients) had birth defects. The most common system involved with birth defects was gastrointestinal (GI) system, 30.61% followed by genitourinary (GU), 29.15% system. Congenital inguinal hernia (17.50%) was the most common disease, followed by hypospadias (14.54%) and anorectal malformation (ARM); 13.98%. Mortality from birth defects were 53.25% of all mortalities. ARM was the most common cause of death (23%), followed by gastroschisis (16%) and intestinal atresia (11%). Highest mortality rates were in tracheo-esophageal fistula/esophageal atresia (TEF/EA)- 83.33%, gastroschisis-80.92%; intestinal atresia-42.53%; omphalocele-32.48%; and congenital diaphragmatic hernia (CDH)- 27.78%.
 Conclusion: Pattern of birth defects and outcome varied from other countries. The prevalence is 31% among pediatric surgical admissions. Some conditions have extremely high mortality rates and need better management.

What do we know about maternal and perinatal mortality and morbidity audits in sub-Saharan Africa? A scoping literature review

PurposeThe purpose of this paper is to provide a situational overview of the facility-based maternal and perinatal morbidity and mortality audits (MPMMAs) in SSA, their current efficacy at reducing mortality and morbidity rates related to childbirth.Design/methodology/approachThis is a scoping literature review based on the synthesis of secondary literature.FindingsNot all countries in SSA conduct MPMMAs. Countries where MPMMAs are conducted have not instituted standard practice, MPMMAs are not done on a national scale, and there is no clear best practice for MPMMAs. In addition, auditing process of pediatrics and maternal deaths is flawed by human and organizational barriers. Thus, the aggregated data collected from MPMMAs are not adequate enough to identify and correct systemic flaws in SSA childbirth-related health care.Research limitations/implicationsThere are a few published literature on the topic in sub-Saharan Africa.Practical implicationsThis review exposes serious gaps in literature and practice. It provides a platform upon which practitioners and policy makers must begin to discuss ways of embedding mortality audits in SSA in their health systems as well as health strategies.Social implicationsThe findings of this paper can inform policy in sub-Saharan Africa that could lead toward better outcomes in health and well-being.Originality/valueThe paper is original.

Morbidity Audit of 704 Traumatic Brain Injury Cases in a Dedicated South Indian Trauma Center.

Background:In the era of evidence-based health care, protocol of intervention in traumatic brain injury (TBI) cases help decide more easily and safely about patients and prevent unnecessary transfer of patients to other centers.Objectives:The objective of this study is to provide protocol-based intervention and evaluate the epidemiological, clinical characteristics of TBI cases.Methods:This prospective study was conducted on 704 patients who were suspected of TBI at the Department of Neurosurgery, Narayana Medical College and Hospital, followed by protocol-based intervention assessed and reassessed repeatedly.Results:Overall, TBI involved 569 (80.82%) adults in the productive age groups (21–60 years); among males 81.47%. Among males, highest (23.15%) cases were in the age group of 31–40 years while in females, majority (27.04%) was among 41–50 years. Road traffic accidents were the most common (54.12%) mechanism of injury followed by fall (21.31%) and two-wheelers (15.20%). More than half sustained mild TBI (51.42%) while 26.28% moderate TBI and 22.30% severe TBI; among males, severe TBI victims 102 (18.82%) were in the productive age group. Loss of consciousness was almost a universal and significant observation (95.45%); vomiting was next common finding (76.42%). Bleeding from the ear-nose-throat (ENT) region was more in males (33.58%) than females (20.75%). Glasgow coma scale was significantly related with loss of consciousness (91.08%), vomiting (63.06%), and ENT bleeding (44.59%) in severe, moderate, and mild injuries.Conclusion:A rational clinical acumen with judicious use of diagnostic protocol leads to better management of TBI without unnecessary imaging and thus reduce total health-care costs.

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.

Morbidity Audit of Women Beedi Workers in an Urban Fringe of West Bengal, India

Morbidity Audit of Women Beedi Workers in an Urban Fringe of West Bengal, India

PTU-099 A Large Prospective Audit of Morbidity and Mortality in Patients with Feeding Gastrostomies Placed for Head and Neck Cancer: Abstract PTU-099 Table 1

Introduction Feeding patients undergoing radical treatment for head and neck cancer via a percutaneous endoscopically or radiologically placed/inserted gastrostomy (PEG, RIG) is common practice. PEG/RIG insertion is not entirely safe and complications may occur with long-term usage. We did a prospective audit of PEG/RIG related complications in patients having them placed prior to surgery for head and neck cancer. Methods Community dietitians reviewed all patients with a gastrostomy placed prior to surgery or radiotherapy for head and neck cancer. They prospectively recorded morbidity and mortality between 2008–2014. In addition hospital databases and case notes were examined. Recorded morbidity included insertion site infection, leakage, over granulation, haemorrhage and buried bumper. Results In the 206 patients there was one death within 30 days from placement, no deaths attributable to gastrostomy placement. One patient underwent a laparotomy for peritonitis. 95 minor complications occurred in 72 (35%) patients or 1:887 days of having a gastrostomy. The commonest complication was peristomal site infection occurring in 55 (27%) patients or 1:1531 days of having a gastrostomy, all of which settled with antibiotics. There was no buried bumpers or tumour implantation at the insertion site reported in the study. There was no procedure related 30 day mortality. Conclusion We have shown a low rate of major complications (0.5%) and a relatively high minor complications rate (35%) of PEGs and RIGs in patients with head and neck cancer. Wound infection can be reduced by careful sterile technique, preoperative antibiotics, a 1 cm abdominal incision and avoiding tightness of the crossbar. We conclude that the use of PEG tubes is a safe method of delivering non-oral nutritional support for patients undergoing treatment for head and neck cancer. References 1 Gauderer MW, Ponsky JL, Izant RJ, Jr. Gastrostomy without laparotomy: A percutaneous endoscopic technique. J Pediatr Surg 1980; 15 :872–5. 2 Mansoor H, Masood MA, Yusuf MA. Complications of percutaneous endoscopic gastrostomy Tube insertion in Cancer patients: A retrospective study. J Gastrintest Cane 2014; 45 :452–459. 3 Burney RE, Bryner BS. Safety and long-term outcomes of percutaneous endoscopic gastrostomy in patients with head and neck cancer. Surg Endosc 2015; 29 (12):3685–9. 4 Hunter JG, Lauretano L, Shellito PC. Percutaneous endoscopic gastrostomy in head and neck Cancer patients. Ann Surg 1989; 210 :42–46. Disclosure of Interest None Declared

A large prospective audit of morbidity and mortality associated with feeding gastrostomies in the community

Morbidity after 30 days and morbidity after 1 year from gastrostomy placement is poorly characterised as patients are discharged into the community. We prospectively recorded morbidity and mortality associated with gastrostomy placement over a five year period. Community dietitians regularly reviewed all patients with a gastrostomy after hospital discharge, prospectively recording morbidity and mortality between 2008 and 2012. In addition hospital databases and case notes were examined. Recorded morbidity included insertion site infection, leakage, over granulation, haemorrhage and buried bumper. The commonest indication for PEG placement was following an acute cerebral injury. There were no deaths and few complications directly related to gastrostomy insertion in 350 patients. We collected a total of 571 years of gastrostomy data. Mortality within 30 days was predominantly from a respiratory infection. 30 day, 3 and 12 month cumulative mortality (and morbidity) were 8% (2%), 16% (10%) and 35% (15%) respectively. 38% of patients required treatment for an insertion site infection with 70% of these having further infections. Overall there was a site infection every 2.1 years a gastrostomy was in situ. Complications such as buried bumpers (5(1.4%)), persistent fistulas (0) and over granulation (7(2%)) were rare. Few gastrostomies required replacement (11%). We have demonstrated reassuringly low rates of gastrostomy-associated morbidity and mortality. There was no direct mortality. The greatest morbidity resulted from gastrostomy-site infection.

PTU-148 A large prospective audit of morbidity and mortality associated with feeding gastrostomies in the community: Abstract PTU-148 Table 1

Introduction Morbidity after 30 days and morbidity after 1 year from gastrostomy placement is poorly characterised as patients are discharged into the community. We prospectively recorded morbidity and mortality associated with gastrostomy placement over a five year period. Method Community dietitians regularly reviewed all patients with a gastrostomy after hospital discharge, prospectively recording morbidity and mortality between 2008–2012. In addition hospital databases and case notes were examined. Recorded morbidity included insertion site infection, leakage, over granulation, haemorrhage and buried bumper. Results There were no deaths and few complications directly related to gastrostomy insertion in 350 patients. We collected a total of 571 years of gastrostomy data. Mortality within 10 days was predominantly from a respiratory cause. 30 day, 3 and 21 month cumulative mortality (and morbidity) were 8% (2%), 16% (10%) and 35% (15%) respectively. 38% of patients required treatment for an insertion site infection with 70% of these having further infections. Overall there was a site infection every 2.1 years a gastrostomy was in situ . Complications such as buried bumpers, persistent fistulas and overgranulation were rare. Few gastrostomies required replacement (11%). View this table: Abstract PTU-148 Table 1 Mortality after gastrostomy placement during study period, N (%) Conclusion This is the first prospective study of morbidity and mortality in a large number of patients undergoing gastrostomy placement over an extended period of time. We have demonstrated reassuringly low rates of gastrostomy-associated morbidity and mortality. There was no direct mortality. The greatest morbidity resulted from gastrostomy-site infection. Disclosure of interest None Declared.

Is benchmarking possible in audit of early outcomes after operations for head and neck cancer?

There is a need for a validated means of adjusting for case mix in morbidity audits of patients with cancer of the head and neck. To address this, we did a multicentre audit of 3 UK NHS cancer networks that treat patients with head and neck cancer, to compare the incidence of early adverse postoperative outcomes and to develop a means of adjusting for case mix. We did a retrospective and prospective audit of the case notes of 901 consecutive patients who had 1034 operations for squamous cell carcinoma (SCC) of the head and neck under general anaesthesia at 3 NHS hospitals. Analysis of raw data showed postoperative 30-day mortality (n=17) to be consistent between sites (1.7%–1.9%) but 30-day complication rates varied more (34%–49%). Logistic regression models predicting morbidity discriminated well (area under the curve 0.74–0.76). Adjusted morbidity rates for the 3 units were compared on a funnel plot with 95% and 99% confidence intervals to account for random variation. It is possible to benchmark surgical performance by focusing on early postoperative outcomes in head and neck surgery. Morbidity is common and usually has a considerable impact on recovery, bed occupancy, cost, and the patient's perception of the quality of care.

Peer review and audit of morbidity after three or more caesarean sections

A review of maternal and newborn outcomes after a third or more caesarean section was conducted among six obstetrician registrars. The main outcome measures were maternal morbidity, intraoperative and postoperative complications and neonatal outcome. A retrospective cohort study was conducted of caesarean sections for women who had previously undergone two or more caesarean section performed by six obstetrician registrars in Sultan Qaboos University Hospital, a tertiary referral hospital in Oman. Retrospective data were collected from electronic health records of 120 Omani women between January 2010 and December 2011 (20 per registrar). Haemorrhage of more than 1000 ml was recorded in 10% of patients, one patient was found to have a bladder injury intraoperatively, and postoperative wound infection occurred in 5% of patients. Difficulty in opening the abdomen was found in one patient, and one case of deep vein thrombosis occurred despite prophylactic heparinisation. One infant was preterm, and four had intrauterine growth restriction. Intraoperative complications, such as blood loss, visceral injury and long mean operating time and postoperative complications, such as deep vein thrombosis, wound infection and febrile morbidity, were comparable among the registrars. The standard of the registrars was comparable, and similar to international standards.

Complications in spinal deformity surgery in the United Kingdom: 5-year results of the annual British Scoliosis Society National Audit of Morbidity and Mortality

To provide a 5-year national overview of corrective spinal deformity surgery in the United Kingdom. Since 2008, the British Scoliosis Society has collected predefined data on spinal deformity surgeries carried out by its members. Participating units collect and submit annual anonymised data pertaining to the number of deformity surgeries performed, age groups, aetiology (idiopathic versus non-idiopathic), mortality, deep infections and neurological deficit (complete, incomplete without resolution and incomplete with resolution). Overall aetiology proportions and complication rates were calculated, as well as funnel plots with control limits of individual complication rates by cases performed. Between 2008 and 2012, 9,295 corrective spinal deformity procedures were performed. 4,445 (48%) were recorded as idiopathic and 2,917 (31%) as non-idiopathic. There were a total of 339 complications (3.6%). Deep infections occurred in 222 (2.82%), incomplete neurological deficit with resolution in 59 (0.65%), incomplete neurological deficit without resolution in 29 (0.32%), complete neurological deficit in 12 (0.13%) and mortality in 17 (0.19%). The complication rates reported in this study compare well with previously published studies. These reported results will hopefully serve to provide a benchmark for units in the UK providing corrective spinal deformity surgery to allow individual units to compare their complication rates against national averages and to provide national complication figures to aid in the consenting process of patients. Use of a spinal deformity registry, such as the British Spine Registry, is required to ensure ongoing service development and optimal healthcare provision.

An audit of morbidity and mortality associated with foreign body aspiration in children from a tertiary level hospital in Northern India.

There is paucity of data regarding the morbidity and mortality of rigid bronchoscopy in children for foreign body (FB) retrieval from India. The aim was to audit data regarding anaesthetic management of rigid bronchoscopy in children and associated morbidity and mortality. Hospital records of all patients below 18 years of age undergoing rigid bronchoscopy for suspected FB aspiration (FBA) between January 1, 2002 and December 31, 2011 were audited to assess their demographic profile, anaesthetic management, complications, and postoperative outcomes. The children were divided into early and late diagnosis groups depending on whether they presented to the hospital within 24 hours of FBA, or later. One hundred and forty children, predominantly male (75%), with an average age of 1-year and 8 months, presented to our hospital for rigid bronchoscopy during the study period. Majority of children presented in the late diagnosis group (59.29% vs. 40.71%). The penetration syndrome was observed in 22% of patients. Majority of patients aspirated an organic FB (organic: Inorganic FB = 3:1), with peanuts being the most common (49.28%). A significantly higher number of children presented with cough (P = 0.0001) and history of choking (P = 0.0022) in the early diagnosis group and crepitations (P = 0.0011) in the late diagnosis group. Major complications included cardiac arrest (2.1%), pneumothorax (0.7%), and laryngeal oedema (9.3%). The average duration of hospitalization in our series was 3.08 ± 0.7 days. Foreign body aspiration causes considerable morbidity, especially when diagnosis is delayed.

The surgical safety checklist survey: a national perspective on patient safety

In 2008, the World Health Organisation (WHO) recommended practices to ensure the safety of patients worldwide. This led to the development of the Surgical Safety Checklist (SSC). Ireland has endorsed the SSC ( www.hiqa.ie/press-release/2008-06-17-health-information-and-quality-authority-launches-world-health-organization , 10). We aimed to determine (i) whether SSC is being implemented, (ii) whether it promotes a safer surgical environment and (iii) identify problems associated with its introduction and on-going implementation. All hospitals in Ireland with operating departments (n = 61) were invited to participate in an online survey. The response rate was 67 %. The WHO SSC or modified version is in place in 78 % (mean time: 20 months) of operating departments that responded. Partaking in Time Out as a team was reported as occurring in 57 % of cases. Greater than 60 % of respondents reported that the SSC was difficult to introduce and implement and that its introduction was time consuming. Further training in using the SSC was reported as desirable by 84 % of respondents. The introduction of the SSC was reported to be associated with an improvement in team communication (72 %), a positive change in team behaviour (63 %), an increase in the consistency of patient care (82 %) and a positive culture of safety in theatre (81 %). The SSC has not been implemented throughout all operating departments in Ireland. Where it has been introduced there has been a perceived positive change in safety culture. However, overall greater education, endorsement, teamwork, and communication will be required to optimise the potential benefits associated with this safety instrument. In order to properly determine the benefit of the SSC following its implementation, a formal audit of morbidity and mortality is required.