Scottish Audit Of Surgical Mortality Research Articles

Use of the high dependency unit, increased consultant involvement and reduction in adverse events in patients who die after colorectal cancer surgery

We prospectively audited adverse events for surgical patients with colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events. Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996 to 2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality. In the 10-year study period, 3029 patients with colorectal cancer, mean age 76 (13-105)years, died under surgical care, of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) patients of whom 1030 (34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P=0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P=0.009), a 37% fall for surgical care (P=0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P=0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P=0.016). The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.

Mortality reporting in interventional radiology: Experience of a pilot audit with the Scottish Audit of Surgical Mortality

To describe the initial pilot phase of the 2009 Scottish Audit of Surgical Mortality (SASM), which includes outcomes and difficulties that arose during any interventional radiology (IR) procedure performed on patients in this audit over an 18 month period. Approximately 40 consultant interventional radiologists from all units in Scotland elected to participate in the audit. Each response was then peer reviewed after anonymisation of the patient and institution. If a relevant ACON (area for consideration or area of concern) was generated, this was checked by one of the other reviewers before communication with the original reporting radiologist and colleagues. There was then a right of reply by the reporting unit before formal documentation was sent out. Initial results were analysed after 18 months period, during which time 95 forms relating to deaths of surgical inpatients were sent to interventional radiologists identified as having been involved in an IR procedure at some time during the patient's admission. Seventy-one forms had been returned by July 2010, of which 46 had gone through the entire SASM process. From these, 10 ACONs were attributed. Anonymised case vignettes and reports from these were used as educational tools. Involvement with SASM is a useful process. Significant safety issues and learning points were identified in the pilot. The majority of ACONs identified by the audit were in patients who had undergone percutaneous biliary interventions.

Improved short term surgical outcomes in Scotland for oesophageal cancer

AimThis study examined the trends in mortality and contributing adverse events associated with death under surgical care for patients with oesophageal cancer. MethodsAdverse events in surgical care were prospectively audited in patients who died with cancer of the oesophagus or oesophago-gastric junction under surgical care in Scotland from 1994 to 2005 through the Scottish Audit of Surgical Mortality (SASM). ResultsBetween 1994 and 2005 (inclusive), 1424 patients with oesophageal cancer (median age 72, 62% male) died. The proportion of oesophageal cancer patients dying on a surgical ward fell significantly from 17% to 13% (p = 0.005). There has been a significant decrease in the annual number of major surgical resections for oesophageal cancer in Scotland from 324 in 1994 to 193 in 2005 (p < 0.001). The proportion of patients operated on in specialist cancer centres increased since 2000. In the period 1996 to 2005, 1157 patients died under surgical care with oesophageal cancer and were audited by SASM. One hundred and thirty five patients (12%) had 239 adverse events. Overall, the number of adverse events decreased over time with 65/130 of those who died following a cancer resection had adverse events. An anastomotic leak was a factor in 25 of these patients. There was a significant decrease in the proportion of deaths following therapeutic endoscopy (p = 0.011). ConclusionThere has been a significant decrease in the number of cancer resections, adverse events and mortality associated with oesophageal cancer surgery at a time of increasing surgical specialisation.

Palliative care for patients with gastrointestinal cancer dying under surgical care: A case for acute palliative care units?

Background and aimsPatients with advanced gastrointestinal cancer may present late to hospital services and die under surgical care. The aim of this study was to examine end of life care in patients dying of gastrointestinal cancer in Scottish hospital surgical wards. MethodsThe Scottish Audit of Surgical Mortality prospectively peer reviews all inpatient deaths under the care of a consultant surgeon. Patients who died with gastrointestinal cancer under surgical care from 1994 to 2006 were evaluated for operative interventions, adverse events, and palliative care provision. Data was compared with inpatient data from the Information Statistics Division of NHS Scotland. ResultsA total of 8019 patients died with gastrointestinal cancer on a surgical ward over 12 years. For 4350 (54%), no operation or endoscopy was performed during the final admission and adverse events were identified in only 86 (2%) of these patients, most commonly due to a complication of an interventional procedures. Specialist palliative care was provided to 57% of patients and was not influenced by cancer site. ConclusionA substantial proportion of patients die with gastrointestinal cancer on general surgical wards without operative or endoscopic intervention and may receive better end of life care in an acute palliative care setting.

Hospital mortality under surgical care

The article by Aziz et al reviews the use of the ‘hospital standardised mortality ratio’ (HSMR) in England as a measure of hospital performance as well as highlighting the inadequacies in its current form. A general surgeon’s data were used to evaluate accuracy of this system. Alarmingly, the results showed that at least 30% of cases were incorrectly attributed to the surgeon, that none of the surgeon’s cases were externally peer reviewed, that there was no clear evidence of adverse events being possibly attributed to the mortality to see if they could have been avoided and that there were so many missing data regarding co-morbidities. Clinical quality registries play an increasingly important role to improve the quality of healthcare in Australia. The 2009 Australian Institute of Health and Welfare report on the proposed national quality indicators emphasised the importance of having national registries, particularly in high cost areas of medicine.1 Indicator 36 (independent peer review of surgical deaths) stated that the original template of the Scottish Audit of Surgical Mortality (SASM) should be adapted for use in Australia. It recommended that these data sources be reported nationally, ensuring standardisation of reporting methods across all states and territories in Australia. We can report that this is now the case with the Australian and New Zealand Audit of Surgical Mortality (ANZASM) being set up in 2006. Aziz et al further pointed out that the HSMR cases are not reviewed externally and that the public could therefore be misinformed by seeing these crude mortality data (the validity and accuracy of the data being in question), especially when in many cases the risk of death is high in this group of patients. In our 2009 national report, the surgeon considered the risk of death to be expected in 11% of cases, considerable in 40% and moderate in a further 19%.2 Co-morbidity was another signifcantly important factor in the study by Aziz et al, with 94% of cases recorded as having an ASA (American Society of Anesthesiologists) grade >1. The Western Australian Audit of Surgical Mortality (WAASM), the Tasmanian Audit of Surgical Mortality (TASM) and SASM reported co-morbidity as 86–99%.3–5 In the 2009 Australian national report, 91% of cases reported at least one co-morbidity and 75% had at least two co-morbidities while only 6% were ASA grade 1 or 2.2 These levels of data and statistical analysis can only come from full surgical participation and a robust surgical case form applied across all states and territories. ANZASM agrees that the UK HSMR methodology looks at hospital mortality in isolation rather than from a regional or national perspective and is therefore open to faws in interpretation in its analysis of data, as Aziz et al clearly point out. Aziz et al go on to say that they consider HSMRs to be inadequate and suggest surgeons participate in large audits similar to SASM, WAASM and TASM. The Royal Australasian College of Surgeons (RACS) and Australian state and territory Departments of Health have committed to the national audit of surgical mortality. To reinforce the importance of the activity, participation in ANZASM was deemed a mandatory part of the Continuing Professional Development (CPD) programme (Category 1 – Surgical Audit and Peer Review) in January 2010. The ethos for this was to ensure complete participation by fellows in the audit process. There is tremendous beneft in having a common surgical case form questionnaire and being able to collect the same data set over a wide spectrum of surgical interventions (and therefore reducing variation in the levels of accuracy in the reporting methodology). Having this national system in Australia across all states and territories, encompassing surgeon reporting and peer review, enables accurate data collection, surgeon refection and general education by sharing de-identifed cases in case note reviews. This can only be a benefcial process to all concerned. The RACS fully encourages the audit programme as it is fully owned by the surgeons with the understanding for the need to have partnerships with governments and other bodies. Surgeon participation in an independent peer review mortality audit process would therefore be an ideal way to better inform the college, as well as the general public, in terms of its accountability in the profession of providing quality care to its patients.

Death within 48 h – Adverse events after general surgical procedures

Background Comorbidity and emergency intervention are established risk factors for post-operative mortality. This study sought to identify adverse events associated with death within 48 h of general surgical procedures. Methods All general surgical patients who died within 48 h of operative intervention from 2002–2006 in Scotland underwent retrospective peer review using established Scottish Audit of Surgical Mortality (SASM) methodologies ( www.SASM.org). Results During the 5 years, 1299 patients died within 48 h of surgery, 1134 (87.3%) admitted as an emergency, with a mean age of 71 years; 898 patients (69.1%) were ASA grade 3, 4 or 5; 727 (56.0%) patients had cardiovascular, 398 (30.6%) respiratory and 191 (14.7%) renal comorbidity. Over time exploratory laparotomy (443, 34.1%) was carried out less often ( p = 0.004) prior to death due to cardiovascular disease (435, 33.5%), mesenteric ischaemia (264, 20.3%) or multi-organ failure (255, 19.6%). The decision to operate by consultant surgeons rose significantly ( p < 0.001). Adverse events were identified in 721 of the 1299 cases; concerns about inappropriate operations ( p = 0.018) and poor pre-operative assessment ( p = 0.012) decreased significantly. Conclusions Patients dying within 48 h of surgery are usually elderly, emergency admissions with significant comorbidities who die of cardiovascular events. Timely, appropriate surgery and high quality peri-operative care delivered by consultant staff may prevent early post-operative mortality.

Mortality Associated with the Treatment of Gallstone Disease: A 10‐Year Contemporary National Experience

Gallstones remain a common clinical problem requiring skilled operative and nonoperative management. The aim of the present population-based study was to investigate causes of gallstone-related mortality in Scotland. Surgical deaths were peer reviewed between 1997 and 2006 through the Scottish Audit of Surgical Mortality (SASM); data were analyzed for patients in whom the principal diagnosis on admission was gallstone disease. Gallstone disease was responsible for 790/43,271 (1.83%) of the surgical deaths recorded, with an overall mortality for cholecystectomy of 0.307% (176/57,352), endoscopic retrograde cholangiopancreatography (ERCP) of 0.313% (117/37,345), and cholecystostomy of 2.1% (12/578) across the decade. However, the majority of patients who died were elderly (47.6% ≥ 80 years or older) and were managed conservatively. Deaths following cholecystectomy usually followed emergency admission (76%) and were more likely to have been associated with postoperative medical complications (n = 189) than surgical complications (n = 36). Although cholecystectomy is a relatively safe procedure, patients who die as a result of gallstone disease tend to be elderly, to have been admitted as emergency cases, and to have had co-morbidities. Future combined medical and surgical perioperative management may reduce the mortality rate associated with gallstones.

The Scottish Audit of Surgical Mortality: a review of areas of concern related to anaesthesia over 10 years

The Scottish Audit of Surgical Mortality is a voluntary, peer reviewed, critical event analysis of patients who die under the care of consultant surgeons in acute hospitals in Scotland. The anaesthetic contribution to surgical mortality over a 10-year period from 1996 was reviewed. The total number of deaths was 44 230 or 1.5% of all admissions. Forty thousand, eight hundred and ninety-six deaths (92%) were audited. Deaths after elective surgery declined over 10 years. Over 80% of deaths followed emergency admission. The number of deaths where an anaesthetist was present was 16 981 or 0.6% of all admissions. Anaesthetic areas of concern were identified in 8% of deaths. Of these, 43% were related to pre-operative assessment. Anaesthesia also played a part in a further 18% of deaths where decision making was shared with the surgical team. Of these, 41% were related to access to critical care. A further 24% related to communication failures, principally when the operation should not have been done or was unnecessary.

Still missing the boat with fatal pulmonary embolism.

Deaths from pulmonary embolism during 1994 among surgical inpatients in three Scottish regions were identified through the Scottish Audit of Surgical Mortality and reviewed to identify the risk factors for thromboembolic disease and the thromboprophylaxis received. Fifty-seven deaths were studied (3 per cent of total deaths); 25 (44 per cent) of the patients had received prophylaxis. Thirty-six patients were in a high-risk group, 19 were at moderate risk and two at low risk. Patients admitted as an emergency, those managed conservatively and those judged to be at moderate risk of thromboembolic disease were most likely not to have received thromboprophylaxis.

Mapping changes in surgical mortality over 9 years by peer review audit

There is increasing public scrutiny of deaths among surgical patients. This analysis sought evidence of changes in practice over time in the management of patients who died under surgical care. The surgeons and anaesthetists in National Health Service hospitals providing the care of all surgical patients in Scotland participated in the Scottish Audit of Surgical Mortality (SASM). Data from peer review audit, critical event analysis and individual feedback of deaths while in surgical care over 9 years (1994-2002) were examined for trends over time. Over a 9-year period, 40,448 patients died while in surgical care. Consultant surgeon and anaesthetist involvement in decision making and operating increased significantly (P < 0.001), and death after elective surgery declined to 0.27 per cent of elective operations. Adverse events were more frequently due to failures of hospital systems or process than to individual clinician errors. Fewer adverse events were identified as having contributed to or caused the death of patients over time (P < 0.001). Failure to use deep vein thrombosis (DVT) prophylaxis and failure to use high-dependency or intensive therapy units (HDU/ITU) became less common, once highlighted by the SASM. Through continuous peer review audit, the SASM has mapped and may have contributed to changes in surgical and anaesthetic practice over a 9-year period, indicating that the rate of adverse events can be decreased by changing clinician practice (DVT prophylaxis) and provision of facilities (HDU/ITU). Similar approaches should be considered by other medical specialties.

NCEPOD: reconciling recommendations with reality in the ICU

The structure and role of the NCEPOD The UK National Confidential Enquiry into Perioperative Deaths (NCEPOD), a registered charity established in the late 1980s, reviews clinical practice and identifies areas where changes in surgical and anaesthetic practices may improve patient outcome. NCEPOD is a largely government-funded, yet independent, body with a chief executive, a steering group, clinical coordinators (representing specialties such as anaesthesia, surgery, pathology, oncology) and administrative staff. NCEPOD relies on a network of reporters located at every NHS and private hospital in England, Wales, Northern Ireland, Guernsey, Jersey, Isle of Man and the Defence Secondary Care Agency. Reporters notify NCEPOD of all deaths occurring in hospital after surgery. While participation in NCEPOD is voluntary in the private sector, it is compulsory for NHS Trusts. A similar function is performed by the Scottish Audit of Surgical Mortality.

Avoidable deaths still occur after large bowel surgery. Scottish Audit of Surgical Mortality, Royal College of Surgeons of Edinburgh.

Postoperative death following large bowel surgery is relatively infrequent and no large study has analysed the cause of all deaths comprehensively and critically. In-hospital deaths following large bowel surgery in South-East Scotland were reviewed by independent assessors. The audit was confidential but not anonymous. Independent assessors' reports were returned to consultants. The audit documented 187 deaths. The independent assessors noted an adverse event in 78 patients (42 per cent). Twenty-six deaths (14 per cent) occurred following an anastomotic leak. A further 43 deaths (23 per cent) occurred because surgery was delayed (17) or there was undue delay in making the initial diagnosis (12) or recognizing a developing complication (14). Consultants operated on only half the patients classed as American Society of Anesthesiologists grade IV or V, or undergoing a second or subsequent operation. Half the patients dying in this study had identifiable deficiencies in their management. There is a clear need for greater consultant input with critically ill patients.

Clinical Practice 08

Aim: To map changes in practice over 7 years of continuous peer review audit of surgical deaths. Methods: Between 1994 and 2000, all patients who died under surgical care (mean: 4504 patients per annum; range: 4331–4657) were peer reviewed for the Scottish audit of surgical mortality (SASM). Results: The mean age rose to 76 years, 88 per cent were emergency admissions, but the absolute number and proportion of deaths following elective admission fell to 0.11 per cent. For operative cases, 80 per cent of fatalities had major co-morbidity. Surgical adverse events were usually related to clinical decision making, not poor facilities (e.g. late referral resulting in delay to surgery in 68 per cent where delays were identified) but contributed to (2 per cent) or caused (1 per cent) the death of some patients. Failure to use HDU (high dependency units), which was highlighted by SASM, peaked as an adverse factor in 1998 and has since declined to 1996 levels due to increased facilities. A consultant decision to operate rose to 97 per cent, consultant input as operator/assistant increased to 76 per cent (P = 0.0001, Chi-square test) and criticisms of surgeon grade and choice of operation declined to 1.7 per cent of deaths by 2000. There was almost a doubling of consultant anaesthetic input to 90 per cent by 2000 (P < 0.0001, Chi-square test). Conclusion: Despite an increasingly elderly population, often admitted as an emergency, SASM has mapped significant changes in practice for patients who die, including the use of HDU, which may reflect overall improvements in the service.

Vascular surgical society of great britain and ireland: scottish audit of surgical mortality, 1997

BACKGROUND: A national audit of surgical deaths can be seen as the final step in what has been termed the 'journey of care' for both the individual patient and for the population as a whole. METHODS: The Scottish Audit of Surgical Mortality (SASM) examines all hospital deaths in Scotland occurring while under the care of a surgical specialist and all deaths within 30 days of an operation. RESULTS: Compliance for the completion of forms relating to vascular deaths during the first 4 years of the SASM (1994-1997) has remained over 92 per cent. In 1997 the compliance was 97 per cent. These figures compare favourably with the other surgical specialties where the overall compliance for 1997 was 92 per cent. Some 14 per cent of the 4408 deaths reported in 1997 occurred in patients admitted with vascular disease, the majority (83 per cent) being emergency admissions. Of these 507 vascular deaths, 293 were postoperative; the remaining 214 patients did not undergo operation. This represents an improvement over the years 1994-1996 when vascular deaths numbered 554, 573 and 524 respectively. The mean age of the patients who died from vascular disease in 1997 was 73 (range 19-92) years. A consultant surgeon made the decision to operate in 98 per cent of the patients with vascular disease who died at operation and was the principal surgeon in 70 per cent of cases. Vascular consultants carried out a higher percentage of operations than their counterparts in other surgical specialties (general surgery, 63 per cent; mean for other subspecialties, 60 per cent). In the non-operative group of vascular deaths in 1997, a vascular consultant was in charge in 66 per cent of cases; the figure for operated cases was 87 per cent. Adverse factors were believed to contribute to death in 10 per cent of cases, but were considered a direct cause of death in fewer than 1 per cent. CONCLUSION: These figures reflect the high quality of vascular services in Scotland, where there is a considerable consultant presence in the management of high-risk patients. This consultant involvement is higher than in other subspecialties and, bearing in mind the high percentage of emergencies, has significant resource implications for the delivery of vascular services.